Trauma in the Elderly

Aka: Trauma in the Elderly, Trauma in Older Patients, Geriatric Trauma, Trauma in Older Adults

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II. Mechanisms

  1. Falls (most common)
    1. Leading cause of Traumatic death in elderly (up to 11% of deaths are due to falls)
    2. Typically occurs from ground level, in the home
    3. Nearly half require admission
    4. Associated with 33% one year mortality
    5. One quarter of cases are due to underlying conditions (CVA, Syncope, Hypovolemia, Arthritis, decreased Vision)
  2. Motor Vehicle Accidents (second most common)
    1. Most often due to elderly pedestrians struck by vehicle
    2. Motor vehicle collisions are also common
      1. Often due to underlying medical condition such as Hypoglycemia (esp. single vehicle accidents)
  3. Elder Abuse
    1. See Elder Abuse
    2. Reported by up to 5-10% of elderly patients
    3. Observe for signs of neglect
    4. Observe for tense personal relationship with Caregiver
    5. Consider intentionally inflicted injury
      1. Bruises at the Breasts or genitalia
      2. Bruises, abrasion, burn injuries, healed Fractures
      3. Pressure Sores, poor hygiene, excessive weight loss

III. Physiology: Pitfalls

  1. Decreased Catecholamine response (decreased Catecholamine receptors)
  2. Decreased cardiovascular reserve
    1. Ejection fraction cannot compensate for blood loss
      1. Decreased cardiac compliance (stiff ventricle)
      2. Decreased contractility
    2. Unable to increase Heart Rate adequately (lower maximum Heart Rate, medications such as Beta Blockers)
      1. See Delayed Tachycardia
    3. Pacemaker
      1. Inadequate tachycardic response to acute blood loss
  3. Poor tolerance for even small decreases in perfusion
    1. Underlying atherosclerotic vascular disease with risk of end-organ ischemia or infarction
    2. Chronic volume depletion or Malnutrition
  4. Decreased pulmonary reserve and risk of Hypoxia
    1. Decreased pulmonary compliance, respiratory Muscle Weakness and decreased diffusion capacity
  5. Decreased Renal Function
    1. Decreased ability to retain resorb fluid and sustain vascular volume in the face of stress Hormones (e.g. Aldosterone, Catecholamines)
    2. Increased susceptibility to Acute Kidney Injury (e.g. nephrotoxicity)
  6. Anticoagulant Use (e.g. Warfarin, Clopidogrel)
    1. Risk of Intracranial Hemorrhage from seemingly Mild Closed Head Injury
  7. Increased risk of medication reactions and adverse effects
    1. See Drug-Drug Interactions in the Elderly
    2. Beta Blockers and Calcium Channel Blockers prevent adequate reflexive Tachycardia
  8. Skin changes
    1. Decreased skin thickness, skin vascularity and skin Mast Cells
    2. Increased risk of Hypothermia
    3. Increased risk of Bacterial Skin Infection and impaired Wound Healing

IV. Examination: Pitfalls

  1. See Primary Trauma Evaluation
  2. See Secondary Trauma Evaluation
  3. General
    1. Geriatric Trauma patients are frequently much more ill than they appear
    2. Maintain a high index of suspicion for serious injury, even in low mechanism injuries
  4. Vital Signs
    1. Initiate early hemodynamic monitoring
    2. Normal Blood Pressure and normal Heart Rate are not equivalent to normovolemia
      1. Physiologic markers (Heart Rate, Blood Pressure) are blunted by medication, comorbidity
      2. Systolic Blood Pressure <110 mmHg over age 65 years may represent shock
  5. Abdominal exam
    1. Trauma abdominal exam misses same occult serious findings as Acute Abdomen in the Elderly
  6. Common Fracture sites in the elderly
    1. Rib Fracture
    2. Hip Fracture and proximal Femur Fracture
    3. Humerus Fracture
    4. Wrist Fracture

