1. Trauma in the Elderly and Pregnant Woman

2. Introduction  In the pregnant trauma patient there are two patients potentially at risk  Need to consider the influence of: - pregnancy related anatomic changes - pregnancy related physiological changes

3. Incidence and aetiology of trauma in pregnancy  A major contributor to maternal mortality worldwide  In NZ, Australia, UK and USA trauma is the leading cause of associated maternal deaths  2/3’s : MVA  1/3: - domestic violence - assaults - suicide  Pregnancy is a risk factor for being assaulted

4. Types of trauma  Penetrating (knife, foreign object) - foetus at greater risk with enlarge uterus - indications for laparotomy same as for non pregnant woman  Blunt ( MVA, assault)  Burns - Foetus: - consider fluid loss, hypoxaemia and sepsis - Pregnant woman - admit for smoke inhalation etc, add %5 to estimation if anterior abdomen involved in burn

5. Mechanisms and Prevention MVC: MVC: leading cause of blunt injury Only 46% pregnant trauma patients are restrained Fears about seat-belt related harm to fetus Unbelted has 2x risk of premature birth and 4x risk of fetal death Only 17% women counselled on appropriate use Lap belt low at the pelvic brim Violence: Violence: significant cause of blunt and penetrating injury ALWAYS HAVE A HIGH INDEX OF SUSPICION Rule out domestic & sexual violence

6. Four groups of Trauma patients to consider  The patient that is injured but unaware they are pregnant - all women should be considered pregnant until proven otherwise - Teratogenic effects  The pregnant patient where gestation < 26 weeks - maternal resus primary goal  Where gestation >26 weeks - two patients to consider  Perimorteum state - early caesarean: maternal resus, fetal survival

7. Anatomy  Uterine enlargement - 12 weeks, 20 weeks and 36 weeks - at 20 weeks fundal height at umbilicus  Uterine wall thins  Amniotic fluid  Placenta  Descent of foetal head  Upward displacement of - GIT - Diaphragm

8. Estimated Foetal Age  1 st trimester uterus is thick walled and intra-pelvic  Out of pelvis > 12 weeks  2 nd trimester uterus contains a large amount of amniotic fluid  3 rd trimester uterus is thin walled, large, fetal head engages pelvis  At 36 weeks uterus reaches costal margin  Ensure distended abdomen is 2 dary to fetus and not blood

9. Physiological changes in pregnancy  Cardiovascular  Respiratory  Haematological  Gastrointestinal  Neurological  Renal

10. Cardiovascular  Increases Cardiac output from first trimester  CO markedly increased by 20 weeks  HR increases by 15 beats/min  BP decreases by 10 mmHg, nadir @ 20 weeks, then increases to pre-pregnancy values @ term  Decreased peripheral vascular resistance  Increased volume of distribution secondary to placenta  Maternal haemorrhage is compensated for by foetal distress ( compare to non pregnant where the patient would become tachycardic and hypotensive

11. Supine Hypotension Syndrome  30 degree tilt after 20 weeks  Loss of 30% blood volume before symptomatic  Low venous return when supine ( up to 30%)

12. Respiratory System  By 20 weeks, decrease in FRC and an increase in tidal volume  No changes in FEV1 and respiratory rate  Respiratory Alkalosis: - secondary to physiological hyperventilation - resulting decrease in PaCO2, increase in PaO2 and a decrease in bicarbonate concentration

14. Haematological System  Plasma volume increases by 45% (6-8 weeks)  Physiological anaemia - dilutional effect  Increased red cell mass  Haemoglobin 105/L  WCC 6,000 – 16,000 ( 1 st and 2 nd trimester)  WCC 20,000 – 30,000 (periparteum)  Hypercoagulable state  Fibrinogen concentration increases

15. Gastrointestinal System  Increased risk of gastric aspiration: - secondary to increase in intra-abdominal pressure - and relaxation of the lower oesophageal sphincter  Delayed gastric emptying  In a Trauma patient do early gastric decompression

16. Neurological  Enlarged pituitary - result more susceptible to shock  Pre-eclampsia - don’t forget this mimics head injury  Consider doses and which anaesthetic drugs to use

17. Renal System  Glomerular hyper filtration -- therefore a reduction in normal plasma creatinine (35-40 mmol/l)

19. Case 1  27 year old female 8 months pregnant  Unbelted passenger involved in a high speed MVA  On arrival:  What next?  primary survey unremarkable  Obvious seat belt sign over pregnant abdomen

20. Seat belt

21. Vital Signs enroute  HR 104/min  Respiratory Rate 25/min  BP 104/54  SpO2 98% on room air

22. On arrival  Patient is confused, agitated and not following commands  She is breathing rapidly and shallowly  Her Vital signs are now: - HR 120/min - BP 90/40 - SpO2 92% on 2l Nasal Prongs

23. Examination  She has bruising to her abdomen  There is subcutaneous emphysema of the chest wall  What now? ? Intubation ? Fast Scan  How sensitive is a fast scan in pregnancy?  How are you going to manage her airway?

