Geriatric Trauma


Article Author:
Alison Southern


Article Editor:
Sharhabeel Jwayyed


Editors In Chief:
Shivajee Nallamothu
Matthew Varacallo
Joshua Tuck


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
11/18/2018 8:00:05 PM

Introduction

Assessment of the geriatric trauma patient is unique, and this population requires special attention. As the elderly population increases, the number of geriatric trauma patients also rises. Age-related changes can make caring for geriatric patients challenging and places them at greater risk of morbidity and mortality. Geriatric patients often suffer from mild to severe cognitive impairment, cardiovascular, as well as pulmonary and other organ system insufficiency that can result in general frailty. These age-related physiologic changes often limit the geriatric patient’s response to traumatic injury and place them at high risk of complications and death compared to younger counterparts.[1][2][3]

Etiology

Falls are the most common mechanism of injury followed by motor vehicle collisions and burns. According to the Centers for Disease Control and Prevention (CDC), in 2014 alone, older Americans experienced 29 million falls causing seven million injuries and costing an estimated $31 billion in annual Medicare costs. Determination of the cause of the fall is an important element of the care plan for each patient. It is important to determine if the fall was the result of an isolated mechanical process or a result of a systemic condition that could put the patient at risk for additional falls. Factors that must be considered include the patient’s functional status prior to the fall, location and circumstances of the fall.  [4][5]

Even if a reliable mechanical cause of the fall can be established, a complete medical evaluation should be considered to evaluate for a pathological condition that caused the fall. Occult anemia, electrolyte abnormalities, disorders of glucose metabolism should be considered.[6]

Attention should be paid to the possibility of cardiovascular causes of the fall that include orthostatic hypotension, dysrhythmia and myocardial infarction. Other pathological states that can lead to falls include infection from urinary, pulmonary or soft tissue sources. Neurologic disorders such as primary or secondary seizures should be on the differential diagnosis. The role of polypharmacy and potential disruptions to normal physiologic function cannot be understated.

Epidemiology

Trauma is the fifth leading cause of death in the elderly population and accounts for up to 25% of all trauma admissions nationally.  Special considerations include multiple comorbidities, polypharmacy, decreased functional reserve, and increased morbidity and mortality, compared to younger adults. [7][8]

As the world population continues to age, geriatric traumas will continue to increase.  Mortality increases after age 70 when adjusting for injury severity score.  Pre-hospital geriatric trauma triage criteria improve identification of those needing trauma center care.

Pathophysiology

Falls result in a fracture in about 5% of casesHip and vertebral body fractures can often present in an occult fashion and can be difficult to diagnose. Due to age-related changes such as brain atrophy, serious intracranial injuries such as subdural hematoma may present subtly and can be overlooked due to mild baseline cognitive dysfunction or other more obvious injuries. Intracranial hemorrhage is more likely in patients taking antiplatelet or anticoagulant medications than in those who do not.

History and Physical

Using all resources available for information gathering is important. Knowledge of the patient’s baseline mental status can be crucial to identifying serious injury. Often vital signs appear normal until the patient deteriorates rapidly. Blood pressure and pulse may mislead and be altered by polypharmacy. Comorbid conditions must be taken into consideration. Following assessment of airway, breathing, and circulation, the physician should perform a complete head to toe physical examination of the patient.

Evaluation

Advanced Trauma Life Support protocols should be followed during the initial evaluation of the geriatric trauma patient. A complete geriatric assessment should be pursued, including medical, cognitive, functional, and social assessments. Due to the possibility of subtle pathological disease states or occult injury, a thorough evaluation should be considered even if a reliable history of a mechanical fall can be established.[9][10]

Treatment / Management

Based on the history and physical exam coupled with risk factor assessment, general screening labs such as complete blood count, comprehensive metabolic panel, EKG, urinalysis (UA), and radiographic studies should be considered. Central nervous system imaging should be considered in patients who are taking antiplatelet or anticoagulant medications and have an appropriate history and mechanism.  [11][12][13]

Patients on anticoagulants found to have a significant intracranial hemorrhage require aggressive management. Reversal of the anticoagulant must be achieved rapidly.

The new oral anticoagulants such as dabigatran (Pradaxa), apixaban (Eliquis), and rivaroxaban (Xarelto) are indicated for a variety of clinical conditions that affect the elderly. These include treatment of venous thromboembolism, stroke prophylaxis in non-valvular atrial fibrillation, and acute coronary syndrome. The new oral anticoagulants have a different mechanism of action than warfarin (Coumadin) acting to inhibit Xa and Thrombin IIa in the coagulation cascade. Reversal of the anticoagulation caused by new oral anticoagulants is different then anticoagulation caused by warfarin. Only dabigatran has a direct reversal agent idarucizumab (Praxbind). Several other targeted antidote reversal agents are in development.

Reversal of anticoagulation caused by warfarin historically relied on the use of vitamin K and fresh frozen plasma (FFP). Recent literature suggests relying on vitamin K and FFP might be less effective than the use of vitamin K and prothrombin complex concentrates.  Vitamin K and fresh frozen plasma (FFP) therapy often require 30 min to 60 min to thaw the FFP. Further, large volumes of FFP in the range of 30 cc/kg (4 to 12 units) are often required for adequate reversal. The time to infuse the necessary volume of FFP can complicate care.  Treatment with vitamin K and prothrombin complex concentrates avoids these limitations. Prothrombin complex concentrates do not require blood group system (ABO) compatibility testing and infusion volumes are less than 100 cc.

