1 / 42

Geriatric Trauma: Beyond “ I’ve Fallen & Can’t Get Up!”

Geriatric Trauma: Beyond “ I’ve Fallen & Can’t Get Up!”. Amy Gutman MD ~ EMS Medical Director prehospitalmd@gmail.com / www.TEAEMS.com. Overview. Epidemiology Pathophysiology Mechanisms of Injury Assessment & Management Strategies Conclusions.

chiku
Download Presentation

Geriatric Trauma: Beyond “ I’ve Fallen & Can’t Get Up!”

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Geriatric Trauma:Beyond “I’ve Fallen & Can’t Get Up!” Amy Gutman MD ~ EMS Medical Director prehospitalmd@gmail.com / www.TEAEMS.com

  2. Overview • Epidemiology • Pathophysiology • Mechanisms of Injury • Assessment & Management Strategies • Conclusions “The more you complain, the longer God lets you live” Unknown

  3. Geriatric Patients • EMT-B class = 150 hrs • EMT-P class = 1200 hrs • Geriatrics hours = 6 • 30-40% all EMS calls with a large percentage being ALS • Anatomically, sociologically & physiologically a “special” population “The secret of staying young is to live honestly, eat slowly, & lie about your age” ~ Lucille Ball

  4. Defining “Geriatric” • Person >65 yo • Chronologic age = actual age • Physiologic age = functional capacity • US life expectancy 2010 • Male: 75.4 yrs • Female: 80.5 yrs • 15% US population • >85yo fastest growing population • By 2030, 25% population >65yo • Better living conditions, healthcare, medications & technology “You're only young once, but you can be immature forever” ~ John Greier

  5. Geriatric Trauma Etiology • 7th leading cause of death in the elderly • 10-14% trauma patients >65yo • 25% trauma admissions • 28% accidental deaths • Enormous resource & financial burden • $20 billion annually • 33% trauma dollars • Trauma costs 3x greater compared younger persons • Injuries disproportionately severe • Mortality, morbidity, length of stay higher than younger patients with similar injuries • For each year >65, 10% increased chance of a trauma-related death “If I were younger, I'd know more” ~James Barrie

  6. High Injury Risk • Normal aging & deterioration • Narrow physiologic tolerances • Decreased reaction time • Decreased eyesight & hearing • Postural instability • Fragile bones & vasculature “Old age is like everything else. To make a success of it, you've got to start young” ~Fred Astaire Trauma in Elderly - 6

  7. Polypharmacy & Trauma • 80% on meds likely contributing to injury • Adverse events exponentially rise with number of drugs • 4% if 5 drugs • 10% if 6-10 drugs • 28% if 11-15 drugs • 54% if >16 • Common interactions • Anticoagulants & anti-platelets increase bleeding time • Anti-hypertensives & vasodilators limit vasoconstriction • Beta-blockers limit O2 demand response “It is not the years in your life, but the life in your years that counts” ~Adlai Stevenson

  8. Impact of Co-Morbidities • Complication rate triples if one co-morbid illness • Oreskovich’s study on geriatric trauma outcomes: • 100 geriatric trauma pts • 96% independent pre-injury • 88% did NOT return to independence • 72% required NH placement “I am not young enough to know everything” ~Oscar Wilde

  9. Geriatric Trauma Outcomes *p<0.001 “Grow old along with me! The best is yet to be” ~Robert Browning

  10. Assessment Strategies • Speak slowly, directly & respectfully • Never “Sweetie”, “Honey”, “Pops” • Eye level in middle of visual field • Utilize family / care-givers but do not diminish patient’s contribution • Ask specific questions as patient may not volunteer information • Protect modesty & body temperature • Transport: • Medications • Glasses / hearing aids / dentures • All important paperwork (i.e. MOLST) “Like our shadows, our wishes lengthen as our sun declines” ~Edward Young

  11. Assessment ~ Safety • If fall “mechanical”, consider pre-quels • Co-morbidities often causal • May not know / confabulate inciting event • Safety assessment may assist with MOI • Living conditions? • Stairs? • Medications & compliance? • Ambulation assists? • Fall hazards? • Driving safety? • Often reluctant to provide information • Loss of autonomy & independence • Separation from family • Hospitalization “The old believe everything, the middle-aged suspect everything, the young know everything“ O. Wilde