24. FAST SCAN  Is less sensitive for free fluid in the pregnant patient than in non-pregnant patients  Sensitivity decreases with gestational age secondary to altered fluid flow in the abdomen  Remember small amounts of intraperitoneal fluid normally present in pregnancy

25. How do you Know she is Pregnant?  Ask her?  bhCG on all women of childbearing age - bHCG doubles q 1.6 days early on then q 3 -4 days by 7 th week - if > 18000 can see gestational sac  Ultrasound / FAST - 11% pregnancy diagnosed in the trauma room

26. Outline of Trauma in Pregnancy  Primary survey and resuscitation of mother  Foetal assessment and detecting injury  Secondary survey of mother with special considerations  Perimortem Caesarean section - fetomaternal haemorrhage - imaging - medication  Critical Care concerns  Mechanism & Prevention EARLY OB CONSULT

27. Trauma in Pregnancy  Hospitalization in 0.4% of pregnant women  Leading cause of non-obstetrical mortality  Causes of death Mother head injury foetus - maternal shock - placental abruption - direct injury (GSW to fetus or pelvic fractures of mother  What do I need to do care for the unborn child? - CARE FOR THE MOTHER

28. Mother - Initial Management  A : Endotracheal intubation, avoid nasal passages  B: (pre)oxygenate well ( will desaturate < 1min)  Watch potential for aspiration, watch chest tube placement  C: foetal distress first sign of maternal hypotension - Supine Hypotensive Syndrome (SHS) (tilt to left >20 wks)  D: Eclampsia vs brain injury  E: Estimate age of foetus

29. Resuscitation  Call for help early - multidisplinary team - involve an obstetrician  Displace uterus laterally and left if above umbilicus  Assess ABC  Estimate gestational age if not known  Uterine fundus > 4 finger breaths above umbilicus at 4 months  If defibrillation, remove foetal monitoring equipment

30. Tilt to left

31. Why displace uterus laterally?  After 20 weeks gestation, uterus may compress great vessels when patient supine  The compression causes: - decrease in systolic BP up to 30 mmHg - 30% decrease in stroke volume - Result decreased uterine blood flow  Manual deflection or placement of patient in lateral decubitus position avoids uterine compression

32. Mother Physiology  A: friable mucous membranes (E2), decreased LES tone, increased abdominal pressure  B: higher diaphragm – 20% less FRC, 20% increased oxygen consumption  Increased Vt and minute ventilation (50%)  C: Elevated HR (10-15), SV (23%), CO (25 – 43%) – anaemia with hypervolaemia  - lower SVR, BP 10 – 15 mmHg/lowest 2 nd trimester  Low venous return when supine (30% C))  BLOOD > 10 weeks increasing plasma (45% at term) > increased RBC (15-30%) - CAN MASK UP TO 30% blood loss  Hypercoagulable state

33. Respiratory Support  Supplemental oxygen  Anoxia develops more quickly in advanced pregnancy like this case because of the respiratory physiology during pregnancy - increased RR (40 to 50%) - oxygen consumption increased by 15 to 20% at rest - PaO2 increased - PaCO2 decreased - decreased bicarbonate  Aim for oxygen saturations > 95%  ABG for PaO2 and PaCO2  Placental oxygenation good when PaO2> 70 mmHg

34. ? Chest Tube for this pregnant patient?  Yes surgical emphysema  Remember diaphragm in a higher position - Result: place chest tube one or two interspaces higher

35. Cardiovascular  Signs of maternal haemorrhage? - look for foetal distress  NOTE: significant blood loss can occur in the uterine wall or retroperitoneal space without external bleeding  30% maternal blood loss before respiratory distress

36. Volume Replacement  2 large bore IV lines  Volume replacement superior to vasopressors that can reduce uterine blood flow initially  Continue until hypovolaemia, hypoxia and foetal distress resolve  Aim to maximise uterine perfusion and oxygenation  Start blood transfusion if significant blood loss suspected or occurred

37. Abdominal changes in pregnant woman  Pregnant women sustain abdominal trauma more easily  The enlarged uterus - protects against visceral injury from lower abdominal penetrating injury - protect retroperitoneal structures  Penetrating injuries above uterus are more likely to cause bowel injuries  Rebound tenderness and guarding less prominent

