Geriatric Trauma: Beyond “ I’ve Fallen & Can’t Get Up!”

1. Geriatric Trauma:Beyond “I’ve Fallen & Can’t Get Up!” Amy Gutman MD ~ EMS Medical Director prehospitalmd@gmail.com

2. Overview • Epidemiology • Pathophysiology • Mechanisms of Injury • Assessment & Management Strategies • Conclusions “The more you complain, the longer God lets you live” Unknown

3. Geriatric Patients • EMT-B class = 150 hrs • EMT-P class = 1200 hrs • Geriatrics hours = 6 • 30-40% all EMS calls with a large percentage being ALS • Anatomically, sociologically & physiologically a “special” population “The secret of staying young is to live honestly, eat slowly, & lie about your age” ~ Lucille Ball

4. Defining “Geriatric” • Person >65 yo • Chronologic age = actual age • Physiologic age = functional capacity • US life expectancy 2010 • Male: 75.4 yrs • Female: 80.5 yrs • 15% US population • >85yo fastest growing population • By 2030, 25% population >65yo • Better living conditions, healthcare, medications & technology “You're only young once, but you can be immature forever” ~ John Greier

5. Geriatric Trauma Etiology • 7th leading cause of death in the elderly • 10-14% trauma patients >65yo • 25% trauma admissions • 28% accidental deaths • Enormous resource & financial burden • $20 billion annually • 33% trauma dollars • Trauma costs 3x greater compared younger persons • Injuries disproportionately severe • Mortality, morbidity, length of stay higher than younger patients with similar injuries • For each year >65, 10% increased chance of a trauma-related death “If I were younger, I'd know more” ~James Barrie

6. High Injury Risk • Normal aging & deterioration • Narrow physiologic tolerances • Decreased reaction time • Decreased eyesight & hearing • Postural instability • Fragile bones & vasculature “Old age is like everything else. To make a success of it, you've got to start young” ~Fred Astaire Trauma in Elderly - 6

7. Polypharmacy & Trauma • 80% on meds likely contributing to injury • Adverse events exponentially rise with number of drugs • 4% if 5 drugs • 10% if 6-10 drugs • 28% if 11-15 drugs • 54% if >16 • Common interactions • Anticoagulants & anti-platelets increase bleeding time • Anti-hypertensives & vasodilators limit vasoconstriction • Beta-blockers limit O2 demand response “It is not the years in your life, but the life in your years that counts” ~Adlai Stevenson

8. Impact of Co-Morbidities • Complication rate triples if one co-morbid illness • Oreskovich’s study on geriatric trauma outcomes: • 100 geriatric trauma pts • 96% independent pre-injury • 88% did NOT return to independence • 72% required NH placement “I am not young enough to know everything” ~Oscar Wilde

9. Geriatric Trauma Outcomes *p<0.001 “Grow old along with me! The best is yet to be” ~Robert Browning

10. Assessment Strategies • Speak slowly, directly & respectfully • Never “Sweetie”, “Honey”, “Pops” • Eye level in middle of visual field • Utilize family / care-givers but do not diminish patient’s contribution • Ask specific questions as patient may not volunteer information • Protect modesty & body temperature • Transport: • Medications • Glasses / hearing aids / dentures • All important paperwork (i.e. MOLST) “Like our shadows, our wishes lengthen as our sun declines” ~Edward Young

11. Assessment ~ Safety • If fall “mechanical”, consider pre-quels • Co-morbidities often causal • May not know / confabulate inciting event • Safety assessment may assist with MOI • Living conditions? • Stairs? • Medications & compliance? • Ambulation assists? • Fall hazards? • Driving safety? • Often reluctant to provide information • Loss of autonomy & independence • Separation from family • Hospitalization “The old believe everything, the middle-aged suspect everything, the young know everything“ O. Wilde

12. Assessment: Primary & Secondary Surveys • Primary Survey • Key: Vitals often unreliable! • A: Aggressive airway management Low intubation threshold Modified spinal immobilization • B: Supplemental O2 with chest / abdominal trauma • C: “Normal” BP may indicate hypotension / shock • Secondary Survey • Keys: Exam often underestimates injury Pain response, hypoxia, hypovolemia varies Pre-morbid illnesses complicate assessment "When you are older you will know that life is a long lesson in humility“ ~James Barrie

