Geriatric Emergency Medicine Information Summary: Trauma Kevin Biese. MD, MAT Kristen Barrio, MD Epidemiology • • • •
Patients ≥ 65 years are 10% of all traumas, but 28% of deaths Trauma is the 7th leading cause of death in elderly Falls are the most common trauma mechanism Motor vehicle collision (MVC) is the most fatal trauma mechanism
General Principles • • •
Cardiac and pulmonary disease and medications may limit physiological response to stressors, (i.e. beta blockers, etc) Trauma patients are under-triaged in violation of paramedic protocols Changing trauma team activation thresholds for elderly patients has been shown to decrease mortality
Head Trauma • • • • •
Patients aged >65 y/o have 30-85% mortality with intracranial hemorrhage (ICH) ICH can occur from seemingly minor trauma, such as a fall from standing Age ≥ 65 considered high risk in Canadian age >60 high risk in New Orleans Head CT protocols Subdural hematomas account for majority of findings on Head CT Beware of delayed acute subdural hematoma (DASH) – consider admission for observation even if negative head CT
Warfarin • • • •
Risk of spontaneous ICH on warfarin is 0.3-5.4% Blunt head trauma on warfarin with minimal or no symptoms: 7-14% have ICH Remember patients frequently have supra-therapeutic INR: 11% with INR >5 For patients with head injury on warfarin, reduced mortality if protocol implemented requiring immediate head CT and FFP be ordered
Cervical Spine Trauma • • •
In blunt trauma victims age>65, C-spine fractures are 2x more likely than in younger patients Odontoid fractures: 20% of elderly c-spine fractures compared to 5% in younger patients Patients >65 included in NEXUS criteria and identified as high risk in Canadian C-Spine Rule
Chest Trauma • • •
In elderly patients with isolated thoracic injuries, mortality of patients >65 was 15% If patient has 3 or more rib fractures mortality was > 30% Most mortality subsequent to pneumonia
Pelvic Trauma • • •
In pelvic fractures, elderly patients have high rates of hemorrhage, transfusion, and ICU admission even with a benign fracture pattern (lateral compression) There is some evidence that early angiographic embolization is helpful in elderly patients with pelvic trauma Hip fractures have 15-20% mortality rate within the first year. Between 25-50% of patients will not regain the ability to ambulate
Burn Injuries • •
Elderly patients represent 1/5 of all burn unit admissions Traditional mortality estimate is age + %burn
References • • • • • • • • • •
Bergeron et al. Elderly trauma patients with rib fractures are at greater risk of death and pneumonia. J of Trauma 2003; 54: 478-85. Callaway, Wolfe. Geriatric Trauma. Emerg Med Clin 2007; 25: 837-860. Demetriades et al. Effect on outcome of early intensive management of geriatric trauma patients. Brit J Surg 2002; 89: 1319-1322. Demetriades et al. Old age as a criterion for trauma team activation. J Trauma 2001; 51: 754-7. Hylek et al. Major hemorrhage and tolerability of warfarin in the first year of therapy among elderly patients with atrial fibrillation. Circulation AHA 2007; 115: 2689-2696 Ivascu et al. Rapid warfarin reversal in anticoagulated patients with traumatic intracranial hemorrhage reduces hemorrhage progression and mortality. J Trauma 2005; 59: 1131-1139. Kimbrell et al Angiographic embolization for pelvic fractures in older patients. Arch Surg 2004; 139: 728-733. Ma et al. Compliance with prehospital triage protocols for major trauma patients. J Trauma. 1999 Jan; 46(1) 168-75. Meldon S, Ma O., Woolard R. Geriatric Emergency Medicine. McGraw Hill, 2004. Touger et al. Validity of a decision rule to reduce cervical spine radiography in elderly patients with blunt trauma. Ann Emerg Med. 2002 Sep; 40(3): 287-93.