Trauma in the Elderly Nathanael Wood, MD Albany Medical Center March 21, 2007

Case Study 1 83 year-old female 83 year-old female Driver, belted, no airbag deployment Driver, belted, no airbag deployment Parking lot speed, minimal auto damage Parking lot speed, minimal auto damage No complaints No complaints Highest HR en route: 90 Highest HR en route: 90 Lowest SBP en route: 110 Lowest SBP en route: 110 Boarded and collared Boarded and collared

PMH: HTN, osteopenia PMH: HTN, osteopenia PSH: Cholecystectomy PSH: Cholecystectomy Meds: Lopressor, calcium Meds: Lopressor, calcium Social: Non smoker, non-drinker Social: Non smoker, non-drinker

Vitals on Arrival to ED HR 95, BP 115/85, RR 18, T 98, O2 97% RA HR 95, BP 115/85, RR 18, T 98, O2 97% RA

Primary Survey A: Patent A: Patent B: Breathing comfortably, equal breath sounds b/l B: Breathing comfortably, equal breath sounds b/l C: Radial and femoral pulses equal, strong C: Radial and femoral pulses equal, strong D: No deficits D: No deficits

Secondary Survey General: Awake, alert General: Awake, alert HEENT: NC/AT HEENT: NC/AT Neck: hard collar, NT Neck: hard collar, NT CV: RRR, pulses equal/strong throughout CV: RRR, pulses equal/strong throughout Lungs: CTA BL Lungs: CTA BL Abd: soft, NT, ND, bowel sounds present Abd: soft, NT, ND, bowel sounds present Extremities: no deformities, no tenderness, FROM Extremities: no deformities, no tenderness, FROM Neuro: Non focal examination, A&O X3 Neuro: Non focal examination, A&O X3

ED Course Neck cleared using NEXUS criteria, hard collar removed Neck cleared using NEXUS criteria, hard collar removed No imaging indicated No imaging indicated Pt refused analgesia Pt refused analgesia Signed out to next resident: Needs to ambulate, likely d/c soon Signed out to next resident: Needs to ambulate, likely d/c soon

ED Course, continued Patient unable to ambulate Patient unable to ambulate CT Abdomen, pelvis… CT Abdomen, pelvis… Grade 3 liver laceration Grade 3 liver laceration Admitted to hospital for observation Admitted to hospital for observation D/C after two days D/C after two days

ED Course, continued Then, one day after d/c… Then, one day after d/c… Neck discomfort. Neck discomfort. Back to ED. Back to ED. CT neck… CT neck… C5 fracture C5 fracture D’OH! D’OH!

How did we miss all that? Unlucky? Unlucky? Different physiology? Different physiology? Medications? Medications?

The “Elderly” What is “Elderly” or “Geriatric”? What is “Elderly” or “Geriatric”? 55? 55? 65? 65? 70? 70? Depends Depends

The “Elderly” 12% of the population is over age 55 12% of the population is over age 55 36% of all ambulance transports 36% of all ambulance transports 25% of hospitalizations 25% of hospitalizations >85, fasted growing age group >85, fasted growing age group

The “Elderly” In 2000, 35 million aged 65+ In 2000, 35 million aged 65+ By 2030, 70 million aged 65+ By 2030, 70 million aged % of US population 20% of US population 70% of ambulance transports 70% of ambulance transports

“Geriatric” > 70 > 70 Exhibits significant anatomical or physiological characteristics associated with advanced aging. Exhibits significant anatomical or physiological characteristics associated with advanced aging.

Trauma in the Elderly Fifth leading cause of death, > 65 years Fifth leading cause of death, > 65 years Significant cause of morbidity. Significant cause of morbidity. Minor trauma may result in functional decline. Minor trauma may result in functional decline. Older patients have worse outcomes despite lesser injury severity. Older patients have worse outcomes despite lesser injury severity.