  12. Assessment: Primary & Secondary Surveys • Primary Survey • Key: Vitals often unreliable! • A: Aggressive airway management Low intubation threshold Modified spinal immobilization • B: Supplemental O2 with chest / abdominal trauma • C: “Normal” BP may indicate hypotension / shock • Secondary Survey • Keys: Exam often underestimates injury Pain response, hypoxia, hypovolemia varies Pre-morbid illnesses complicate assessment "When you are older you will know that life is a long lesson in humility“ ~James Barrie

  13. Mechanisms of Injury

  14. MVC Epidemiology • 26 million+ geriatric drivers • Falls #1 morbidity but MVCs #1 trauma-related mortality • 2nd highest fatal crash rate • 21% overall fatality rate • 7x more likely to be hospitalized or killed than younger patients • In collisions, 80% geriatric drivers found to be at fault “Just remember, once you're over the hill you begin to pick up speed” ~Charles Schultz

  15. MVCMOI • “Why did this driver crash?” • 20% syncope • 13% intoxicated • Less likely ETOH / high speeds than younger drivers • Unrestrained (83%) • Daytime (81%) • 2 cars (75%) • Weekdays (72%) • Intersection / near home (50%) • Making left turn (20%) “Youth is the time for adventures of the body, but age for the triumphs of the mind” ~Logan Smith

  16. Auto vs Pedestrian • Geriatrics > any other age group (even pediatrics) • 46% at crosswalks • Average crosswalk gait 4ft/s • Average elderly gait 3 ft/s • Typical MOI • Head down • Rushing even if unsteady • Often it near curb • 25% mortality if >65 yo • TBI • Vascular injuries • Thoraco-abdominal, including pelvic & rib fractures “Old age comes at a bad time” ~Unknown

  17. Homicide / Suicide • 2002: 852 geriatric homicides • Easy target • Home invasions • Elder abuse • 70% GSWs self-inflicted • Depression • Chronic illnesses • Suicide-Homicide “pacts” • 10% GSWs accidental “Youth is the gift of nature, but age is a work of art” ~Garson Kanin

  18. Elder Abuse • Less recognized / reported than child or spousal abuse • 5,000 - 250,000+ cases annually • 32:1000 elderly • Risk factors for victim • Female > age 80 • Dementia • Dependence on abuser • Risk factors for abuser • Spouse of children of the abused • Financial dependence on victim • Substance abuse • Prior history of violence “Old age isn’t so bad when you consider the alternative” ~Maurice Chevalier

  19. Elder Abuse Assessment • Multiple bruises in various states of healing • Unexplained or untreated injuries w/ inconsistent stories • Dehydration / malnutrition • Bedsores • Mandatory & confidential reporting to adult protective services / police “Beautiful young people are accidents of nature, but beautiful old people are works of art” E. Roosevelt

  20. Falls • M=F; females more likely injured • Always ask about the “pre-quel” • Postural instability • Impaired vision & hearing • Decreased reaction time • Medications • Inciting medical event • High injury risk with fall from standing height • TBI • Rib / Hip fractures • “Special Consideration” in Trauma Triage as high risk of cervical injuries with falls from standing height “It is always in season for old men to learn” ~Aesculepius

  21. Falls • 40% geriatric trauma • 35% >65yo, 50% >80yo fall annually • In 2005 falls led to: • 160,000 deaths • 1.8 million ED visits • 433,000 hospitalizations • MCC of trauma morbidity • 25% sustain “serious injury” • 50% pts discharged to rehab / NHs • 20% fatal falls occur while in NHs • Fall injuries cost $53 million / year “You don't stop laughing because you grow old. You grow old because you stop laughing” ~M Pritchard

  22. Cardiovascular Pathophysiology • Decreased cardiac reserves • Limited increases in SV & CO • Decreased catecholamine response • Decreased valve efficiency • Hypovolemia = hypoperfusion • Lactic acidosis & shock without classic signs of shock • Decreased arterial compliance with increased arteriosclerosis • Baseline HTN, PVD • Conduction system degenerates • Arrhythmias “As the arteries grow hard, the heart grows soft” ~HL Mencken

  23. Cardiovascular Pathophysiology • “Pre-quel” cardiac events • Limited ability to increase SV, HR & CO to combat hypovolemia • Increased O2 demand from cardiac stress not tolerated well • Ischemia • Worsening CO • Cardiovascular collapse • “Normal” BP if on antihypertensives = shock “To me, old age is always fifteen years older than I am” ~Bernard Baruch

