ElderTrauma : 2012 Update

1. ElderTrauma:2012 Update Robert D. Barraco, MD, MPH, FACS, FCCP Chief, Geriatric Trauma Lehigh Valley Health Network Allentown, PA

2. Objectives • Describe the epidemiology and physiology of geriatric trauma and its impact on our system. • Discuss recent literature in the area of geriatric trauma.

3. Committee Update NO ONEIN THIS ROOMIS GETTING YOUNGER

5. Background • Injury rates are rising • 38% of inpatients were aged 65 years and over, 43% days of care • Those aged 75 years and over 24% of all inpatients Source: NHDS

6. Epidemiology • Trauma is the 5th leading cause of death in the elderly • In order of most to least common: • Falls • MVC • Pedestrian struck • Stab wounds • Gunshot wounds • others

7. Mechanism of Injury • Falls • Most common method of injury in the elderly • Most responsible for cause of death • By 2020, 47.8 billion dollars spent on the treatment of geriatric falls

8. Mechanism of Injury • Motor Vehicle Crash • MVC are #1 cause of trauma related cause of death ages 65-74 • In accidents involving elderly patients • 80% were found to be at fault • 18% syncopal episode was the inciting agent

9. Mecahnism of Injury • Pedestrian struck by MV • Involves the elderly more than any other age group. • Cause • Confusion • Vision or hearing deficiency • Poor gait

10. Bodily Changes:Sunset or Sunrise? • Changes in all body systems • Less reserve • Relatively unable to compensate • Physical exam findings unreliable

11. Nervous System • Sensory decline • Motor decline • Memory impairment • Impaired temperature/ blood pressure control • Sleep changes

12. Cardiovascular System •  Stretch of cardiac muscle • Atherosclerosis: Hardening of the arteries • Can’t compensate with heart rate • Fat in-growth of SA and AV nodes

13. Respiratory System • Stiffening of chest wall and lung •  Oxygen •  amount of air with maximal breath •  Work of respiratory muscles

14. Urologic System •  Kidney failure •  Drug clearance and processing •  Response to dehydration

15. GI System • Swallowing problems • Reflux • Diverticuli

16. Immune System •  Cancer •  Autoimmune disease like Rheumatoid Arthritis •  Infections/ complications

17. Endocrine System • Reduced ability to respond to stress • Loss of glucose tolerance leads to diabetes

18. Bones, Joints and Muscles •  Muscle strength, endurance and size • Osteoporosis •  Fractures •  Joint disease • Osteoarthritis

19. Please Remember: These are general trends. Individual results may vary...

23. Factors affecting outcome and mortality in Eldertrauma

24. 2001 • Triage Issues • Parameters (End Points) for Resuscitation 2010 • Correction of anti-coagulation • Age as indicator for trauma alert • Supraphysiologic Resucitation

25. What is “Elderly”? Level II In general, where specific guidance is not otherwise given for the purposes of determining independent risk for adverse outcomes following trauma, patients >65 years of age can be considered as “elderly”.

26. Prehospital Triage and Activation Level II • Injured patients with advanced age (>65) and pre-existing medical conditions (PEC’s) should lower the threshold for field triage directly to a designated/verified trauma center.

27. Prehospital Triage and Activation Level III • A lower threshold for trauma activation should be utilized for injured patients>70 years age who are evaluated at trauma centers. • Elderly patients with at least one body system with an AIS>3 should be treated in designated trauma centers, preferably in ICU’s staffed by surgeon-intensivists.

28. Literature Support: Trauma Center Triage/Care

29. Effectiveness of Prehospital Trauma Triage… • Retrospective study • Three NJ counties with Level 1 trauma centers • 18% undertriage in elderly men, 15% in elderly women • Age cutoff 65 years J Emerg Nursing 2003; 29:109-15

30. Old Age as a Criterion for Trauma Activation • Retrospective review 7.5 years • Level 1 urban trauma center • 25% of age 70 and over met one standard criteria • Mortality 50%, ICU 40%, OR 35% • 75% not meet criteria • Mortality 16%, ICU 24%, OR 19% • Age 70 a stand alone criteria for activation J Trauma 2001 Oct; 51(4): 754-6

31. Should Age be a Factor… • NTDB review • At all levels of injury, patients older than 60 have 3 fold increased morbidity and 5 fold increased mortality with minor ISS (0-15), 2- and 4-fold with major ISS. • Minor ISS were often Level II activations • Suggests Level 1 activation age 60 and over J Trauma Issue/Volume 69(1), July 2010, pp 88-92

32. The impact of advanced age on trauma triage decisions and outcomes: a statewide analysis • 13,820 (27%) elderly patients. • Significantly less likely trauma team activation despite similar severity • More often required urgent craniotomy and orthopedic procedures • Undertriaged elderly patients had 4 times the mortality rate Am J Surg. 197(5):571-4; discussion 574-5, 2009 May.