V. Labs

  1. See Diagnostic Testing in Trauma
  2. Metabolic Acidosis
    1. Associated with increased mortality risk
  3. Hypokalemia
    1. Common in the elderly on Diuretics
  4. Coagulation Tests (INR, PTT, Platelet Count)
    1. Indicated for Anticoagulant use or underlying Coagulopathy suspected

VI. Imaging

  1. FAST Exam
  2. Head CT
    1. Consider MRI Brain if equivocal CT Head results
    2. Maintain a low index of suspicion
      1. Elderly are high risk of Intracranial Hemorrhage (e.g. dura more susceptible to tearing)
      2. Cerebral atrophy delays symptom onset
    3. Indications
      1. Head Injury with loss of consciousness in age > 60 years old
      2. Head Injury without loss of consciousness in age >65 years old
      3. Head Injury and Anticoagulant use (typically repeated again depending on agent used)
      4. Altered Mental Status regardless of known Head Injury
  3. CT Cervical Spine
    1. High cervical (C1, C2) Vertebral Fractures are common
    2. Maintain a low threshold for obtaining CT Cervical Spine (esp. if CT Head is performed)
    3. NEXUS Criteria may be unreliable over age 65 years (and Canadian C-Spine Rules excludes this population)
  4. Chest Imaging
    1. Thoracic Trauma is associated with a high mortality rate in the elderly
    2. Chest XRay or Chest CT
      1. Maintain low threshold for CT Chest in the elderly
      2. Chest XRay will typically miss Rib Fractures (significant Pneumonia and mortality risk in the elderly)
      3. Chest CT may also identify Lung Contusion, aortic injury
  5. Musculoskeletal Injuries
    1. Upper extremity Fractures
      1. Distal Radius Fracture
      2. Humerus Fracture
      3. Radial Head Fracture and other elbow injuries
    2. Lower extremity Fractures
      1. Hip Fractures (esp. Osteoporosis, women)
        1. Missed Fracture on XRay in 10% of cases
        2. Obtain MRI (preferred if available) or CT Hip if suspicious of Fracture and non-diagnostic xray
        3. Consider Femoral Nerve Block (spares systemic Opioids)
      2. Tibial Plateau Fracture
      3. Patella Fracture
      4. Distal fibula Fracture (and bimalleolar and Trimalleolar Fractures)

VII. Management

  1. See Trauma Evaluation
  2. Airway and Breathing management
    1. Consider Supplemental Oxygen
    2. Exercise a lower threshold for Advanced Airway management
    3. Elderly are more likely to have a difficult airway (reduced mouth opening, poor Dentition)
    4. Rapid Sequence Intubation agents require adjustment and review of contraindications
      1. Reduce Etomidate and Benzodiazepine doses by 20-40% of usual dose (decrease Hypotension risk)
      2. Consider Ketamine (but avoid if known vascular disease)
  3. Hemorrhagic Shock
    1. Blood Transfusion in Trauma indications are the same regardless of age
    2. Avoid premature Blood Transfusion in the elderly
  4. Fluid Resuscitation in Trauma
    1. Early goal directed fluid Resuscitation to correct hypoperfusion
    2. Reassess physiologic markers (Heart Rate, Blood Pressure, mentation)
      1. May be difficult to interpret due to baseline status and medications
  5. Early Nutritional Support
    1. Elderly patients present with chronic Malnutrition with risk of adverse outcomes

VIII. Prognosis

  1. Frailty predicts complications
    1. Frail Trauma patients more rapidly decompensate, and remain ill for longer periods of time
    2. Clinical Frailty Score
      1. http://geriatricresearch.medicine.dal.ca/pdf/Clinical%20Faily%20Scale.pdf

IX. Prevention

  1. See Fall Prevention in the Elderly
  2. See Abuse in the Elderly
  3. See Elderly Drivers with Cognitive Impairment
  4. See End-Of-Life Care

X. References

  1. Manasco et al (2016) Crit Dec Emerg Med 30(12): 3-10
  2. (2012) ATLS Manual, 9th ed, American College of Surgeons

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