  24. Neurological Pathophysiology • Altered mentation increases with age due to atrophy, co-morbidities • Alterations impede assessments • Dementia / memory impairments • Vision, hearing, speech • Don’t mistake “deaf” with “dumb! • Difficult determining “normal” if no family, friends or caretakers “How old would you be if you didn't know what old was?” ~Satchel Paige

  25. Neurology: Subdural Hematoma • SDH most common TBI • Often minor or “forgotten” trauma • Bridging veins tear causing blood to accumulate between dural & arachnoid spaces • Atrophy leaves large space for blood accumulation, delaying symptom onset • Mortality • Adult 4-8%; geriatric 15-30% • Mortality 90% if anticoagulated + GCS<8 • Dementia increases mortality risk “There are 3 signs of old age. The 1st is your loss of memory & the other 2….” Unknown

  26. C-Spine Injuries • Fall from standing height, minor trauma • May involve >1 level • Often unstable & associated with TBI • 25% mortality • No prehospital “clearance” • >65 yo “high risk” (Canadian C Spine & NEXUS criteria) • Low risk mechanisms = 24% fx rate • Decreased pain sensation • Central cord syndrome • Stenosis, spondylosis + hyperextension • UE >LE symptoms • Osteoporosis & Osteoarthritis • Narrow spinal canal can cause cord injury s/o fracture “I have everything I had 20 years ago, only it’s all a little bit lower” ~Gypsy Rose Lee

  27. Pulmonary Pathophysiology • Decreased chest wall strength & compliance • Kyphosis / Lordosis • Weak musculature • Decreased pulmonary circulation with underlying lung disease • Increased inhalation time, residual capacity & tidal volume • Decreased alveolar surface area, number of alveoli & O2 exchange • Rapid progression to respiratory failure with minimal hypoxia “You can live to 100 if you give up all the things that make you want to live to 100” ~Woody Allen

  28. Chest Trauma / Rib Fractures • Common with minor trauma • Any rib fracture doubles morbidity & mortality • Co-existing injuries • Prolonged ICU stay • 31% pneumonia rate • Bergeron’s study on geriatric trauma pts with rib fractures • Mean hospital stay 27 days • 30% mechanically ventilated • 5 X mortality rate than younger pts “Old Age: First you forget names, then you forget faces, then you forget to pull your zipper up, then you forget to pull your zipper down” Leo Rosenberg

  29. Thoraco-Abdominal Trauma • Minimal trauma required to produce injury (ie. seat-belts) • Exam often unreliable, vitals misleading • 4-5x higher morbidity than younger patients with same injuries • Pelvic fractures • 30% mortality within 1st 72 hrs • Often lateral compression injuries w/ arterial hemorrhage “Life is what we make it; always has been, always will be” Grandma Moses

  30. Renal Pathophysiology • By age 65 lose 40% glomeruli • Diminished renal blood flow • Less effective toxin filtration • Chronic dehydration from decreased total body water • Hypotension leads to renal failure • Micturition syncope common “Age is strictly a case of mind over matter. If you don’t mind then it doesn’t matter” Jack Benny

  31. Endocrine Pathophysiology • Caloric requirements decrease with age, but “nutrient” demands remain constant • Glucose intolerance & diabetes increase • Hyperglycemia associated with worse outcome in medical / trauma patients • High risk of infection / sepsis • Malnutrition • Sepsis with “mild” infection (decreased immune response) • Often afebrile or hypothermic • Minimal reserves to fight infection “Old age is no place for sissies” ~Bette Davis

  32. Hypothermia • 75% of injured geriatrics • Hemorrhage leads to hypotension then hypothermia • Impaired thermoregulation • Decreased sub-q tissue • Severe complications • Arrhythmias • Coagulopathies • Increased mortality “As one grows older, one becomes wiser and more foolish” ~François Duc

  33. Integument Pathophysiology • Thin skin, decreased collagen & sub-q fat • Easily tears & bruises • 20 mins on a backboard begins pressure ulceration • Decreased immune response & capacity for wound healing • Decreased collagen • Less microorganism protection • Abnormal clotting • Tetanus often out-of-date “Middle age is when your age starts to show around your middle” ~Bob Hope

  34. Burn Pathophysiology • 4% geriatric trauma-related deaths • 13% of all burn unit admissions • 50% in-hospital mortality • “Burn mortality” is burn percentage causing 50% mortality • Adults = 50% if 80% TBSA burned • 60-70yo = 50% if 35% TBSA burned • >70yo = 50% if 20% TBSA burned “The only source of knowledge is experience” ~Albert Einstein