33. Undertriage of elderly trauma patients to state-designated trauma centers • Even when trauma is recognized and acknowledged by EMS, providers are consistently less likely to consider transporting elderly patients to a trauma center. Arch Surg. 143(8):776-81; discussion 782, 2008 Aug.

34. Elderly Injury: A Profile of Trauma Experience in the Sunshine (Retirement) State • In the moderate and minor injury categories, TC survival was significantly better for both groups. • The proportion of NTC fatalities as potentially preventable is significantly higher than trauma centers.

35. Elderly Injury: A Profile of Trauma Experience in the Sunshine (Retirement) State • When the effects of all reported diagnoses are considered, potentially preventable mortality for patients with noninjury comorbidity is significantly lower in TC. • Moreover, by using “discharge to home” as an indicator of completeness of recovery, TCs seem to be significantly more effective than NTC The Journal of Trauma: Issue: Volume 48(4), April 2000, pp 581-586

36. Trauma in the very elderly: a community-based study of outcomes at trauma and nontrauma centers • Head injury, injury severity, and lack of TC verification are associated with hospital mortality in very elderly trauma patients. J Trauma. 52(1):79-84, 2002 Jan.

37. Anticoagulation Level III • All elderly patients who receive daily therapeutic anticoagulation should have appropriate assessment of their coagulation profile as soon as possible after admission. • All elderly patients with suspected head injury receiving daily anticoagulation should be evaluated with head CT as soon as possible after admission.  • Patients receiving warfarin with a post-traumatic intra-cranial hemorrhage should receive initiation of therapy to correct their INR toward a normal range within 2 hours of admission.

38. PTSF Geriatric Trauma Committee Vision: Pennsylvania’s Trauma System will pioneer and excel in the care of the injured elderly. Goals: • Evaluate/Examine Best Practices in Geriatric Trauma Care in the Commonwealth • Limit variation and improve outcomes through standardization of care • Discuss and resolve issues of importance to the care of the Geriatric Trauma Patient • Evidence-Based Reviews as available or create our own to guide care • Research to provide tools to change practice and provide the best care to our community • TraumaSystems approach to issues

39. Definition • Geriatric trauma will be defined in the Commonwealth of Pennsylvania as injured patients age 65 and over.

40. PTSF Geriatric Trauma Committee On the agenda: • Best practices/usable protocols • Interfacility standard work: • Common protocols for clinical situations • Anticoagulant reversal • Syncope • Triage • Prevention Initiatives

41. Mechanism for Head Injury and taking Coumadin: GCS < 14? Yes No Stat PT/INR/PTT Type and Cross Obtain stat head CT with stat read Transfer to Level 1 or 2 trauma center Begin correction as able Injury on CT? Mechanism for Head Injury and taking Coumadin: Able to obtain stat head CT and read it? Yes No Admit, observe Consider CT in AM Yes No Stat PT/INR/PTT Type and Cross Stat head CT with stat read See Level 3-4 algorithm Transfer to Level 1 or 2 trauma center Coumadin and CHI protocol:Non-trauma vs. Level 3/4

42. Geriatric Triage Research • No denominator • Need to see if numbers would overwhelm resources • Rich database of PCRs with PEHSC • Will look at data points for answers at state level • Will use locoregional EMS if needed

43. Geriatric Issues in Trauma Care

44. Frailty

45. AAST 2011 • PREDICTORS OF CRITICAL CARE RELATED COMPLICATIONS IN COLECTOMY PATIENTS USING THE NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM: EXPLORING FRAILTY AND AGGRESSIVE LAPAROSCOPIC APPROACHES. • ARE THE FRAIL DESTINED TO FAIL?: FRAILTY INDEX AS A PREDICTOR OF SURGICAL MORBIDITY AND MORTALITY IN THE ELDERLY

46. Surgery in the Elderly • 21% of those over age 60 will undergo surgery and anesthesia as compared with only 12 percent of those aged 45 to 60 years by 2030 • 20% of all open heart surgery >70

47. Surgery in the Elderly • Overall risk steadily declining • Heart disease mortality 3-5% • Heart attack 1-4% • CHF 4-10% • Lungs most common: 15-45%

48. Frailty • Unintentional weight loss (10 pounds or more in a year) • General feeling of exhaustion • Weakness (as measured by grip strength) • Slow walking speed • Low levels of physical activity.

49. Trauma in the Elderly: Frailty • Frailty Scales: Measure thinking, functionality and general health status. • Higher scores were associated in increased complications and decreased chance of being discharged to home.

50. VES-13 • The VES-13 relies on patient self-report. • VES-13 is function-based. • In the national sample of elders, a score of 3+ identified 32% of individuals as vulnerable. • This vulnerable group had four times the risk of death or functional decline when compared to elders scoring 3 or less.