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Gray Hair – The New Normal

Gray Hair – The New Normal. Trauma in the Elderly Karen R. O’Bosky MD. Overview. Population changes Physiologic differences Resuscitation in the Elderly Effect of anticoagulants and antiplatelet medications Undertriage in the Elderly. The Graying of America.

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Gray Hair – The New Normal

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  1. Gray Hair – The New Normal Trauma in the Elderly Karen R. O’Bosky MD

  2. Overview • Population changes • Physiologic differences • Resuscitation in the Elderly • Effect of anticoagulants and antiplatelet medications • Undertriage in the Elderly

  3. The Graying of America • One of the fastest growing populations • Baby boomers are turning 65 • 2010-2019 >10,000 per day turn 65 • By 2050 there will be 90 million adults >65yrs old compared to 43 million in 2012 • Currently 13% of the population and account for 23% of all trauma admissions • Limited (but growing) literature pool addressing geriatric trauma • Only Level II and Level III evidence – no randomized control trials

  4. Epidemiology of Geriatric Trauma • Trauma is the 5th leading cause of death • >65 currently account for up to 1/3 of all traumas but account for 30-40% of trauma mortalities • Recent Meta-analysis by Hashmi et al. (2014) from the University of Arizona: • Overall mortality in >64 years old 14.8% • Twice the odds of mortality with age >74 • Odds of dying do not change significantly after age 74 • Mortality rate increases with ISS >16 – likelihood of death 10 times higher than ISS <16, ISS > 24 the likelihood of death was 50 times higher.

  5. Risk Factors for Trauma • Frailty • Weakness • General deconditioning • Loss of visual acuity • Hearing loss • Osteoporosis • Balance/Gait disturbance • Slowed reaction times • Cognitive impairments • History of trauma • Decreased sensation of pain • Alcohol and drug abuse • Elder abuse

  6. Mechanisms of Trauma • Falls -71% • Motor Vehicle Accident – 25% • Other -4% • Penetrating • suffocation • burns, etc

  7. Falls • Leading cause of preventable injury • Of those who fall 90% are simple falls • Blunt head trauma and long bone injuries cause the greatest morbidity and mortality • Severity of injury often underestimated • Average cost per fall is $18,000

  8. Motor Vehicle Accidents • Doubled rate of mortality than for younger trauma victims with matched ISS scores • Blunt head trauma • Long bone fracture • Blunt chest trauma – common and has a high morbidity and mortality when associated with the post trauma complications of respiratory failure and pneumonia

  9. Physiologic Differences in the Elderly • When stressed fewer reserves leading to increased organ failure • Increased number of comorbidities • Smaller margin of error

  10. Cardiovascular • 83% of deaths related to cardiovascular disease occur in persons >65 • Prevalence of heart failure is 1/100 • Anatomic changes and their consequences: • Number of myocytes declines, collagen and elastin increase -> increased fibrotic cardiac muscle and decreased ventricular compliance • 90% of autonomic tissue in the sinus node is replaced by fat and connective tissue -> poor conduction, increased rates of arrhythmias

  11. Cardiovascular Cont. • Progressive dilatation of the valvular annuli -> increased valvular regurgitation • Increased calcification of the valvular leaflets -> increased stenosis especially aortic stenosis. • Changes in the great vessels and peripheral vascular increases afterload – SBP increases with age • Heart rate decreases with age and there is decreased sensitivity of the heart to respond to catecholamines -> cardiac output relies more on preload than on increasing heart rate – therefore more sensitive to hypovolemia. • Diastolic relaxation more energy dependent and requires more oxygen – mild hypoxia can prolong diastole and lead to pulmonary congestion

  12. Respiratory • Chronic respiratory disease is the 4th leading cause of death • General decline in respiratory function even without lung disease • Anatomic changes and their consequences: • Kyphosis and vertebral collapse -> decreased chest wall compliance • Calcification of costal cartilage and contractures of intercostal muscles-> decline in rib mobility • Maximum inspiratory and expiratory force decreases up to 50%

  13. Respiratory Cont. • Loss of lung tissue elasticity -> increased alveolar compliance, collapse of small airways, and air trapping • Air trapping leads to increased residual volume (volume remaining after maximal expiration) • Small airway collapse limits flow rates and decreased vital capacity • Ventilatory response to hypoxia and hypercapnea fall by up to 50% • Decrease in cough reflex and dysfunction in swallowing -> aspiration

  14. Renal • 25% of persons >65 have moderate to severe decrease in renal function • Mean age of dialysis patients is 61.5 years and the numbers are increasing • There is a progressive decrease in the renal cortex and 40% of nephrons become sclerotic • Atrophy of the afferent and efferent arterioles and renal blood flow falls by 50% • Overall decrease in GFR (and therefore creatinine clearance) by 45% by 80 years old • Serum creatinine levels may remain unchanged due to decreased muscle mass

