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Geriatric Trauma Resuscitation

Geriatric Trauma Resuscitation. Kevin L. Ferguson MD FACEP Clinical Assistant Professor of Emergency Medicine University of Florida Gainesville, Florida. Geriatric Population. 12.5 % of population age > 65 (1990) 28% of all deaths by trauma Estimated at 35 Million in 1995

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Geriatric Trauma Resuscitation

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  1. Geriatric Trauma Resuscitation Kevin L. Ferguson MD FACEP Clinical Assistant Professor of Emergency Medicine University of Florida Gainesville, Florida

  2. Geriatric Population • 12.5 % of population age > 65 (1990) • 28% of all deaths by trauma • Estimated at 35 Million in 1995 • Estimated to be 52 M by 2020 • Anticipated increased participation in activities likely to incur injury

  3. Demographics • Analysis of EMS dispatch activity of 1154 patients, 70+ year old, over one year in Tucson, AZ • 65.1% women; 34.9 % men • 53.1% 70-79; 39.3% 80-89; 7.6% 90+ • Involved in 21.9% of all 911 calls • EMS use rate 83.8/1000 vs... 42/1000 for younger patients Spaite DW, Criss EA, Valenzuela TD, et al Ann Emerg Med Dec... 1990;19:1418-1421

  4. Mechanisms of Injury • Fall 60.7% 78.9% on level surface,10% med. etiol • MVA 21.5% 71.8% > 2 vehicles • Fight 2.4% • Acc. poison 2.3% • Choking 2.1% • Self inflicted inj 1.7% includes ingestions • Assault 0.7% • Misc.. 8.6% Drowning, MCA, burns etc.. Spaite DW, Criss EA, Valenzuela TD, et al Ann Emerg Med Dec.. 1990;19:1418-1421

  5. Patterns of Injury • Head/Face 25.1% • Upper Extremity 17.2% • Hip 14.5% • Lower Extremity 13.8% • Spine 9.8% More in MVA’s • Chest/Abd 5.0% Spaite DW, Criss EA, Valenzuela TD, et al Ann Emerg Med Dec.. 1990;19:1418-1421

  6. Pre-existing Co-morbid factors • Age 70.5 yr. range 60-91 • Sex 58% male 42% female • Prior Medical Illness: • Pulmonary 15% • Cardiac 46% • Renal 1% • Diabetes Mellitus 11% • Other 57% Shapiro, Bartlett et al:Am Surgeon 60(9):695-8 Sept 1994

  7. Case Control Study of Major Trauma in Geriatric Patients • Data from Major Trauma Outcome Study (MTOS) by ACS • Analysis of 46,613 major trauma patients admitted to 120 Trauma Centers over 4 years • included age, mechanism of injury, outcome, length of stay, complications vitals signs, Glasgow coma score, Trauma Score, AIS, and H-ICD-9CM codes • Data used to establish age-dependent mortality rates

  8. MTOS Methods • More detailed analysis of Washington Hospital Center (WHC) n=4,098 • included DRG’s costs, charges • autopsy records analyzed for unknown pre-existing disease • Trauma research records • Resuscitation chart reviews • Hospital chart review

  9. MTOS Results • “...at any ISS level, survival is lower for the older than for younger patients” • older non-survivors had a mean TS 3 points higher that younger nonsurvivors • “...older patients with a TS > 13 had a mortality 10 times higher than the corresponding group of younger patients...(those) who appear to have a good prognosis are much more likely to die.”