  35. Musculoskeletal Pathophysiology • Postural changes • Kyphosis • Spinal stenosis • Decreased spinal flexibility • Increased knee & hip flexion • Decreased muscle strength • High risk of compression fractures with minor trauma • Osteoporosis & arthritis • Decreased bone density • Decreased fatty tissue “Inside every older person is a younger person wondering what the hell happened” ~Jennifer Yane Trauma in Elderly - 35

  36. “Hip” Fractures • Often proximal femur / femoral neck fractures • Suspect all previously ambulatory patient who can no longer walk due to pain • Associated with abdominal / pelvic injury • High mortality: • 14% at 30 days • 35% at 1 year • 40% require rehab / NH placement “I intend to live forever, or die trying” ~Groucho Marx

  37. Management Strategies • Key: Prevention of early & late complications • Appropriate fluid resuscitation • Avoid low-flow states • Serial cardiopulmonary exams • Lung sounds • Cardiac monitoring • Pulse oximetry • Capnography • Multiple studies demonstrate under-triage of geriatric patients to trauma centers “Aging is not lost youth but a new stage of opportunity and strength” Betty Friedan

  38. Geriatric Trauma Triage • Consider trauma center 1st line destination • If >80 yo, trauma center mortality 8% vs 56% in non-trauma centers • Recognize high risk injury patterns • Falls + AMS • Falls + inability to ambulate • Thoraco-abdominal • Pelvic or femur • Trauma + SBP <100 mmHg “Old age is the most unexpected of all the things that happen to a man” ~Trotsky

  39. Airway Management • Early & aggressive • Limited cardio-pulmonary reserves • Limited ability to open mouth & move neck • Kyphosis & arthritis • Sedation can induce apnea • CPAP is great adjunct, but patients at higher risk for barotrauma / pneumothorax “You're getting old when all the names in your black book have MD after them” ~Arnold Palmer

  40. >70yo triaged to trauma center for: GCS <15 + TBI Falls + evidence of TBI (even from standing position) SBP <100 mmHg Pedestrian struck Multisystem trauma Suspected proximal long bone fracture post-MVC Consider Trauma Center Triage if: COPD CAD / CVD Clotting disorder Warfarin therapy Diabetes Dialysis Immunocompromised Liver Disease Ohio Geriatric Trauma Triage (National Standard of Care) “I was taught to respect my elders; I’ve now reached the age when I don't have anybody to respect” ~ George Burns

  41. References • Ohio State Board of EMS Trauma Committee; 2008 • Brady Textbook of ITLS; 2004 • Bourn. “The “2 P’s” of Geriatric Trauma”. 2008 • Holland. “Geriatric Falls & Trauma”; 2009 • Fowler. OSU Department of EM • CDC MMRW “Life Expectancy”; 2010 • Antonenko. UND Department of Surgery; 2005 • Bulger. Harborview Medical Center; 2004 • NHTSA “Walking Through the Years”; 2008 • AARP “Older Adult Pedestrian Safety”; 2009 • Richmond. Louisville FD; 2007 • Barishansky. “Understanding Our Geriatric Pts”; 2009 • Rosen. “Geriatric Trauma”. EM 6th Ed; 2008 • Aschkenasy. “Trauma & Falls in the Elderly”. EM Clinics of North America; 2006 • www.emsresponder.com. “Geriatric Trauma”. 2008 • EAST. “Practice Management Guidelines for Geriatric Trauma”. 2009 • Blanda. “Geriatric Trauma: Current Problems, Future Directions”; Summa Health Systems; 2007 • Victorino. “Trauma in the Elderly Pt”. Arch Surg; 2003 • Perdue. “Geriatric Trauma”. J.Trauma; 1998 • Touger. “Geriatric Trauma”. An EM; 2002 • McKinley. “Geriatric Trauma”; Arch Surg; 2000 • Steill. “Canadian C-Spine Rule vs NEXUS Low-Risk Criteria in Patients with Trauma”. NEJM; 2003 “When men reach their sixties and retire they go to pieces. Women just go right on cooking” Gail Sheehy

  42. SUMMARYprehospitalmd@gmail.com / www.TEAEMS.com • Injury “pre-quels” & MOI • Vitals & physical exam may underestimate injury • Increased complications, mortality & length of stay compared to younger pts • Tremendous financial burden, often with poor outcomes • Consider “over-&-early” triage to a trauma center “Age and treachery will triumph over youth and skill” Anonymous

More Related