Geriatric Trauma

Report
GERIATRIC TRAUMA:
WHAT DO WE
KNOW?
AGS
Kevin Biese, MD, MAT
Ellen Roberts PhD, MPH
Jan Busby-Whitehead, MD
University of North Carolina at Chapel Hill
Division of Geriatric Medicine
Center for Aging and Health
Department of Emergency Medicine
THE AMERICAN GERIATRICS SOCIETY
Geriatrics Health Professionals.
Leading change. Improving care for older adults.
LEARNING OBJECTIVES
• Describe the unique presentations of geriatric
trauma
• Identify areas of particular risk for elderly
patients with traumatic injuries
• Suggest care process changes that may
improve the care of geriatric trauma patients
Slide 2
GERIATRIC TRAUMA: OUTLINE
• The basics
• Rib fractures
• Pelvic fractures
• Head trauma
• Warfarin
• C-spine fractures
• Triage
Slide 3
GERIATRIC TRAUMA: DISCLAIMERS
• Most studies are retrospective reviews
• No standard definition of “geriatric” or
“elderly”
Slide 4
GERIATRIC TRAUMA: EPIDEMIOLOGY
• Elderly are growing in numbers
• Patients ≥65 years account for 10% of all
traumas, but 28% of deaths!
• Trauma is the 7th leading cause of death in
elderly
Slide 5
GERIATRIC TRAUMA: MECHANISMS
• Falls — most common
 Balance, strength, vision
• Motor vehicle collision (MVC) — most fatal
 Judgment, vision, reaction times decreased
 Crash fatality rates are much higher
• Burns — 1/5 of all burn unit admissions
 Mortality estimate = age + % burn
Slide 6
GERIATRIC TRAUMA:
COMPLICATING FACTORS
• Past medical history
 Cardiac and pulmonary disease limit physiological response
to stressors
 Vital signs are difficult to interpret
• Medications
 Anticoagulants
 Beta blockers
• Cause of the event
 Myocardial infarction, syncope, stroke, hypoglycemia
Slide 7
CASE 1: INTRODUCTION
• 71-year-old woman restrained driver in MVC
• “T-boned” on passenger side
• Unknown rate of speed
• No airbag deployment
• Prolonged extrication
• Not ambulatory at scene
• EMS: systolic blood pressure (SBP) 100, HR 80,
oxygen saturation 100% on non-re-breather mask
Slide 8
CASE 1:
ADDITIONAL INFORMATION
• Patient is complaining of shortness of breath, left
chest wall pain, and left clavicle pain
• She hit her head with reported loss of consciousness
• Patient denies neck or back pain
• No nausea or abdominal pain
• Yellow trauma alert — no trauma team activation
Slide 9
CASE 1:
PRIMARY SURVEY
• A  Patient speaking in complete sentences
• B  Clear bilaterally, but diminished effort;
significant bruising/pain left chest wall
• C  Good pulses  4, 2 IVs in place
• D  Glasgow Coma Scale (GCS) 14, moving
all 4 extremities
• E  Patient exposed, warm blankets placed
Slide 10
CASE 1:
SECONDARY SURVEY
• Vital signs: 103/51, 80, 18, 36.3 F, 100% NRB
• General: Dyspneic, awake and alert
• HEENT: 3-cm laceration on left side of scalp, PERRLA
• Chest: Bruising left clavicle/left chest wall with tenderness
• CV: RRR with HR 80
• Abdomen: No bruising, soft, non-tender, non-distended
• Pelvis stable
• Neurologically intact
Slide 11
CASE 1:
PAST MEDICAL HISTORY
• Hypertension
• Osteoporosis
• “Non-cardiac chest pain”
• Medications:
 Hydrochlorothiazide
 Alendronate (Fosamax)
• Allergies:
 Penicillin
Slide 12
CASE 1: CHEST X-RAY
Slide 13
CASE 1: PELVIS X-RAY
Slide 14
CASE 1: CHEST CT
Left 1, 3, 4, 5, 6 rib fractures, left scapular fracture,
left clavicle fracture, small pneumothorax
Slide 15
CASE 1: LAB RESULTS
• Hematocrit — 36
• Potassium — 2.9
• Creatinine — 1.0
• INR — 1.0
Slide 16
CASE 1: HOSPITAL COURSE
• Day 1 – Admitted to surgical ICU, L chest tube placed
• Day 2 – Rapid atrial fibrillation, amiodarone drip with
conversion to sinus rhythm
• Day 5 – Chest tube pulled
• Day 7 – Hypoxic, hypotensive, rapid atrial fibrillation,
left pleural effusion, intubated
• Day 8 – Left chest tube replaced
• Day 12 – Chest tube removed
• Day 22 – D/C to home
• 5 months later – Doing well
Yellow trauma — 22-day hospital stay!
