Fred A. Luchette, MD Department of Surgery Stritch School of Medicine

1. Fred A. Luchette, MD Department of Surgery Stritch School of Medicine Loyola University Medical Center Trauma in the Geriatric Patient Detroit Trauma Symposium, 2012

2. Objectives • Understand changing demographics of America and MOI in elderly • Gain knowledge about effect of aging on organ function • Be able to demonstrate knowledge about nuances of caring for injured geriatric patient.

3. Trauma - MVC

4. Trauma - Alcohol

6. Geriatric Trauma • Defined as older than 65 years: 12% in 2012 • Average life span in 1900: 47 years • Average life span in 2000: 76 years • Predicted number of 85 years of age will double by 2020 • By 2050, 20% of population over 64 years

7. U.S. Census Bureau

8. National Problem • Trauma 5th COD in elderly • Disproportionate number of fractures • 28% of trauma deaths even though only 12% of population • Every year over 65, odds of dying from injury increase 6%

9. Location of Injury Oyetunji TA, et al. Epidemiologic trends in elderly domestic injury. J Surg Res. 2012;173: 206-211

10. Discharge Disposition Oyetunji TA, et al. Epidemiologic trends in elderly domestic injury. J Surg Res. 2012;173: 206-211

11. Mechanism of Injury • Most to least common: • Falls • MVC • Pedestrian struck • Stab wounds • Gunshot wounds • Others

12. Falls • Most common method of injury in the elderly • Most responsible for cause of death • 50% of admitted eventually d/c’ed to Nursing home • Cost from fall injuries are estimated at 53 million dollars

13. Falls • Reason for fall • Cardiac: Dysrhythmia • Metabolic: Hypokalemia, hypoglycemia • Neurologic: Dementia, CVA • Misc: GI hemorrhage • Provider must decipher the inciting agent in order to optimize the treatment

14. MVC • Falls are the #1 overall cause of trauma related injuries • MVCs are #1 cause of trauma related death ages 65-74 • In accidents involving elderly patients • 80% were found to be at fault • 18% syncopal episode was inciting event

15. What do You do to Have Fun??

16. Please Wear a Helmet!

17. Pedestrian Struck by Auto • Involves the elderly more than any other age group. • Cause • Confusion • Vision or hearing deficiency • Poor gait

18. Elder Abuse • Less recognized than child or spousal abuse • Approximately 5,000 to 25,000 cases each year in US • 32 per 1000 adults over 65 years old are abused • Abuser is most commonly spouse or children of the abused • No definite sex predomination • Similar to child abuse, if the physician deems it not safe for patient to return home, social services must be notified and admission is justified

19. Contributing Factors to Injury • Osteoporosis, Osteoarthritis • CVA, Hypertension, Ischemic Heart Dis. • Diabetes, Balance disturbance, Impaired vision • Depression, Parkinson’s Dis., Dementia

20. Environmental Factors • Rugs, lighting, stairs • Bathtubs and showers • Footwear and uneven ground • Weather and walking aids

21. Acute Medical Conditions • Syncope, Dysrhythmias, CVA, TIA • Acute MI, Seizure, Acute Renal Failure • Infection, Hypoglycemia, AAA • New medications, hypovolemia • Acute fractures

22. Special Considerations • Physiologic reserve • β-blockers • 20% of those with CAD • 10% of those with hypertension • Anticoagulants • Warfarin • Anti-platelet agents

23. Anti-platelet Agents • ASA • Clopidogel (Plavix) • Dabigatran (Pradaxa)

24. Traumatic Brain Injury • Therapeutic warfarin increases mortality 4-5 fold • Reversal of anticoagulation within 2 hours reduced mortality to that of non-anticoagulated patient (10%) • Factor VII can also be used

25. Effect of Aging on Organ Function • Organ physiology begins to deteriorate as early as age 30 • Progressive changes for remainder of life • Rate of change in function differs among organs, but is fairly constant

26. Effect of Aging on Skin • Extrinsic changes • UV light • Thinner, dryer, wrinkled, sages • Intrinsic changes: Decrease in • Density of hair follicles • Mast cells, macrophages, fibroblast • Antigen presenting cells

27. Changes to Brain with Aging • Neuronal changes and glial cell loss • Cell death due to Wallerian degeneration • Reduced plasticity and repair mechanisms • Decreased brain volume increases subdural space • Decreased CBF and vascular reactivity

28. Cardiovascular Physiology • Cardiac output (CO) declines by 1% per year after age 30 • By age 80, the CO is 50% less compared to a 20 year old • Changes in CO are directly related to: • Decreased filling during diastole • Diminished response to cathecholamines • Decreased compliance of arteries

30. Pulmonary Function • Decreased chest wall compliance due to loss of elasticity increases risk for ARDS • VC, FEV, and functional reserve decreased • Mucociliary function declines • COPD is common in elderly • High flow O2 may suppress hypoxic drive

31. Renal Physiology • Renal mass and number of glomeruli decrease • Decline in creatinine clearance • Affects clearance: PCN, Amino, Digoxin • Collecting tubules less able to concentrate • Urine output is not a reliable endpoint for resuscitation

32. Other Physiologic Changes • Immune system function deteriorates • Increased risk for infections • Endocrine and Metabolic • Osteoporosis

33. Clinical Care of Geriatric Trauma • Prehospital • Gather info on past medical history and events • Avoid undertriage • Co-morbidities often inciting cause of injury • Low threshold to intubate • Cautious resuscitation due to limited cardiac func

34. Head and Cervical Spine • Less force needed to fracture skull and/ or spine compared to younger pts. • Low energy impact can cause subdural • Liberal use of head CT • Indications: Multiple injuries, + LOC, deficit, dementia, use of anticoagulants

35. Head and Cervical Spine • Cervical spine • Same as in young patients • Rigid collar in field • Higher incidence of central cord syndrome • Due to DJD and vascular disease

36. Chest Injuries • Rib fractures are the most common injury • 3 point restraint saves lives but produces thoracic injuries • EKG most sensitive tool to predict cardiac complications

37. Abdomen & Pelvis • Abdomen • Exam is unreliable in multiply injured • Liberal use of ultrasound and CT scan • Pelvis • Any fracture is significant for high mortality

38. Extremity Injury • Overall, isolated extremity injury is tolerated fairly well in elderly • Low energy fractures are common • Liberal use of radiographs for diagnosis

39. Wellness in Geriatric Patients

40. Prevention • Falls • Driving • Abuse • Firearms

42. Summary • Geriatric trauma patients are fastest growing group in trauma centers • Higher morbidity, mortality, & LOS compared to younger patients with similar injuries • Vital signs and UO are less reliable for determining adequacy of tissue perfusion • Liberal triage and admission with use of invasive monitoring

43. Summary • Pearls and Pitfalls • Co-morbidities are more important than chronologic age • Consider early transfer to trauma center • Seek out events prior to accident • Syncope responsible for 20% of MVCs