Twilight Trauma: Major Trauma in Older Adults

1. Twilight Trauma:Major Trauma in Older Adults Katrina O’Leary Trauma Quality Improvement Co-ordinator Midland Trauma System Trauma Symposium April 5 2019

2. Old people from previous years

3. >65 age group makes up 14% of the total NZ population Old people in 2019

4. Midland Region NZ Waikato District Health Board Bay of Plenty District Health Board HauoraTairawhitiDistrict Health Board Taranaki District Health Board Lakes District Health Board

5. Key management principles of major trauma in older adults • *adapted from London Major Trauma Systems (2017) and Victorian State Trauma System (2014) • Emergency assessment & management still include ABCDE • Early specialised assessment & intervention to minimise adverse outcomes & maximise recovery • Early MDT engagement • Avoid under under-triage • Consider precipitating medical events

6. Ageing processes modify the response to trauma • Consider early reversal of anticoagulant therapy • Pain should be an important assessment • Confusion may not be cognitive decline-consider TBI • Pre determined management plans should be included • Perceptions and attitudes can influence clinical judgement and expectations

7. 1. Emergency Department management considerations • Low threshold for activating a trauma call • Falls = major trauma = death • Road traffic crashes • Poor bone health Photo of members from Hauora Tairawhiti Emergency Department Registered Nursing staff

8. Primary Survey Airway • Higher aspiration risk • Slower gastric motility • Slower oesophageal and oro-pharyngeal response • Dental fragility, dentures and access • Oral wasting and weakness • Jaw and temporomandibular joint changes • Naso-pharyngeal fragility • higher risk of high cervical fracture even in low velocity events

9. Breathing • Decreased respiratory reserve • Consider HDU/ICU admission • The presence of chronic disease means these patients are less tolerant of pulmonary injuries and resultant increase in mortality • Higher risk of inadequate oxygenation • Reduction in ventilation efficiency • Reduced chemoreceptor response to hypoxia • Reduced gas exchange • Higher risk of infection • Reduced ventilation efficiency • Reduced mucociliary clearance • Blunted immune response

10. Cardiovascular • Lower Cardiac Output • Stiffer compliance • Reduced Stroke Volume • Response slower to insults on cardiovascular system • Difficult to generate adequate response • Masked hypovolemic shock from medications • Decreased sympathetic activity • Catecholamine resistance • Decreased baro-receptor response • Accommodation to higher systolic pressures • Poor resilience to haemodynamic instability following haemorrhage

11. Increased risk of bleeding from anticoagulants (reverse early) • High risk of oedema from volume resuscitation due to pre existing cardiac conditions • Higher risk of rate and conduction changes • Lower renal efficiency • Blunt chest trauma has a high risk of cardiac contusion. • Consider 12 Lead ECG, telemetry, Cardiology input, ECHO • Increased risk for complications once discharged for conduction disorders.

12. Disability • Decreased brain mass increases likelihood of subdural haemorrhage and intra-parenchymal haematoma • Difficulty assessing Glasgow Coma Scale secondary to visual/auditory/cognitive decline • A lower threshold for CT scan should be considered as there is a higher risk of traumatic brain injury in older adult major trauma secondary to the use of anticoagulant medication • Cerebral bridging veins often tear leading to an increased risk of secondary cerebral haemorrhage.

13. Exposure/Environment • Increased risk of loss of thermal regulation • due to a decrease in dermal thickness and loss of vascularity. • Maintain body temperature by means of external warming either passively with blankets or a warming blanket. • Skin is thinner as a result and there is a higher risk of early pressure areas developing

14. Secondary survey • Comprehensive to avoid missed injuries • Allow time for the older adult to respond • History should be taken from multiple sources (GP, St John, family, pharmacist) • Frailty, nutritional state, functional impairment-how will these affect management and recovery?

15. 2. In-patient management for older adult major trauma admissions • Management should be early, vigilant and aggressive where appropriate • This preserves mobility and function and can determine discharge destination

16. The 10 step management plan.... • 1. Early allied health referral • 2. Delirium precautions • 3. Tertiary survey • 4. Medicines Reconciliation • 5. Bone health review

17. 6. Social and support network assessment • 7. Alcohol screen • 8. Early goal setting • 9. Early discharge planning • 10. Social and psychological effects

18. References • Bulger, E., Arneson, M., Mock, C., & Jurkovich, G. (2000). Rib Fractures in the Elderly. The Journal of Trauma: Injury, Infection and Critical Care, 48(6), 1040-1047. • Health Quality & Safety Commission. (2012). Medicine Reconciliation Standards, Version 3. Wellington. • Home | Stats NZ. Retrieved from https://www.stats.govt.nz/ • Kehoe, A., Smith, J., Edwards, A., Yates, D., & Lecky, F. (2015). The changing face of major trauma in the UK. Retrieved from https://emj.bmj.com/content/emermed/32/12/911.full.pdf • London Major Trauma Systems NHS: London operational delivery networks. (2017). Management of elderly major trauma patients. London: National Health Service. • Major Trauma in Older People-2017 Report. (2017). Retrieved from https://www.tarn.ac.uk/Content.aspx?c=3793 • O'Leary, K., Kool, B., & Christey, G. (2017). Characteristics of older adults hospitalised following trauma in the Midland region of New Zealand. New Zealand Medical Journal, 130(1463). • Osteoporosis New Zealand. (2017). Clinical Standards for Fracture Liaison Services in New Zealand. Wellington. • Reske-Nielsen, C., & Medzon, R. (2016). Geriatric Trauma. Emergency Medicine Clinics, 34(3), 483-500. doi: 10.1016/j.emc.2016.04.004 • Sirmali, M., Turut, H., Topcu, S., Gulhan, E., Yazici, U., Kaya, S., & Tastepe, I. (2003). A comprehensive analysis of traumatic rib fractures: morbidity, mortality and management. European Journal of Cardio-Thoracic Surgery, 24(1), 133-138. doi: 10.1016/S10107940(03)00256-2 • Spellacy, E., Winters, R., & Dawson, T. (2012). Trauma in the Older Adult: A topic of great scope. Presentation, Tauranga Hospital, Bay of Plenty District Health Board. • Victorian State Trauma System, State of Victoria. (2014). Major Trauma Guidelines & Education: Older person trauma. Melbourne.

19. “Old age is no place for sissies” • Bette Davis