Types of Trauma Falls Falls MVAs MVAs Violence Violence Burns Burns

Falls

Falls and the Elderly Leading cause of elder trauma Leading cause of elder trauma Occur in 1/3rd of independent elders Occur in 1/3rd of independent elders More common in nursing home residents More common in nursing home residents 10% of falls result in significant injury 10% of falls result in significant injury Severity/frequency increases with age Severity/frequency increases with age May be a symptom of general decline May be a symptom of general decline 50% 1 year mortality if hospitalized for a fall 50% 1 year mortality if hospitalized for a fall

MVAs

MVAs and the Elderly 13-15% of all MVAs 13-15% of all MVAs Higher incidence of Higher incidence of 2 vehicle MVAs 2 vehicle MVAs Pedestrian-MVAs Pedestrian-MVAs Mortality Mortality

MVAs and the Elderly: Patterns Intersections Intersections Good weather Good weather Close to home Close to home During daylight During daylight

Geriatric Abuse & Neglect

Physical, psychological injury of older person by their children or care providers Physical, psychological injury of older person by their children or care providers Knows no socioeconomic bounds Knows no socioeconomic bounds

Geriatric Abuse & Neglect Contributing factors Contributing factors Advanced age: average mid-80s Advanced age: average mid-80s Multiple chronic diseases Multiple chronic diseases Sleep pattern disturbances leading to nocturnal wandering, shouting Sleep pattern disturbances leading to nocturnal wandering, shouting Family has difficulty upholding commitments Family has difficulty upholding commitments

Geriatric Abuse & Neglect Primary findings Primary findings Trauma inconsistent with history Trauma inconsistent with history History that changes with multiple tellings History that changes with multiple tellings

Burns

Burns and the Elderly More likely to suffer injury More likely to suffer injury Unable to evacuate burning structures Unable to evacuate burning structures Cognitive impairment Cognitive impairment Decreased coordination Decreased coordination Older homes (wiring, smoke detectors, etc.) Older homes (wiring, smoke detectors, etc.)

Burns and the Elderly High mortality rates High mortality rates 50% BSA burn 50% BSA burn <65 years, 50% fatal <65 years, 50% fatal >65 years, approaching 100% fatal >65 years, approaching 100% fatal

Effects of Aging

Cardiovascular System Speed, force of myocardial contraction decreases Speed, force of myocardial contraction decreases Cardiac conducting system deteriorates Cardiac conducting system deteriorates Resistance to peripheral blood flow rises, elevating systolic blood pressure Resistance to peripheral blood flow rises, elevating systolic blood pressure Blood vessels lose ability to constrict, dilate efficiently Blood vessels lose ability to constrict, dilate efficiently What effects will these changes have on ability to compensate for shock? For heat and cold exposure?

Respiratory System Respiratory muscles lose strength; rib cage calcifies, becomes more rigid Respiratory muscles lose strength; rib cage calcifies, becomes more rigid Respiratory capacity decreases Respiratory capacity decreases Gas exchange across alveolar membrane slows Gas exchange across alveolar membrane slows Cough, gag reflexes diminish increasing risk of aspiration, lower airway infection Cough, gag reflexes diminish increasing risk of aspiration, lower airway infection What will be the consequences of these changes during chest trauma?

Musculoskeletal System Osteoporosis develops, especially in females Osteoporosis develops, especially in females Spinal disks narrow, resulting in kyphosis Spinal disks narrow, resulting in kyphosis Joints lose flexibility, become more susceptible to repetitive stress injury Joints lose flexibility, become more susceptible to repetitive stress injury Skeletal muscle mass decreases Skeletal muscle mass decreases What effect do these changes have on incidence and severity of orthopedic trauma? Packaging? Backboards? Intubating? Long term outcomes?