13. Mechanisms of Injury

14. MVC Epidemiology • 26 million+ geriatric drivers • Falls #1 morbidity but MVCs #1 trauma-related mortality • 2nd highest fatal crash rate • 21% overall fatality rate • 7x more likely to be hospitalized or killed than younger patients • In collisions, 80% geriatric drivers found to be at fault “Just remember, once you're over the hill you begin to pick up speed” ~Charles Schultz

15. MVCMOI • “Why did this driver crash?” • 20% syncope • 13% intoxicated • Less likely ETOH / high speeds than younger drivers • Unrestrained (83%) • Daytime (81%) • 2 cars (75%) • Weekdays (72%) • Intersection / near home (50%) • Making left turn (20%) “Youth is the time for adventures of the body, but age for the triumphs of the mind” ~Logan Smith

16. Auto vs Pedestrian • Geriatrics > any other age group (even pediatrics) • 46% at crosswalks • Average crosswalk gait 4ft/s • Average elderly gait 3 ft/s • Typical MOI • Head down • Rushing even if unsteady • Often it near curb • 25% mortality if >65 yo • TBI • Vascular injuries • Thoraco-abdominal, including pelvic & rib fractures “Old age comes at a bad time” ~Unknown

17. Homicide / Suicide • 2002: 852 geriatric homicides • Easy target • Home invasions • Elder abuse • 70% GSWs self-inflicted • Depression • Chronic illnesses • Suicide-Homicide “pacts” • 10% GSWs accidental “Youth is the gift of nature, but age is a work of art” ~Garson Kanin

18. Elder Abuse • Less recognized / reported than child or spousal abuse • 5,000 - 250,000+ cases annually • 32:1000 elderly • Risk factors for victim • Female > age 80 • Dementia • Dependence on abuser • Risk factors for abuser • Spouse of children of the abused • Financial dependence on victim • Substance abuse • Prior history of violence “Old age isn’t so bad when you consider the alternative” ~Maurice Chevalier

19. Elder Abuse Assessment • Multiple bruises in various states of healing • Unexplained or untreated injuries w/ inconsistent stories • Dehydration / malnutrition • Bedsores • Mandatory & confidential reporting to adult protective services / police “Beautiful young people are accidents of nature, but beautiful old people are works of art” E. Roosevelt

20. Falls • M=F; females more likely injured • Always ask about the “pre-quel” • Postural instability • Impaired vision & hearing • Decreased reaction time • Medications • Inciting medical event • High injury risk with fall from standing height • TBI • Rib / Hip fractures • “Special Consideration” in Trauma Triage as high risk of cervical injuries with falls from standing height “It is always in season for old men to learn” ~Aesculepius

21. Falls • 40% geriatric trauma • 35% >65yo, 50% >80yo fall annually • In 2005 falls led to: • 160,000 deaths • 1.8 million ED visits • 433,000 hospitalizations • MCC of trauma morbidity • 25% sustain “serious injury” • 50% pts discharged to rehab / NHs • 20% fatal falls occur while in NHs • Fall injuries cost $53 million / year “You don't stop laughing because you grow old. You grow old because you stop laughing” ~M Pritchard

22. Cardiovascular Pathophysiology • Decreased cardiac reserves • Limited increases in SV & CO • Decreased catecholamine response • Decreased valve efficiency • Hypovolemia = hypoperfusion • Lactic acidosis & shock without classic signs of shock • Decreased arterial compliance with increased arteriosclerosis • Baseline HTN, PVD • Conduction system degenerates • Arrhythmias “As the arteries grow hard, the heart grows soft” ~HL Mencken

23. Cardiovascular Pathophysiology • “Pre-quel” cardiac events • Limited ability to increase SV, HR & CO to combat hypovolemia • Increased O2 demand from cardiac stress not tolerated well • Ischemia • Worsening CO • Cardiovascular collapse • “Normal” BP if on antihypertensives = shock “To me, old age is always fifteen years older than I am” ~Bernard Baruch

24. Neurological Pathophysiology • Altered mentation increases with age due to atrophy, co-morbidities • Alterations impede assessments • Dementia / memory impairments • Vision, hearing, speech • Don’t mistake “deaf” with “dumb! • Difficult determining “normal” if no family, friends or caretakers “How old would you be if you didn't know what old was?” ~Satchel Paige