Reversal of the anticoagulation caused by warfarin or new oral anticoagulants should be based on current institution-specific guidelines that are under constant revision.

Understanding the need for a thorough evaluation and aggressive resuscitation of the injured geriatric patient is instrumental in improving outcomes.

Pearls and Other Issues

Undertriage of geriatric trauma patients at risk for moderate to severe injury is a major problem and often begins during the pre-hospital assessment. Studies have shown that patients treated at a trauma center have improved outcomesOther studies found that compared with younger patients with similar injury severity scores (ISS) patients over 70 had a three-fold increase in mortalityBased on these and other studies, the American College of Surgeons’ triage criteria suggests patients age 55 years and above be considered for transport to a trauma center to receive their care. Also, geriatric trauma criteria have been implemented at the state level to address undertriage.

These criteria help identify patients who would be more appropriately transported to a trauma center. Data on the use of geriatric trauma criteria suggest overall outcomes have improved.  Pre-hospital providers must maintain a high clinical suspicion for serious injury, regardless of mechanism of injury.

Elder abuse is under-reported, and the incidence is rising. The prevalence of elder abuse in the United States is estimated to be about 10%. It can present in many ways, for example, physical, emotional, financial, sexual, and neglect. Physicians should maintain a high level of suspicion to identify those at risk. Those in immediate danger should be hospitalized.

Enhancing Healthcare Team Outcomes

Geriatric trauma is on the rise and often presents in sinister ways. Because of advanced age, a decline in organ function and limited reserve, geriatric patients are more likely to die compared to younger people when sustaining the same type of trauma. Thus, assessment and treatment of the geriatric trauma patient must be conducted by taking into consideration of their unique physiology and associated co-morbidity. Because geriatric trauma can have diverse presentations, a multidisciplinary approach is necessary. Often geriatric abuse can present with somatic and neuropsychiatric features, and the key is to be aware of this pathology. The majority of geriatric patients can heal after trauma, but the healing period is long. Many often remain in the hospital for prolonged periods and even when discharged tend to have a residual loss in function. As the care of the geriatric trauma patient improves, it is hoped that the morbidity and mortality will also decrease. Meanwhile, the onus is on healthcare workers to recognize early signs of injury in this very vulnerable population.[14][15][16]


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Geriatric Trauma - Questions

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Which of the following statements is false about elderly trauma patients?



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Which of the following statements is true about trauma in elderly patients?



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Why do geriatric patients involved in trauma have a higher mortality than younger patients?



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Polypharmacy is an important consideration in the geriatric trauma patient evaluation. Which of the following is true regarding the use of new oral anticoagulants?



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A 72-year-old woman is brought to the emergency department by paramedics after she suffered a fall. Paramedics found the patient to be alert, unable to walk complaining of right arm and leg pain. There were no gross abnormalities on physical exam. Her vital signs were reported to be in the normal range. On arrival to the emergency department, the patient was complaining bitterly of right shoulder and hip pain. She was awake and alert, could not provide any specific information about the fall. She could not provide any information about her past medical history other then she had a “heart condition” and took “a lot of medications.” Her vital signs were blood pressure 105/75 mmHg, heart rate 115 bpm, respiratory rate 18/min, temperature 98.0 F, and oxygen saturation 96%. Physical exam revealed a female in moderate distress complaining of pain in her right arm and hip. She was alert and oriented to person and place only. Her primary survey revealed the ABCs were all intact. An IV, morphine 6 mg, 4mg ondansetron, x-ray of right shoulder and hip were ordered. After the patient had been medicated, she was sent to radiology for her x-rays. When she returned, she was more somnolent, but still, alert. X-rays revealed a fracture of the proximal humerus and a fracture of the femoral neck. Screening admission labs and Foley catheter were ordered. When the nurse returned to the room, the patient was found to be moaning and unresponsive to verbal commands, her Glasgow coma scale (GCS) was approximately 10. What is the next step in her treatment?



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Geriatric Trauma - References

References

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Hecht G,Slee CA,Goodell PB,Taylor SL,Wolinsky PR, Predictive Modeling for Geriatric Hip Fracture Patients: Early Surgery and Delirium Have the Largest Influence on Length of Stay. The Journal of the American Academy of Orthopaedic Surgeons. 2018 Oct 24     [PubMed]
Hamidi M,Zeeshan M,O'Keeffe T,Nisbet B,Northcutt A,Nikolich-Zugich J,Khan M,Kulvatunyou N,Fain M,Joseph B, Prospective evaluation of frailty and functional independence in older adult trauma patients. American journal of surgery. 2018 Oct 16     [PubMed]
Pan PJ,Lin PH,Tang GJ,Lan TY, Comparisons of mortality and rehospitalization between hip-fractured elderly with outpatient rehabilitation and those without: A STROBE-compliant article. Medicine. 2018 May     [PubMed]
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Dreinhöfer KE,Mitchell PJ,Bégué T,Cooper C,Costa ML,Falaschi P,Hertz K,Marsh D,Maggi S,Nana A,Palm H,Speerin R,Magaziner J, A global call to action to improve the care of people with fragility fractures. Injury. 2018 Aug     [PubMed]
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McGibbon CA,Slayter JT,Yetman L,McCollum A,McCloskey R,Gionet SG,Oakley H,Jarrett P, An Analysis of Falls and Those who Fall in a Chronic Care Facility. Journal of the American Medical Directors Association. 2018 Aug 11     [PubMed]

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