Nervous System Brain weight of decreases 6 to 7% Brain weight of decreases 6 to 7% Brain size decreases Brain size decreases Cerebral blood flow declines 15 to 20% Cerebral blood flow declines 15 to 20% Nerve conduction slows up to 15% Nerve conduction slows up to 15% What effect will decreased nerve conduction have on pain sensation and reaction time? How will brain degeneration change the effect of head trauma?

Gastrointestinal System Senses of taste, smell decline Senses of taste, smell decline Gums, teeth deteriorate Gums, teeth deteriorate Saliva flow decreases Saliva flow decreases Cardiac sphincter loses tone, esophageal reflux becomes more common Cardiac sphincter loses tone, esophageal reflux becomes more common Peristalsis slows Peristalsis slows Absorption from GI tract slows Absorption from GI tract slows What effects can these changes have on the nutrition of older persons? How does this change the response to traumatic injury?

Renal System Renal blood flow decreases 50% Renal blood flow decreases 50% Functioning nephrons decrease 30 to 40% Functioning nephrons decrease 30 to 40% What effect will these changes have on ability to eliminate drugs from the body?

Integumentary System Dermis thins by 20% Dermis thins by 20% Sweat glands decrease; sweating decreases Sweat glands decrease; sweating decreases What effect will this have on:  Severity of burn injuries?  Wound healing?  Cold and heat tolerance?

Geriatric Assessment

Factors Complicating Assessment Variability Variability Older people differ from one another more than younger people do Older people differ from one another more than younger people do Physiological age is more important than chronological age Physiological age is more important than chronological age

Factors Complicating Assessment Response to illness Response to illness Seek help for only small part of symptoms Seek help for only small part of symptoms Perceive symptoms as “just getting old” Perceive symptoms as “just getting old” Delay seeking treatment Delay seeking treatment Trivialize chief complaints Trivialize chief complaints

Factors Complicating Assessment Presence of multiple pathologies Presence of multiple pathologies 85% have one chronic disease; 30% have three or more 85% have one chronic disease; 30% have three or more One system’s acute illness stresses other’s reserve capacity One system’s acute illness stresses other’s reserve capacity One disease’s symptoms may mask another’s One disease’s symptoms may mask another’s One disease’s treatment may mask another’s symptoms One disease’s treatment may mask another’s symptoms

Factors Complicating Assessment Altered presentations Altered presentations Diminished, absent pain Diminished, absent pain Depressed temperature regulation Depressed temperature regulation Depressed thirst mechanisms Depressed thirst mechanisms Confusion, restlessness, hallucinations Confusion, restlessness, hallucinations Generalized deterioration Generalized deterioration Vague, poorly-defined complaints Vague, poorly-defined complaints

Factors Complicating Assessment The Organs of the Aged Do Not Cry!

Factors Complicating Assessment Communication problems Communication problems Diminished sight Diminished sight Diminished hearing Diminished hearing Diminished mental faculties Diminished mental faculties Depression Depression Poor cooperation, limited mobility Poor cooperation, limited mobility

Factors Complicating Assessment Polypharmacy Polypharmacy Too many drugs! Too many drugs! 30% of geriatric hospitalizations drug induced 30% of geriatric hospitalizations drug induced Anti-hypertension drugs (beta-blockers) may mask early signs of shock Anti-hypertension drugs (beta-blockers) may mask early signs of shock Diuretics (Lasix, HCTZ) may make pt relatively dehydrated Diuretics (Lasix, HCTZ) may make pt relatively dehydrated

History Taking Probe for significant complaints Probe for significant complaints Chief complaint may be trivial, non-specific Chief complaint may be trivial, non-specific Patient may not volunteer information Patient may not volunteer information

History Taking Dealing with communication difficulties Dealing with communication difficulties Talk to patient first Talk to patient first If possible, talk to patient alone If possible, talk to patient alone Formal, respectful approach Formal, respectful approach Position self near middle of visual field Position self near middle of visual field Do not assume deafness or shout Do not assume deafness or shout Speak slowly, enunciate clearly Speak slowly, enunciate clearly

History Taking Do NOT assume confused or disoriented patient is “just senile!”