25. Neurology: Subdural Hematoma • SDH most common TBI • Often minor or “forgotten” trauma • Bridging veins tear causing blood to accumulate between dural & arachnoid spaces • Atrophy leaves large space for blood accumulation, delaying symptom onset • Mortality • Adult 4-8%; geriatric 15-30% • Mortality 90% if anticoagulated + GCS<8 • Dementia increases mortality risk “There are 3 signs of old age. The 1st is your loss of memory & the other 2….” Unknown

26. C-Spine Injuries • Fall from standing height, minor trauma • May involve >1 level • Often unstable & associated with TBI • 25% mortality • No prehospital “clearance” • >65 yo “high risk” (Canadian C Spine & NEXUS criteria) • Low risk mechanisms = 24% fx rate • Decreased pain sensation • Central cord syndrome • Stenosis, spondylosis + hyperextension • UE >LE symptoms • Osteoporosis & Osteoarthritis • Narrow spinal canal can cause cord injury s/o fracture “I have everything I had 20 years ago, only it’s all a little bit lower” ~Gypsy Rose Lee

27. Pulmonary Pathophysiology • Decreased chest wall strength & compliance • Kyphosis / Lordosis • Weak musculature • Decreased pulmonary circulation with underlying lung disease • Increased inhalation time, residual capacity & tidal volume • Decreased alveolar surface area, number of alveoli & O2 exchange • Rapid progression to respiratory failure with minimal hypoxia “You can live to 100 if you give up all the things that make you want to live to 100” ~Woody Allen

28. Chest Trauma / Rib Fractures • Common with minor trauma • Any rib fracture doubles morbidity & mortality • Co-existing injuries • Prolonged ICU stay • 31% pneumonia rate • Bergeron’s study on geriatric trauma pts with rib fractures • Mean hospital stay 27 days • 30% mechanically ventilated • 5 X mortality rate than younger pts “Old Age: First you forget names, then you forget faces, then you forget to pull your zipper up, then you forget to pull your zipper down” Leo Rosenberg

29. Thoraco-Abdominal Trauma • Minimal trauma required to produce injury (ie. seat-belts) • Exam often unreliable, vitals misleading • 4-5x higher morbidity than younger patients with same injuries • Pelvic fractures • 30% mortality within 1st 72 hrs • Often lateral compression injuries w/ arterial hemorrhage “Life is what we make it; always has been, always will be” Grandma Moses

30. Renal Pathophysiology • By age 65 lose 40% glomeruli • Diminished renal blood flow • Less effective toxin filtration • Chronic dehydration from decreased total body water • Hypotension leads to renal failure • Micturition syncope common “Age is strictly a case of mind over matter. If you don’t mind then it doesn’t matter” Jack Benny

31. Endocrine Pathophysiology • Caloric requirements decrease with age, but “nutrient” demands remain constant • Glucose intolerance & diabetes increase • Hyperglycemia associated with worse outcome in medical / trauma patients • High risk of infection / sepsis • Malnutrition • Sepsis with “mild” infection (decreased immune response) • Often afebrile or hypothermic • Minimal reserves to fight infection “Old age is no place for sissies” ~Bette Davis

32. Hypothermia • 75% of injured geriatrics • Hemorrhage leads to hypotension then hypothermia • Impaired thermoregulation • Decreased sub-q tissue • Severe complications • Arrhythmias • Coagulopathies • Increased mortality “As one grows older, one becomes wiser and more foolish” ~François Duc

33. Integument Pathophysiology • Thin skin, decreased collagen & sub-q fat • Easily tears & bruises • 20 mins on a backboard begins pressure ulceration • Decreased immune response & capacity for wound healing • Decreased collagen • Less microorganism protection • Abnormal clotting • Tetanus often out-of-date “Middle age is when your age starts to show around your middle” ~Bob Hope

34. Burn Pathophysiology • 4% geriatric trauma-related deaths • 13% of all burn unit admissions • 50% in-hospital mortality • “Burn mortality” is burn percentage causing 50% mortality • Adults = 50% if 80% TBSA burned • 60-70yo = 50% if 35% TBSA burned • >70yo = 50% if 20% TBSA burned “The only source of knowledge is experience” ~Albert Einstein

