CONSIDERATIONS AND PITFALLS IN GERIATRIC TRAUMA

1. CONSIDERATIONS AND PITFALLS IN GERIATRIC TRAUMA Carlos A. Barba, MD, FRCSC, FACS

2. INTRODUCTION • In last 30 years • Population increase 39% • > 65 y.o grew by 89% • > 85 y.o grew by 232% • 2000 = 35 million • 2030 = 65 million

3. INTRODUCTION • Debate regarding who is consider “old” • “young-old” = over 65 • “old-old” = over 80 • People live longer, healthier and more active • Activity, mechanized society and changes with age = greater risk injury in elderly

4. CONSIDERATIONS PHYSIOLOGIC EFFECTS OF AGING • Stiffening of myocardium • Decrease in pulmonary compliance • Atrophic mucosa = decrease clearance sputum • Loss renal reserve (creatinine clearance) • Brain atrophy • Decrease senses: vision and hearing • Muscle mass, immune system, glc intol.

5. CONSIDERATIONSMECHANISMS OF INJURY • Falls are most common • Decrease in senses, postural stability(age or from other events) • 70% all deaths in geriatric • syncope as cause should be investigated • cardiac, CVA, metabolic, anemia, psychogenic • consultation to specialists may be necessary

6. CONSIDERATIONSMECHANISM OF INJURY • MVA follows • Only newest drivers higher rate • more accidents per mile, despite less driving • more accidents in daytime or good weather • Decrease vision, hearing and longer reaction • Pedestrian • Highest mortality • 46% in designated crossing areas

7. CONSIDERATIONSMECHANISM OF INJURY • SW and GSW follow pedestrian • Elderly abuse is seen more frequent • When compared to younger population • Worst outcome for given ISS • In all mechanisms, all body regions • Outcome worse by up 89% • Physiologic scores are poor predictors outcome except GCS

8. TRAUMA AND COMORBID DISEASE • Prevalence 4th decade is 17% • Sixth decade = 40% and 69% by 75 y.o. • Presence of these have significant impact in assessment and management • Priorities are the same, but stressing response present

9. TRAUMA AND COMORBID DISEASE • Some specifics: • B-Blockers may mask tachycardia of hypovolemia • Ischemic heart disease may worsen with tachycardia • Epidural catheters and respiratory therapy for patient with pulmonary disease

10. TRAUMA AND COMORBID DISEASE • Difficult to quantify the comorbid disease and severity • Most studies associated comorbid disease with high mortality • Renal and malignancy have the highest • Also increase mortality when number of comorbid problems increase

11. PITFALLS IN MANAGEMENT • Pre-Hospital and initial resuscitation follows PHTLS and ATLS guidelines • When checking airway remove and check for dental prosthesis during EMS • Cervical spine protection indicated • If times permit information and clues regarding comorbid problems

12. PITFALLS • During primary survey a clinically stable patient may be in cardiogenic shock • Some have recommended early and aggressive invasive monitoring in ICU setting • Rely more in pre-hospital history and mechanism of injury • Overresuscitation may be as morbid as underresuscitation

13. PITFALLS • Evidence that age 40 could be reasonable to consider liberal use of hemodynamic monitoring • Especially if major injury, significant comorbidity or conflicting results after resuscitation • Men have worst outcome than women • Usually highest ISS

14. SPECIFIC SITES OF INJURY • Head injury • Higher mortality and poorer functional outcomes • Because lost 10% of weight, subtle presentations when bleed present • Subdural more common • Liberal use of CT scan

15. Sites of Injury (Cont) • Chest • Minor injuries could lead to significant complications • Continuos use of pulse oxymetry and ABG’s • Abdominal • Intolerant to hypovolemia and shock • Early surgical consider for significant hemorrhage

16. Sites of Injury (Cont) • Spinal • Degenerative changes makes it difficult • Upper cervical (odontoid) are frequent • Central cord injury is more common • Musculoskeletal • Most common system injured • Humerus in 30% UE,distal radius is most common

17. Sites of Injury (Cont) • Hip fractures are a leading cause of death among elderly (13-30% in first year) • Skin and soft tissues • Atrophic, decrease protection • Increase wound infection • 70% tetanus • Baux Index in burns (Mortality = Age plus % TBSA burned)

18. FUNCTIONAL OUTCOME • Controversial reports • Recently over 50% of discharged patients return to independence • Suggestion that the same for “old-old” • More research is necessary

19. COST OF TRAUMA CARE IN THE ELDERLY • Known that elderly consume more dollars after injury • >65 consumed 25% cost for injured patients but only 12% hospitalized trauma population • Longer hospital stays and greater need for intensive care • Comorbidity increases length of stay

20. PITFALLS IN TRAUMA CARE FOR THE ELDERLY • No specific triage criteria for transport and elderly victim to trauma center • ACS recommend >55 consider for trauma center triage • In theory, outcome should be better • Prevention seems to be very important • Secondary prevention after injury when cognitive impairment apparent

21. ETHICAL AND SOCIAL IMPLICATIONS • Challenge in this population • Communication about advance directives, quality of life and impact of trauma in life style are mandatory • Withdrawal of support in over 13% and reflects humane medical care • Early aggressive management adequate until clear picture evident

22. CONCLUSIONS • Incidence will increase • Important to know effects of aging • Mortality is higher with age, comorbid diseases and ISS • Triage to trauma centers those with high index suspicion • High index of suspicion even if stable

23. CONCLUSIONS • Early aggressive resuscitation, diagnosis and treatment warranted • Wait until clear clinical picture • Humane and dignified approach if futility • Still needed • Functional outcome studies, more effective resuscitation and management protocols