  15. Renal Cont. • Ability to conserve sodium and excrete hydrogen ions decreases -> decreased compensation for sodium losses and impaired acid-base compensation • Decrease in the sensation of thirst compounds the kidneys inability to regulate osmolality • Renal insufficiency alters drug clearance and dosing • Increased collagen content of the bladder -> limited distensibility and emptying • BPH/prostatic cancer -> outflow obstruction • Increased overactivity of the bladder and increased incontinence

  16. Other Changes • Decreased metabolism of drugs metabolized in the liver • Enhanced susceptibility to infections and decrease in the bone marrow’s ability to produce neutrophils • Decreased production of T cells and B cells • Chronically elevated acute phase proteins and inflammatory cytokines -> implicated in frailty and anemia • Increase in glucose intolerance • Decreased thermoregulatory ability -> increased risk of hypothermia

  17. What qualifies Hypotension? • High rate of baseline hypertension and decreased heart rate • Relative hypotension and lack of tachycardia may mask expected signs of hypovolemia • SBP < 90 mmHg increased risk of mortality 3.1-5.3 fold • SBP <110 mmHg increased risk of mortality twofold • For every 10 mmHg decrement in SBP mortality rate increases 4.8%

  18. Serum Lactate • Serum lactate can be used as a measure of occult hypoperfusion • An initial venous lactate is a strong predictor of in hospital mortality • Bar-Or et al. (2013) used a lactate driven protocol for resuscitation in the initial 24 hours in conjunction with early trauma surgeon involvement to improve mortality • Decrease in mortality has been persistently about 20%

  19. Journal of the American Geriatrics SocietyVolume 61, Issue 8, pages 1358-1364, 26 JUL 2013 DOI: 10.1111/jgs.12365http://onlinelibrary.wiley.com/doi/10.1111/jgs.12365/full#jgs12365-fig-0001

  20. Base Deficit • A low base deficit has been shown to be associated with increased mortality in trauma patients, especially in patients >55 years if age. • A base deficit of < or = to -6 is associated with severe injury and increased mortality • a normal base deficit value was not found to be a negative predictor of severe injury in patients >55 years old

  21. Base Deficit in the Elderly: A Marker of Severe Injury and Death. Davis, James; MD, FACS; Kaups, Krista; MD, FACS Journal of Trauma-Injury Infection &amp; Critical Care. 45(5):873-877, November 1998.

  22. Shock Index • Shock index = HR / SBP • Easily calculated in the field • Shock index > 1 has been demonstrated to be an independent predictor for mortality • SI >1 also more likely to have need for transfusion, exploratory laparotomy, and in-hospital complications in the elderly population from the national trauma database • ***patients with hypertension and therefore b-blockade were excluded • Further study on a more representative sample required Pandit et al. 2014

  23. Early Invasive Monitoring and ICU Care • Previous trauma guidelines in the elderly suggested early use of Swan Ganz catheters • Many non-invasive options available that can be used with less invasive maneuvers and instituted early. • Study by McKinley et al. (2000) demonstrated that the elderly do respond to aggressive resuscitation • The best endpoints for resuscitation are still an area for research • Consider early ICU admission for any elderly patient who you suspect may not be fully resuscitated

  24. Anticoagulants and Antiplatelet agents • 1/3 of patients requiring hospitalization for TBI are >65 years old • Largest group to use anticoagulants and antiplatelet medications is also >65 years old • Atrial fibrillation is the most common reason for anticoagulant use • Cardiovascular stenting is the most common reason for antiplatelet use

  25. Anticoagulants • Most common is Warfarin • Examples of new oral anticoagulants: Pradaxa (dabigatran), Eliquis (apixaban), Xarelto (rivaroxiban) • Oral anticoagulants increase the risk of being admitted for injury • Warfarin use prior to injury increases mortality after traumatic brain injury independent of age • More likely to have progression of an initial injury on repeat CT scan and more likely to develop new hemorrhagic foci

  26. Reversal of Anticoagulation • Treatment with aggressive INR reversal decreases hemorrhage progression and improves mortality • Recommended initiation of reversal on elevated INR in under 2 hours and full reversal in under 4 hours • Correct to an INR value of less than 1.6 • Products for reversal: • FFP • Prothrombin complex concentrates – Kcentra, FEIBA, etc • Vitamin K IV

  27. Antiplatelet Medications • Examples include Aspirin, Plavix (clopidogrel), Pletal (cilostazol), Ticlid (ticlodipine) • Increased risk of mortality from TBI with pre-injury antiplatelet use • Less likely to have progression of bleed when compared to warfarin • Transfusion of platelets has not demonstrated significant benefit