35. Musculoskeletal Pathophysiology • Postural changes • Kyphosis • Spinal stenosis • Decreased spinal flexibility • Increased knee & hip flexion • Decreased muscle strength • High risk of compression fractures with minor trauma • Osteoporosis & arthritis • Decreased bone density • Decreased fatty tissue “Inside every older person is a younger person wondering what the hell happened” ~Jennifer Yane Trauma in Elderly - 35

36. “Hip” Fractures • Often proximal femur / femoral neck fractures • Suspect all previously ambulatory patient who can no longer walk due to pain • Associated with abdominal / pelvic injury • High mortality: • 14% at 30 days • 35% at 1 year • 40% require rehab / NH placement “I intend to live forever, or die trying” ~Groucho Marx

37. Management Strategies • Key: Prevention of early & late complications • Appropriate fluid resuscitation • Avoid low-flow states • Serial cardiopulmonary exams • Lung sounds • Cardiac monitoring • Pulse oximetry • Capnography • Multiple studies demonstrate under-triage of geriatric patients to trauma centers “Aging is not lost youth but a new stage of opportunity and strength” Betty Friedan

38. Geriatric Trauma Triage • Consider trauma center 1st line destination • If >80 yo, trauma center mortality 8% vs 56% in non-trauma centers • Recognize high risk injury patterns • Falls + AMS • Falls + inability to ambulate • Thoraco-abdominal • Pelvic or femur • Trauma + SBP <100 mmHg “Old age is the most unexpected of all the things that happen to a man” ~Trotsky

39. Airway Management • Early & aggressive • Limited cardio-pulmonary reserves • Limited ability to open mouth & move neck • Kyphosis & arthritis • Sedation can induce apnea • CPAP is great adjunct, but patients at higher risk for barotrauma / pneumothorax “You're getting old when all the names in your black book have MD after them” ~Arnold Palmer

40. >70yo triaged to trauma center for: GCS <15 + TBI Falls + evidence of TBI (even from standing position) SBP <100 mmHg Pedestrian struck Multisystem trauma Suspected proximal long bone fracture post-MVC Consider Trauma Center Triage if: COPD CAD / CVD Clotting disorder Warfarin therapy Diabetes Dialysis Immunocompromised Liver Disease Ohio Geriatric Trauma Triage (National Standard of Care) “I was taught to respect my elders; I’ve now reached the age when I don't have anybody to respect” ~ George Burns

41. References • Ohio State Board of EMS Trauma Committee; 2008 • Brady Textbook of ITLS; 2004 • Bourn. “The “2 P’s” of Geriatric Trauma”. 2008 • Holland. “Geriatric Falls & Trauma”; 2009 • Fowler. OSU Department of EM • CDC MMRW “Life Expectancy”; 2010 • Antonenko. UND Department of Surgery; 2005 • Bulger. Harborview Medical Center; 2004 • NHTSA “Walking Through the Years”; 2008 • AARP “Older Adult Pedestrian Safety”; 2009 • Richmond. Louisville FD; 2007 • Barishansky. “Understanding Our Geriatric Pts”; 2009 • Rosen. “Geriatric Trauma”. EM 6th Ed; 2008 • Aschkenasy. “Trauma & Falls in the Elderly”. EM Clinics of North America; 2006 • www.emsresponder.com. “Geriatric Trauma”. 2008 • EAST. “Practice Management Guidelines for Geriatric Trauma”. 2009 • Blanda. “Geriatric Trauma: Current Problems, Future Directions”; Summa Health Systems; 2007 • Victorino. “Trauma in the Elderly Pt”. Arch Surg; 2003 • Perdue. “Geriatric Trauma”. J.Trauma; 1998 • Touger. “Geriatric Trauma”. An EM; 2002 • McKinley. “Geriatric Trauma”; Arch Surg; 2000 • Steill. “Canadian C-Spine Rule vs NEXUS Low-Risk Criteria in Patients with Trauma”. NEJM; 2003 “When men reach their sixties and retire they go to pieces. Women just go right on cooking” Gail Sheehy

42. SUMMARYprehospitalmd@gmail.com / www.TEAEMS.com • Injury “pre-quels” & MOI • Vitals & physical exam may underestimate injury • Increased complications, mortality & length of stay compared to younger pts • Tremendous financial burden, often with poor outcomes • Consider “over-&-early” triage to a trauma center “Age and treachery will triumph over youth and skill” Anonymous