  10. MTOS Results • Older patients with a good TS derived prognosis may in fact have poor outcomes. • 2/3 elderly nonsurvivors arrived with a SBP > 90 compared to only 28% of young nonsurvivors • Autopsy revealed 30% with “substantial” coronary artery disease (% occult?) • Average hospital stay was twice as long for elderly vs.. younger group

  11. MTOS Summary & ConclusionsBeware the STABLEelderly patient • Overall mortality of older patients is 89% greater than younger patients • Mortality has a high incidence of associated head injury • ISS, when adjusted for age, is a good predictor of mortality • Apparently well older trauma patients with TS >13 or SBP >90 has a significant chance of death

  12. MOI Frequency and Mortality  65 < 65 % rel freq. /mortality % rel freq./mortality • Fall 40.6/11.7 11.0/6.0 • MVA 28.2/20.7 33.5/9.6 • Auto v Ped 10/32.6 7.9/13.5 • Stab Wound 2.6/17.3 11.9/4.7 • GSW 5.5/52.1 13.0/19.5 • MCA 0.4/11.8 7.7/11.9 Champion, Copes Buyer et al Am J Pub Health 1989;79:1278-1282

  13. Elderly vs. Youth Mortality • Young patient who die are more obviously sick at presentation < 65 65 • Emergent intubation 40% 6% • Present in shock 88% 41% • ISS 31 19.2 • TS 7.7 11.8 Osler, Hales, Baack et al;Am J Surg 156:537 Dec.. 1988

  14. Elderly Death v Survival • Prob. of fatal outcome increases linearly with age by 1% per year over 65 • Factors associated with poor prognosis • Severe head injury-GCS • Hypotension • prolonged ventilation • pneumonia • Early, cardiac function limits survival in elderly Osler, Hales, Baack et al;Am J Surg 156:537 Dec.. 1988

  15. Hemodynamic MonitoringScalea, Simon, et al • Compared survival rates in geriatric multiple trauma when resuscitation was monitored early vs. delayed by non-emergent testing. • 1986 mean time to HD monitoring, 5.5 hours- Mortality 93% • 1987 mean time 2.2 hours-Mortality 47%

  16. Hemodynamic MonitoringScalea, Simon, et al • 1985- 60 patients mean age 72.3 • Risk Factors for death-Auto v Ped, diffuse trauma, initial SBP < 130, Acidosis, Multiple long bone Fx, Head injury • All 11 with multiple Fx & all with acidosis died • Overall mortality 27/60 44% • 17/27 died after 4 days most of MOF (MODS) • Patients with any 1 Risk factor 85% mortality

  17. Hemodynamic MonitoringScalea, Simon, et al • 1986- Invasive monitoring patients w/ risk factor • 15 patients divided by HD characteristics I & II • Group I (n=8)-Q < 3.5 L/min., no response to fluids, Tx with inotropes, all died of cardiogenic shock < 24hrs. 3 had nl BP & pulse just prior to arrest

  18. Hemodynamic MonitoringScalea, Simon, et al • Group II (n=7)- Q > 3.5 mean 4.2L/m but 5/7 had SvO2 < 60; 5/7 required inotropes, all had increased Q, and SvO2 • Optimization occurred 12-18 hours post admission • 1 SURVIVED ICU • 6 died of MODS, mean LOS 24.6 days

  19. Hemodynamic MonitoringScalea, Simon, et al • 1987- 30 patients Tx with early HD monitoring. Non-emergent tests delayed • C-spine, CXR, Pelvis, • Airway management, IV’s,NGT, foley, Chest tubes • Delay CT head for H/O LOC but awake • Splint possible Fx’s if closed delay x-ray • DPL in ICU while monitoring lines placed

  20. Hemodynamic MonitoringScalea, Simon, et al • Group A-(n=13) Q < 3.5L/m • 3 non-responders all died of cardiogenic shock, • 3 responded but died of MODS, • 1 responded, went to OR for 10hrs, back to ICU w/ Q= 3.5, responded again but developed MODS & Died • 6 augmented to mean Q of 6.9 L/m and ALL survived

  21. Hemodynamic MonitoringScalea, Simon, et al • Group B-(n=8) Q 3.8 - 5.2 L/m but Sx hypoperfusion • 2 responded to volume, 6 to inotropes with a mean Q = 6.8 L/m, SvO2 corrected in all • 3 patients with severe head injuries died @ 4-8 wks • 1 patient died of unknown cardiac arrest @ 3wks • 4 survived to discharge