Slide 17
RIB FRACTURES
IN THE ELDERLY (1 of 2)
• Prospective cohort of 405 patients admitted with rib
fractures from blunt trauma
• 113 patients > 65 years old
• Elderly had much higher mortality (20% vs. 9%)
• Isolated thoracic trauma
 75% of elderly patients sustained this by fall from standing
 Mortality 15% if age >65; 0% if <65
 Pneumonia 34% if age >65; 11% if <65
• Most geriatric deaths occurred >72 hours after trauma
and resulted from sepsis or respiratory failure
Bergeron E, et al. J Trauma. 2003;54:478-485.
Slide 18
RIB FRACTURES
IN THE ELDERLY (2 of 2)
Age (years)
3-6 rib fractures
>6 rib fractures
<65
≅10%
≅25%
≥65
≅30%
>60%
If >65 with 3 or more rib fractures, admit;
if >6 rib fractures, ICU
Bergeron. J of Trauma 2003; 54: 478-85.
PELVIC FRACTURES
IN THE ELDERLY (1 of 2)
• Usually associated with falls from standing &
MVCs
• Higher percentage of lateral compression
fractures than in younger patients
 Fewer “severe” fracture patterns
• High rates of hemorrhage, transfusion, and
ICU admission, even with “benign” fracture
patterns
Slide 20
PELVIC FRACTURES
IN THE ELDERLY (2 of 2)
• 92 consecutive blunt trauma pelvic fracture patients received
angiographic embolization (AE) for “liberal indications”:
 Hemodynamically labile, concerning fracture pattern (open
book, vertical shear, butterfly), or pelvic hematoma on CT
• Patients >60 years (n=17) were compared with younger patients
 No difference in injury severity score, pelvic fracture pattern,
SBP, or blood requirement
 >60 years: 94% chance of active bleed vs. 52% in younger
patients
• Consider AE before hemodynamic collapse in elderly patients
with significant pelvic fractures
Kimbrell. Arch Surg. 2004.
Slide 21
CASE 2
• 90-year-old woman presents 3 days after fall
in bathroom, when she hit her head on toilet
• No symptoms for 2 days
• This morning, mild headache and face pain
• Medications: warfarin, oxycodone,
amitriptyline
Slide 22
HEAD TRAUMA IN ELDERLY
• Bridging veins travel further
• More space for hematoma collection
before symptoms
• Age >65 have 30%85% mortality
with intracranial hemorrhage (ICH)
 25 higher than younger
patients with matched injuries
• Considered high-risk in brain imaging
protocols (New Orleans, Canadian)
Webmm.ahrq.gov, retrieved June 3, 2011.
Slide 23
WARFARIN AND ICH IN ELDERLY
• 9% of elderly patients with traumatic brain injury are
on 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
• Patients frequently have supra-therapeutic INR
 11% have INR >5
• Beware delayed acute subdural hematoma (DASH) —
consider admission for observation even if head CT is
negative
• Check INR
Slide 24
AGGRESSIVE
COUMADIN PROTOCOL (1 of 2)
• Emergency department initiated new protocol for
patients with suspected head trauma on warfarin
 Immediate evaluation
 Immediate head CT
 Type & cross match
 Thaw 2 units AB FFP
• If positive head CT
 Transfuse FFP, Vitamin K IV, neurosurgery evaluation
• If negative head CT
 Admit for observation
Ivascu FA, et al. J Trauma. 2005;59:1131-1139.