  28. Undertriage • Geriatric patients often do not receive appropriate trauma care • Delay in recognizing trauma • Long time to discovery • Family underestimates severity of trauma • Nursing facility initially attempts treatment before calling for EMS • Emergency responders may not recognize potentially severe injuries • Prolonged transport times from non-trauma facilities to trauma facilities

  29. Undertriage • ACS – Committee on Trauma suggests guidelines to base local triage systems on • Based on mechanisms of trauma, physiologic and anatomic parameters • Often elderly do not meet these initial criteria and are not brought to a trauma center. • Definition of undertriage = Injury severity score (ISS) >15 and brought to a non-trauma center – acceptable rate is 5% • Undertriage can occur within an institute based on levels of involvement of the trauma surgeon

  30. In-House Undertriage • Rogers et al. 2012 evaluated in-house undertriage (UT) • UT was a significant predictor of mortality • Twice as likely to die from their injuries as correctly triaged patients • More likely to have a Fall as mechanism of trauma

  31. Statewide Examples of Undertriage • Phillips et al. (1996) UT rate of 31.2% in all patients but 56.7% in geriatric patients. Also noted that the system undertriaged falls more often than other types of blunt trauma • Lane et al. (2003) demonstrated that in 1997 Pennsylvania across the state the UT rate was 63.4% and showed that age negatively predicts that a trauma victim will be treated at a trauma center.

  32. Should Age be a Criteria for Activation? • Currently age in the absence of diagnosable injury is insufficient for trauma team activation but age and pre-existing conditions should lower the threshold for field triage to a trauma center • Many trauma surgeons advocate age alone be added as a criteria for activation and that elderly patients be transferred to a level I or II trauma center • Demitriades et al. (2001) proposed adding age >70 to trauma activation criteria to reduce undertriage and provide the most timely care for patients that most likely require ICU admission in the first 24 hours after trauma

  33. Current East Guidelines Evaluation and management of geriatric trauma: An Eastern Association for the Surgery of Trauma practice management guideline. Calland, James; Ingraham, Angela; Martin, Niels; Marshall, Gary; Schulman, Carl; MD, PhD; Stapleton, Tristan; Barraco, Robert; MD, MPH Journal of Trauma and Acute Care Surgery. 73(5) Supplement 4 EAST Practice Management Guidelines:S345-S350, November 2012. DOI: 10.1097/TA.0b013e318270191f

  34. Geriatric Trauma Teams/Services • Many institutions have started geriatric trauma teams • Multidisciplinary approach • Mangram et al (2012) 1 year evaluation of a multidisciplinary trauma service at Methodist Dallas Medical Center. • Decrease ED length of stay • Decreased time to OR • Decreased ICU stay • Decreased overall hospital stay • Decreased mortality from 5.7% to 3.8% • Decreased in-hospital complications • Further data is needed as different types of geriatric specific trauma teams are developed

  35. Summary • The Geriatric population is increasing • The geriatric population has a different physiologic response • Trauma mechanisms are different in the elderly • Undertriage is common and all members of the trauma system should be vigilant when dealing with geriatric patients • Consider objective data such as serum lactate and base deficit instead of vital signs when evaluating elderly patients • Consider the possible use of anticoagulants and antiplatelet medications when evaluating elderly patients • Should we develop geriatric specific teams and services for trauma at our institutions?

  36. References • Bar-Or D. et al. Association between a geriatric trauma rescucitation protocol using venous lactate measurements and early trauma surgeon involvement and mortality risk. J Am Geriatr Soc. 2013;13:1358-1364. • Bonne S. and Schuerer D.J.E. Trauma in the Older Adult Epidemiology and Evolving Geriatric Trauma Principles. ClinGeriatr Med. 2013: 137-150. • Calland J.F. et al. Evaluation and Management of geriatric trauma: An Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73:s345-s350. • Hashimi A. et al. Predictors of mortality in geriatric trauma patients: a systematic review and meta-analysis. J Trauma Acute Care Surg. 2014;76:894-901 • Lane P. et al. Geriatric Trauma patients – are they receiving trauma center care? AcadEmerg Med 2003;10:244-250.

  37. References • Mitra B. et al. Massive blood transfusions post trauma in the elderly compared to younger patients. Injury Int J Care 2014. article in press. • Pandit V. et al. Shock index predicts mortality in geriatric trauma patients: An analysis of the National Trauma Data Bank. J Trauma Acute Care Surg. 2014;76:1111-1115. • Peck K.A. et al. The impact of preinjury anticoagulants and prescription antiplatelet agents on outcomes in older patients with traumatic brain injury. J Trauma Acute Care Surg. 2014;76: 431-436. • Phillips S. et al. The failure of triage criteria to identify geriatric Patients with trauma: results from the Florida Trauma Triage Study. J Trauma. 1996;40:278-83. • Rogers A. et al. Old and Undertriaged: a lethal combination. Amer Surg. 2012: 711-15.

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