The Elderly Trauma Patient Trauma Care Beyond the ED

1. Dr. Kathleen E. Walsh University of Wisconsin School of Medicine and Public Health SCRTAC Conference 12/6/2012 The Elderly Trauma PatientTrauma Care Beyond the ED

2. Kathleen E. Walsh DO, MSUniversity of Wisconsin Department of MedicineDivision of Emergency Medicine12/6/2012 No Financial Disclosures

3. Lecture Outline • The “Silver Tsunami” • Geriatric Trauma • Alfred, Stella, and John

4. The “Silver” Tsunami

5. Aging of America • Sources: 1900-1980: U.S. Bureau of the Census, Decennial Censuses of Population. 1990: U.S. Bureau of the Census, Projections of the Population of the United States, by Age, Sex, and Race: 1983 to 2080.

6. Wisconsin – Aging Distribution • Source: Wisconsin Department of Administration, Demographic Services Center and DWD, Office of Economic Advisors

7. “Baby Boomers” - Trauma • The number of people over the age of 85 will double by the year 2020. • By 2050, people over age 64 will make up over 20% of the US population compared with 12% today. • The elderly sustain a disproportionate share of fractures and serious injury, accounting for approximately 28% of deaths due to trauma - while representing only 12% of the overall trauma population.

8. Geriatric Trauma

9. Geriatric Trauma: Top 6 #1 FALLS #2 Motor Vehicle Collisions #3 Pedestrian Related Collisions #4 Burns #5 Accidental Hypothermia #6 Elder Abuse and Neglect

10. Falls • http://www.youtube.com/watchv=hTYDBJ0kP3I

11. STELLA

12. STELLA 80 y/o female found at bottom of basement steps by daughter; last seen 24 hours ago PMHX: HTN, hyperlipidemia, OA PSHX: cholecystectomy MEDS: Metoprolol, HCTZ, Zocor

13. Stella: Physical Exam • GEN; somnolent, but arousable • VSS: BP 175/80; HR 110, RR 16, T96, O2 90%RA • HEENT: RIGHT side temporal hematoma; Pupils 4mm equal and reactive. • CHEST: decreased BS b/l; • ABD: soft, NT, ND • EXTR: “closed” right tib/fib distal fx and dislocated ankle

14. Stella’s Head CT • Subdural Hematoma (red arrow) with mid line shift (green arrow) shift of Brain past center line.

15. Aging & Neurological Changes • Brain: decrease in brain weight and size. • Nerves: decreased muscle strength; deep-tendon reflexes; nerve conduction slows • Thermoregulation:  temperature sensitivity (Hot and Cold) What do you see? • Head trauma causes stretching of the bridging vessels; increased tearing and bleeding • Slowed motor skills; deficits in balance and coordination • Blunted febrile response to infection • Slowed speed of cognitive processing

16. Acute vs. Chronic Subdural • Acute Subdural Chronic Subdural

17. Aging &Musculoskeletal Changes • Lean body mass replaced by fat & redistribution. • Bone loss; Decreased ligament and tendon strength. • Articular cartilage erosion. Changes in posture What will you see? Fractures with minimal trauma (e.g. compression fx) Flexion/extension movement can cause spinal cord injury without fracture Decreased pain sensation may mask pain of fracture

18. Stella’s hospital course…. • Transferred to Level I trauma center • Neuro ICU  Craniotomy to remove subdural • Ortho OR to repair fracture • 2 week hospital stay then transfer to rehab and now living in assisted living facility

19. ALFRED

20. ALFRED 86 y/o male arrives from Assisted Living Facility after fall while walkingto dining room. Witnessed, did not hit head. LEFT wrist pain and deformity. AL staff noted low grade fever and mild confusion x 1 day. PMHX: Glaucoma; kidney stones MEDS: Tylenol, MVI, Vit D and Calcium; Eye drops

21. ALFRED: Physical Exam PE • Gen: alert to name only (baseline A&Ox4) • Vitals 90/70, HR 110, RR 26, T 102.5, O2 94% 2L • HEENT: dry mucosa, food in mouth • LUNGS: coarse upper • CV: tachy, regular;no murmur • ABD: soft, NT/ND; mild right flank pain • EXTREM: LEFT wrist bony deformity; +pain; digits warm, well perfused, pulse 2+

22. ALFRED continued…… CC: Fever and Confusion • Fever 102.5!! (significant in the elderly) • Blunted in the elderly; usually low • HR 110 and regular • Response to fever, dehydration, etc. • Blood Pressure 90/70 • Normal vs. wide vs. narrow

23. Aging &Cardiovascular Changes • Heart wall stiffening – “pump” not as efficient • Hardening valves (murmurs) • Atherosclerosis (“clogged arteries”) What do you see? • Decreased heart rate and cardiac output  wide pulse pressure, easily fatigued, SOB • Postural and diuretic-induced hypotension. May cause dizziness and syncope. • Elderly can move to decompensated, irreversible shock very rapidly (no more reserve)

24. Cardiovascular – “Pulse Pressure” Can tell you a lot about the patient’s condition! • Pulse pressure = difference between the systolic and diastolic pressures ---- > gives you the amount of pressure change to create the pulse. • Example: 120/80 millimeters of mercury (mmHg), 120-80= 40 (pulse pressure) which is considered a normal and healthy “pulse pressure”

25. Narrow vs. Wide Pulse Pressure • Narrow = 25 mmHg or less (usually “poor” sign) • think SHOCK, blood loss, sepsis, heart failure, cardiac tamponade • Wide = consistently greater than 100 mmHg • “stiffness” of major arteries, leaky aortic valve, chronic anemia, heart block • Chronically elevated PP – risk of atrial fibrillation, CVD Blacher J et.al. Pulse pressure not mean pressure determines cardiovascular risk in older hypertensive patients. Arch Intern Med. 2000 Apr 24;160(8):1085-9.