Slide 25
AGGRESSIVE
COUMADIN PROTOCOL (2 of 2)
• 82 patients, 19 with ICH
• Time to initiate warfarin reversal dropped from
4.3 hours pre-protocol to 1.9 hours
• Mortality dropped from 48% to 10%
Ivascu FA, et al. J Trauma. 2005;59:1131-1139.
Slide 26
CASE 3
• A 97-year-old woman fell while getting out of
bed
• Normal activity throughout day; eventually
presents with moderate neck pain
• No neurological deficits on exam
Slide 27
GERIATRIC C-SPINE FRACTURES
Type II odontoid fractures are the most common
LearningRadiology.com, retrieved June 3, 2011.
Slide 28
ODONTOID FRACTURES
Insert image/ diagram of 3 types of odontoid
fractures.
GERIATRIC C-SPINE FRACTURES
• Blunt trauma victims >65 years are 2 more likely than
younger patients to have C-spine fractures
• Odontoid fractures: 20% of elderly C-spine fractures
vs. 5% in younger patients
• Debate in literature about management of types II, III
odontoid fractures
• Patients >65 years included in NEXUS, identified as
high risk in Canadian C-Spine Rule
• X-rays frequently inadequate
• Have a low threshold to use CT on geriatric C-spine
Touger. Ann Emerg Med. 2002.
Slide 30
TRIAGE
• Elderly trauma patients are under-triaged, in
violation of paramedic protocols
• Should the elderly be triaged more
aggressively?
Slide 31
CRITERIA FOR TRAUMA
TEAM ACTIVATION (TTA) (1 of 3)
• Review of Trauma
Registry at UCLA and LA
County from 19932000
• Included admitted trauma
patients age >70, except
interhospital transfers,
ground-level falls,
subacute subdurals
• 25% met TTA criteria:




SBP <90 or Pulse >120
RR <10 or >29
Unresponsive to pain
Gunshot wound to trunk
• 883 patients included
Demetriades D, et al. J Trauma. 2001;51:754-756.
Slide 32
CRITERIA FOR TRAUMA
TEAM ACTIVATION (TTA) (2 of 3)
90%
80%
85.70%
TTA
Non- TTA
67.20%
70%
62.50%
60%
• 63% of patients with
severe injuries did not
meet standard TTA
criteria
50%
39.40%
40%
30%
• Among all patients who
did not meet criteria,
mortality was 16%
25.50%
20%
10%
5.50%
0%
ISS <15
ISS 16-29
ISS 30+
ISS = Injury Severity Score
• Include age 70 years
as TTA criterion?
Demetriades D, et al. J Trauma. 2001;51:754-756.
Slide 33
CRITERIA FOR TRAUMA
TEAM ACTIVATION (TTA) (3 of 3)
• The same UCLA group added age 70 years as a TTA
criterion
• Data were analyzed on 336 trauma patients with ISS > 15
and age 70 years: 260 patients admitted before age
became a criterion and 76 admitted afterward
• Groups were similar in injury, age, gender, ISS, and
Abbreviated Injury Score
• Mortality was 53.8% before, 34.2% after (P=.003)
• Consider early and aggressive resource mobilization for
elderly trauma victims
Demetriades D, et al. Br J Surg. 2002;9:1319-1322.
Slide 34
GERIATRIC TRAUMA:
TAKE-HOME POINTS
• Elderly patients break easily — don’t minimize
• Mobilize resources for elderly trauma victims
• Rib fractures associated with high mortality; if patient
has >2 rib fractures, admit
• Consider angiographic embolization for pelvic
fractures even before hypotension
• Beware warfarin!
• Low threshold for CT of geriatric C-spine; when
(re)taking the boards, think odontoid
Slide 35
CASE 1
• EMS brings in a 71-year-old woman who was “Tboned” on the passenger side while driving at an
unknown rate of speed.
• There was no air bag deployment, but it took several
minutes to get her out of her car and she was nonambulatory at the scene.
