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Elderly: Minor Injury and Major Catastrophe

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Elderly: Minor Injury and Major Catastrophe

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    1. Elderly: Minor Injury and Major Catastrophe Michael J. Cahalane, MD, FACS Associate Professor of Surgery

    2. Elderly More than 13% of U.S. Population is over 65 By 2030 elderly will be 20% of the population 65 million National Hospital Discharge Survey SummaryNational Hospital Discharge Survey Summary

    3. Impact People over 65 are hospitalized for trauma at twice the rate of the general population Fifth leading cause of death in the elderly 25% of all trauma related deaths Mortality rate is ~6X greater than in younger victims One fourth of hospital expenditures for trauma

    4. Life Expectancy At age 85, 5.2 years for men 6.4 years for women

    5. Figure 1. Probability of Survival after the Age of 80 among U.S. Whites and Japanese, Swedish, French, andEnglish and Welsh Persons Born from 1885 to 1889.Figure 1. Probability of Survival after the Age of 80 among U.S. Whites and Japanese, Swedish, French, andEnglish and Welsh Persons Born from 1885 to 1889.

    6. Elderly Trauma Physiologic changes Blunted response to injury Less reserve Pathologic changes

    7. Cardiac Changes Decreased ventricular compliance progressive stiffening Degeneration in valves Fibrocalcifacation of conduction system Reduced -adrenergic response decreased receptor response rather than catecholamine production Many older patients have preexisting volume depletion diuretics and malnutrition

    8. Pulmonary Changes With Aging Decline in compliance of thorax loss of elasticity Increased lung compliance Alveolar loss decreased surface area Pseudocialiated mucosa atrophies FEV1 and VC decrease by 150ml/decade Closing volume increases V/Q mismatch occurs in the lower parts of lung Cough reflex and antibody responses diminish

    9. Renal Changes with Age Decreased glomerular filtration rate Glomeruli are lost Tubular function decline Inability to preserve volume in response to stress hormones (aldosterone, vasopressin and cortisol) Serum creatinine can be misleading in renal function assessment

    10. Changes with Aging Mouth flora change gram negatives predominate Cerebral atrophy Increased space in cranial vault Brain decreases in size ~10% between ages 30 and 70 Brain can move greater distances allowing tearing of vessels causing hematomas and intracranial bleeding in trauma Glucose intolerant, less muscle mass and nutritional reserve

    11. Changes with Ageing Immune system senesces Wound healing is slower

    12. Co-morbid Disease Fourth decade 17% Sixth decade 44% Age 75 65%

    16. Clopidrogel (Plavix) Anti-platelet agent Irreversibly inhibits P2 nucleotide receptor on platelet surface No Antidote

    17. Trauma with Clopidrogel Little evidence platelet transfusion is effective Factor VIIa has been used off label Increased mortality in elderly trauma patients with intracranial hemorrhage Risk of non-operative management may be lower

    18. Solid Organ Injury - Clopidrogel Resuscitate Immediate platelet transfusion Preemptive use of Recombinant factor VIIa Possible FFP If spleen splenectomy If liver or kidney consider angioembolization Packing damage control reassess platelet function

    19. Patterns of Injury Falling predominates Motor vehicle crashes Pedestrian struck

    21. Falling Falling is primary cause of injury over age 65 Up to 24% sustain a serious injury 70% of deaths in falls are in the elderly 1/3 of community dwelling people fall each year Nursing home falls may be 3X higher Women are twice as likely to sustain serious injury

    22. Falling in the Elderly Impaired mobility, cognition, gait, balance, and vision Often a manifestation of acute or chronic occult illness May be a side effect of medication Narcotics, antidepressants, ? blockers, calcium channel blockers, diuretics Associated with total number of medications and recent change in dose

    25. Spine Fractures Rheumatoid arthritis and DISH disseminated idiopathic hypertrophic arthropathy predispose to fracture by causing functional ankylosis Osteoporosis and osteomalacia increase risk of spine fracture with trivial injury Geriatric spine fractures: an emerging healthcare crisis. Chapman J, Bransford R J Trauma 2007 vol:62 iss:6 Suppl - Pan-scanning with reformatting reduces missed injuries

    26. Odontoid Fractures Type 2 odontoid fractures is most common type in people>70 Surgery is better than halo and vest in geriatric populations Lower mortality from pneumonia, cardiac or respiratory failure Frangen T, et al. Odontoid fractures in the elderly: dorsal C1/C2 fusion is superior to halo-vest immobilization. J Trauma. 2007 Jul;63(1):83-9.

    28. Motor Vehicle Crashes Increasing number of elderly drivers 13% in 1990 were 65 and older 4% over 75 years Drivers over 75 have a crash rate second only to those under 25 Highest rate of fatal crashes Leading mechanism bringing elderly to a trauma center

    29. Chest Trauma Rib fractures are hallmark Flail chest

    30. Rib Fracture Elderly with rib fractures have twice the mortality of younger patients Each rib fracture increases mortality by 19% and risk of pneumonia by 27% Bulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib fractures in the elderly. J Trauma. 2000;48:1040-1046 Epidural reduces mortality (16 to 4%) Wisner DH. A stepwise logistic regression analysis of factors affecting morbidity and mortality after thoracic trauma: effect of epidural analgesia. J Trauma. 1990;30:799-804

    31. Diabetes Elderly diabetics have a 2.6 times higher chance of injury than in non-diabetic elderly in crashes in a case controlled study Koepsell TD, et al Medical conditions and motor vehicle collisions in older adults J Am Geriatr Soc 42,695, 1994Koepsell TD, et al Medical conditions and motor vehicle collisions in older adults J Am Geriatr Soc 42,695, 1994

    32. Pedestrian Struck Highest population based fatality rate for pedestrians at any age Elderly over 65 account for more than 20% of vehicle-pedestrian fatalities 46% of fatalities occur within a crosswalk Standard time for crosswalks is 4 feet/second unattainable for many

    33. Assault/Domestic Abuse 4-14% of trauma admissions Mortality is higher than in younger people Stab wounds 17.3% vs.4.7% Gunshot wounds 52.1% vs. 19.5% ~2 million cases of elder abuse/neglect occur each year 2-5% of elderly population About 1 case in 14 is reported

    36. Conclusions The elderly are a special subgroup of adult trauma victims Primary prevention is most important Minor injury can result in major health catastrophe Early monitoring and aggressive care is imperative

    39. Brain Decreases in size ~10% between ages 30 and 70

    40. Mortality by ISS J Trauma. 1999 Apr;46(4):702-6. Morbidity and mortality in elderly trauma patients. Tornetta P 3rd, Mostafavi H, Riina J, Turen C, Reimer B, Levine R, Behrens F, Geller J, Ritter C, Homel P.

    41. Table 1. Five-Year Survival at Various Ages and Life Expectancy at 80 for U.S. Whites and for Japan, Sweden, France, and England for Cohorts Born in 1880-1884, 1885-1889, and 1890-1894 and for the Year 1987.Table 1. Five-Year Survival at Various Ages and Life Expectancy at 80 for U.S. Whites and for Japan, Sweden, France, and England for Cohorts Born in 1880-1884, 1885-1889, and 1890-1894 and for the Year 1987.

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