History Taking Obtain thorough medication history Obtain thorough medication history More than one doctor More than one doctor More than one pharmacy More than one pharmacy Multiple medications Multiple medications Old vs. current medications Old vs. current medications Shared medications Shared medications Over-the-counter medications Over-the-counter medications

Physical Exam Examine in warm area Examine in warm area May fatigue easily May fatigue easily May have difficulty with positioning May have difficulty with positioning Consider modesty Consider modesty Decreased pain sensation requires thorough exam Decreased pain sensation requires thorough exam

Physical Exam If they say it hurts, it probably REALLY hurts! EXAMINE CAREFULLY

Physical Exam Misleading findings Misleading findings Inelastic skin mimics decreased turgor Inelastic skin mimics decreased turgor Mouth breathing gives impression of dehydration Mouth breathing gives impression of dehydration Inactivity, dependent position of feet may cause pedal edema Inactivity, dependent position of feet may cause pedal edema Rales in lung bases may be non-pathologic Rales in lung bases may be non-pathologic Peripheral pulses may be difficult to feel Peripheral pulses may be difficult to feel

Trauma

Head Injury More likely, even with minor trauma More likely, even with minor trauma Signs of increased ICP develop slowly Signs of increased ICP develop slowly Patient may have forgotten injury, delayed presentation may be mistaken for CVA Patient may have forgotten injury, delayed presentation may be mistaken for CVA Decreased brain mass increases risk of ICH Decreased brain mass increases risk of ICH What change in the elderly accounts for increased ICP’s slower onset?

Cervical Injury Osteoporosis, narrow spinal canal increase injury risk from trivial forces Osteoporosis, narrow spinal canal increase injury risk from trivial forces Sudden neck movements may cause cord injury without fracture Sudden neck movements may cause cord injury without fracture Decreased pain sensation may mask pain of fracture Decreased pain sensation may mask pain of fracture

Hypovolemia & Shock Decreased ability to compensate Decreased ability to compensate Progress to irreversible shock rapidly Progress to irreversible shock rapidly Tolerate hypoperfusion poorly, even for short periods Tolerate hypoperfusion poorly, even for short periods

Hypovolemia & Shock Hypoperfusion may occur at “normal” pressures Hypoperfusion may occur at “normal” pressures Medications (beta blockers) may mask signs of shock Medications (beta blockers) may mask signs of shock Cardiac and renal disease make fluid resuscitation more risky. Cardiac and renal disease make fluid resuscitation more risky. Why can older persons be hypoperfusing at a “normal” blood pressure?

Positioning & Packaging May have to be modified to accommodate physical deformities

Environmental Considerations

Tolerate temperature extremes poorly Tolerate temperature extremes poorly Contributing factors Contributing factors Skin changes Skin changes Cardiovascular disease Cardiovascular disease Endocrine disease Endocrine disease Poor nutrition Poor nutrition Drug effects Drug effects

Environmental Considerations HIGH INDEX OF SUSPICION Any patient with altered LOC or vague presentation in hot or cool environment

Which came first?

Which came first? Trauma or… MI? MI? PE? PE? CVA? CVA? TIA? TIA? Dementia? Dementia? Intoxication? Intoxication? Spontaneous fracture? Spontaneous fracture?

Summary The elderly are coming. The elderly are coming. Minor mechanisms can create major injuries. Minor mechanisms can create major injuries. No complaint does not mean no injury. No complaint does not mean no injury. Minor injuries can cause major morbidity. Minor injuries can cause major morbidity. What came first: injury or the trauma? What came first: injury or the trauma? CV disease and medications can mask early signs of shock. CV disease and medications can mask early signs of shock. Lower threshold for transport to trauma center. Lower threshold for transport to trauma center.

Questions?

Thank you.