• Upon examining her, you note that she has chest wall
bruising, a tender pelvis, and vital signs significant for
BP of 100/60, HR of 80, and oxygen saturation of
100% on a non re-breather oxygen mask.
Slide 36
CASE 1, QUESTION 1
Which of the following is not true regarding the epidemiology
of geriatric trauma? Select the one best answer.
A. Although people 65 years account for only 10% of all trauma
evaluations, they account for more than 25% of all trauma mortality.
B. Burn mortality is estimated at percentage body surface burned plus
age of patient in years.
C. Falls are a common cause of significant morbidity in the elderly.
D. Motor vehicle accidents are the most common cause of traumatic
injuries in the elderly.
Slide 37
CASE 1, QUESTION 2
True or False?
Patients aged >65 years old with 2 or
more rib fractures have a higher than 30%
mortality rate.
Slide 38
CASE 1, QUESTION 3
Which of the following statements regarding triaging
elderly trauma patients is not true?
A. Cardiac and pulmonary disease limit physiologic response to
stressors.
B. Elderly patients involved in traumatic accidents are more likely
to be triaged to trauma centers than younger patients with the
same pre-hospital assessment by EMS providers.
C. Institutions that include age as a criterion in their trauma
activation system have improved outcomes in caring for geriatric
trauma patients.
D. Medications taken by the elderly can render vital signs more
difficult to interpret.
Slide 39
CASE 2
A 90-year-old woman presents to your emergency
department complaining of a headache and painful
neck.
She fell 3 days ago while standing up from the toilet.
She is neurologically intact with a Glasgow Coma Scale
of 15 on exam. Her medications include warfarin.
Slide 40
CASE 2, QUESTION 1
True or False?
Both the Canadian Head CT Scan rule and
the New Orleans Head CT Scan rule identify
patients over the age of 65 as high risk.
Slide 41
CASE 2, QUESTION 2
Which of the following statements regarding patients on
warfarin is not true? Select the one best answer.
A. Delayed acute subdural hemorrhage occurs in patients on warfarin.
B. Eleven percent (11%) of all patients on warfarin presenting to an
emergency department have an INR > 5.
C. In cases of blunt head trauma in patients on warfarin with no or
minimal symptoms, the incidence of intracranial hemorrhage is 4%.
D. Nine percent (9%) of all elderly patients with traumatic brain injury
are on warfarin.
Slide 42
CASE 2, QUESTION 3
Which of the following types of cervical spine
fractures is most increased in frequency in elderly
patients?
a) Clay-shoveler’s fracture
b) Hangman’s fracture
c) Jones fracture
d) Odontoid fractures
Slide 43
ANSWER KEY
• Case 1
 Question 1: D
 Question 2: False
 Question 3: B
• Case 2
 Question 1: True
 Question 2: C
 Question 3: D
Slide 44
BIBLIOGRAPHY (1 of 2)
• Bergeron et al. Elderly trauma patients with rib fractures are at
greater risk of death and pneumonia. J Trauma. 2003;54:478-485.
• Callaway W. Geriatric trauma. Emerg Med Clin. 2007;25:837-860.
• Demetriades et al. Old age as a criterion for trauma team
activation. J Trauma 2001;51:754-757.
• Demetriades et al. Effect on outcome of early intensive
management of geriatric trauma patients. Br J Surg. 2002;89:13191322.
• Hylek et al. Major hemorrhage and tolerability of warfarin in the first
year of therapy among elderly patients with atrial fibrillation.
Circulation. 2007;115:2689-2696.
Slide 45
BIBLIOGRAPHY (2 of 2)
• 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;46:168-175.
• Touger et al. Validity of a decision rule to reduce cervical spine
radiography in elderly patients with blunt trauma. Ann Emerg
Med. 2002;40:287-293.
Slide 46
SPECIAL THANK YOU
Special thanks to Brian Downing, MD
Slide 47
THANK YOU FOR YOUR TIME!
Visit us at:
www.americangeriatrics.org
Facebook.com/AmericanGeriatricsSociety
Twitter.com/AmerGeriatrics
linkedin.com/company/american-geriatricssociety
Slide 48

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