  22. Hemodynamic MonitoringScalea, Simon, et al • Group C-(n=9) Q >5.8 no SvO2 de-saturation • No inotropes,maintenance fluids, All survived • 4 had no life threatening injury, 1 died • note 4 patients without sig injuries died in 1986 • Overall survival 53% in 1987-88 vs.. 7% in 1986 (p < .001) • Highly significant difference in optimized Q & SVR in survivors vs.. non-survivors. (p=.0001)

  23. Hemodynamic MonitoringScalea, Simon, et al • Vital signs are insensitive indicators of perfusion in geriatric trauma patients • Improved survival is dependent on EARLY (1- 2 hours) repayment of tissue oxygen debt • Q < 3.5 L/m or SvO2 < 60% indicative of impaired VO2 • Most will require inotropes as well as volume to resuscitate • Monitoring made the biggest difference in those who are clinically less severely injured

  24. Shock Defined by Oxygen Utility • VO2 is normally dependent on metabolic demands, independent of DO2 • Shock State exists whenever VO2 is inadequate for tissue needs or when dependent on DO2 • Presence of normal vital signs DOES NOT exclude shock

  25. Metabolic Response to Shock: Initially O2 extraction increases which decreases CvO2. Arterial pH does not drop until late, due to lactatic acid from anaerobic metabolism. Note: correlation between linear VO2/DO2 relationship

  26. Calculating DO2 & VO2 • CaO2 = the content of oxygen in arterial blood. • CaO2= (Hgb x SaO2 x1.34) + PaO2 x 0.003) • Q= Cardiac output • VO2= C(a-v)O2 x QWhere C(a-v) is the difference between arterial and venous oxygen content • At basal conditions VO2 = 250ml/min, DO2 =1000 ml/min, and O2 Extraction = 25%

  27. Resuscitation by Oxygen Delivery • Goals of Resuscitation • Identify the underlying etiology • Hypoxemia • Hypovolemia • Pump failure • Get VO2 independent of DO2 • Repay Tissue O2 Debt as rapidly as possible

  28. How can we accomplish this in ED • Swan-Ganz • Invasive • Complications • Time Consuming • Non-continuous monitoring • Trending not available • Not an option in most ED’s!

  29. Impedance Cardiography • IQ Measures: • Impedance (Baseline) • Heart-synchronous • impedance changes Continuous measurement of this resistance (called impedance) enables the measurement, calculation, and monitoring of the full cardiac cycle including stroke volume, cardiac output, contractility parameters, and total thoracic fluid status.

  30. Origin of the Impedance Waveform • Heart-Synchronous Variations in Impedance • Changes in Volume and Velocity of Flow • Flow-dependent Variation in Orientation of Disk-shaped Erythrocytes • Volume of Electrically Participating Material (Blood)

  31. Flow-dependent Variation in Orientation of Disk-shaped Erythrocytes

  32. Study Objective • Determine the degree of correlation of Cardiac Index measurements using a Pulmonary Artery Catheter (PAC) and standard themodilution technique Vs. Impedance Cardiography. • This would make using Fick equation feasible.

  33. Enrolled • 62 Patients enrolled • 60 % Male • 75% Post-operative heart • 25% Mixed Medical-Surgical ICU

  34. Impedance Cardiography vs. Thermodilution Cardiac Index Correlation R= 0.722

  35. Aggressive Care Justified? • Low threshold for Mechanical ventilation • HD monitoring and optimization • Early tracheostomy • Early nutritional support • Early fracture fixation and ambulation • Average 15 day LOS / 10 ICU days Shapiro, Bartlett et al:Am Surgeon 60(9):695-8 Sept 1994

  36. Favorable outcome • 78% overall survival, 100% of non-ICU, 68% ICU patients • 53% Independent function at discharge • Up to 28 % require only short term rehabilitation and return to independent living Shapiro, Bartlett et al:Am Surgeon 60(9):695-8 Sept 1994

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