26. Altered Mental Status

27. Dementia versus Delirium

28. DELIRIUM vs. DEMENTIA

29. CAM (Confusion Assessment Method) Created in 1990 as a tool to identify pts with delirium • Feature 1: Acute Onset or Fluctuating Course • Feature 2: Inattention • Feature 3: Disorganized thinking • Feature 4: Altered Level of consciousness Delirium Diagnosis =presence of features 1 and 2 and either 3 or 4. Inouye, S., van Dyck, C., Alessi, C., Balkin, S., Siegal, A. & Horwitz, R. (1990). Clarifying confusion: The confusion assessment method. Annals of Internal Medicine, 113(12), 941-948.

30. Acute Mental Status Change Need to think of differential! • Infection • Electrolyte abnormality • Angina • Urinary retention • Constipation or Bowel Obstruction • Acute renal failure • Medication toxicity • TIA or Stroke

31. Dementia Screening “ SLUMS”Saint Louis University Mental Status Examination • Alternative screening test to the MMSE • 11 items measuring aspects of cognition • Orientation, short-term memory, calculations, naming of animals, clock drawing, recognition of geometric figures. • Advantages: detects early dementia and takes into consideration education level Tariq SH, Tumosa N, Chibnall JT, Perry MH 3rd, Morley JE. Comparison of the Saint Louis University mental status examination and the mini-mental state examination for detecting dementia and mild neurocognitive disorder--a pilot study. J Geriatr Psychiatry. 2006 Nov;14(11):900-10.

32. Early DementiaClock Drawing Test (CDT) • CDT (memory, visuospatial skills) • Mini Mental Status Exam shows orientation, memory, and language functions. • Because of the CDT's focus on visuospatialability and executive function, it may be more useful than the MMSE in detecting dementia in its early stages. Borson S, Brush M, Gil E, Scanlan J, Vitaliano P, Chen J, Cashman J, Sta Maria MM, Barnhart R, Roques J.J Gerontol A BiolSci Med Sci. 1999 Nov;54(11):M534-40.

33. CDT Examples

34. ALFRED w/u • Distal Radius Fx • Reduced &Splinted • Labs • Hyponatremic • ARI • +UTI • Treatment • Fluids • IV antibiotics • PO pain med

35. ALFRED Day #3 – DELIRIUM &FEVER • ?infection, medications, electrolytes, urinary retention, constipation • 101 temp • No BM x 2 days • N & V x 2 • Lytes WNL • X-ray = large kidney stone lodged in ureter.

36. ALFRED Day #5 • Alert, afebrile • s/p Lithotripsy • Continued antibiotics • Tylenol for pain • PT/OT • Discharged to rehab in 1 week

37. John

38. John 80 yo farmer driving tractor into town hits neighbor’s mailbox, falls and is “pinned” between steering wheel and gear shift. Found dyspneic (SOB) and confused. PMHX: COPD, HTN, Hyperlipidemia,GOUT MEDS: Lisinopril, Zocor, Omeprazole, Albuterol Inhaler prn

39. John: Physical Exam Gen: A & O x 2 appears “dyspneic” and anxious VS: BP 180/110 RR 30 HR 115 O2 86%RA, T 102.8 LUNGS: decreased BS at bases, crackles & wheezing; RIGHT side rib discomfort CV: tachycardic, regular ABD: soft, +BS EXTREM: cool, pulse 1+

40. JOHN’S W/U • Labs: • nmllytes, UA neg +WBC, mild anemia • EKG: sinus; LBBB • CXR PNEUMONIA! Rib Fracture x2

41. Aging &Respiratory System • Decreased respiratory muscle strength; “stiffer” chest wall • Drier mucus membranes • Decreased response to low O2 or high CO2 • Lung tissue loss and decreased diffusion capacity What will you see? Elderly with baseline PaO2 of between 78 and 92 mmHg Decreased cough and mucus/foreign matter clearance Increased risk of infection and bronchospasm with airway obstruction

42. Aging & Gastrointestinal System • Decreases in strength of chewing muscles, taste, and thirst perception. • Decreased gastric motility with delayed emptying. Atrophy of protective mucosa; Malabsorption • Impaired sensation to defecate What will you see? Risk of chewing impairment, fluid/electrolyte imbalances, poor nutrition. Gastric changes: altered drug absorption, increased risk of reflux; Drug-induced ulcers.
 Constipation, Risk of fecal incontinence with disease

43. JOHN – Day 4 Confused and agitated! Repeat labs – all wnl! EKG stable CXR – improved ABD – no constipation • Friend visiting pt – mentions he misses his “beer drinking” buddy; How much? 6-8/day === ETOH withdrawal! -- CIWA protocol John is discharged after 2.5 weeks in hospital

44. Take Home Points

45. Caring for the Geriatric Patient • Effective communication • Understand the physiology of aging • Recognize early delirium

46. Older Generation • Common stereotypes include mental confusion, illness, sedentary lifestyle, and immobility • Baby boomer generation is more active and healthy.

47. Thank you!!