38. Increased vascularity and blood flow  Dilated pelvic vasculature - increased risk of retroperitoneal haemorrhage from abdominal and pelvic trauma  Blood flow to uterus 600ml/min  Foetal oxygenation is dependent on uterine blood flow, there is no autoregulation  Uterine blood flow also reduced by - vasoconstriction (drugs) - maternal hypercarbia and hypocarbia

39. Complications of Trauma Often life-threatening  Uterine rupture  Placental abruption  Amniotic fluid embolism  Fetomaternal haemorrhage and alloimmunization  Preterm labour  Premature rupture of membranes  Serious pelvic injury can lead to maternal hypotension as a result of direct injury to foetus, uterus, placenta and uterine vessels

40. Causes of maternal death  Most are due to head trauma or haemorrhage shock

41. Commonest cause of Foetal death  In severe maternal injury, it is maternal death  In “minor” injury it is placental abruption

42. Factors associated with increased foetal mortality  Maternal hypotension  High maternal injury severity score  Ejection from motor vehicle  Maternal pelvic fracture  Car vs pedestrian  Maternal history of alcohol use  Motorcycle crash  Maternal smoking history  Uterine rupture  Ref American Family Physician October 2004: 70 (7) p1303

43. Foetal Viability by age Beyond umbilicus is likely viable (> 24 weeks)

44. Foetal Assessment Avoid fetal hypoxia at all costs Maternal blood oxygen content Uterine blood flow Fetal oxygen dissociation curve is shifted to left: small change in maternal PaO 2 = large change in fetal oxygen saturation Avoid maternal hyperventilation Maternal alkalosis poorly tolerated Leads to uterine vasoconstriction

45. How Do I manage the Foetus  Resuscitate the mother  Oxygen & blood  Monitor the fetus  cardiotocographic monitoring (CTM)  if >20 weeks, x 6 hrs (EAST Guidelines, 2005)  Watch for warning signs of injury to the fetus  Vaginal bleeding, fetomaternal hemorrhage, uterine contractions, uterine rupture, placental abruption, premature labour  Fetal distress is often first sign of maternal hypotension

46. Foetal Injury  Treat maternal injuries first  Uterine rupture: rare, rapidly fatal  Placental abruption: 3-50% of trauma - >50% fatal for foetus - Uterine contractions, pain, bleeding 78%) - Can lead to DIC, haemorrhagic shock, renal failure  Can bleed profusely with pelvic fracture due to dilated veins - Foetus rarely directly injured until 3 rd trimester (skull, long bones)  Kleihauer-Betke(KB) test to detect foetal blood mixed into maternal blood

47. Foetal Monitoring Uterine contractions:  A) Uterine contractions: 90% stop spontaneously Fetal HR:  B) Fetal HR: Normal HR (120-160) Beat to beat variability Baseline variability Decelerations (esp. late)

49. Foetal Monitoring

50. Case:  She becomes hypotensive  - how do you manage this?  She now goes into cardiac arrest in the resuscitation bay after CT  - how do you manage this

51. How do you CPR in a pregnant Trauma patient?  External chest compression more difficult - decreased chest compliance  Hand position on sternum - above centre - need to accommodate for upward displacement of the diaphragm by gravid uterus  May be not effective 2 nd and 3 rd trimester: - aortacaval compression - decreased cardiac output  May require a caesarean to perform effective CPR - within 4-5 minutes

52. Secondary survey  Medical and Obstetric History  Head to toe physical examination  Include a pelvic examination to identify: - vaginal bleeding - ruptured membranes - bulging perineum  Log roll to the left  Consider imaging  Bloods: FBC Coags, U & E’s KB test ( kleihauer – Betke test for patients in their 2 nd and 3 rd trimester)

53. Secondary Survey and Considerations Secondary Survey: Secondary Survey: Pelvic examination: ◦ Vaginal bleeding ◦ Ruptured membranes ◦ Bulging perineum ◦ Prolapsed cord Ongoing CTM: ◦ Presence of contractions ◦ Abnormal fetal heart rate and rhythm Special considerations: Special considerations: Fetomaternal hemorrhage Imaging Medications

54. Consider Domestic violence  Pregnancy often represents dependency and loss of autonomy and control  Abusers will take advantage of this  Think of it as a possibility  Look for signs - emotional withdrawal, depression, self-blame - look for signs of older injury

55. Imaging Concerns Do not defer imaging as pt. is pregnant (benefit outweighs risk) i.e. Fetal risk of harm less than risk of death/ harm from missed injuries or delays in treatment Risk related to ionizing radiation and IV contrast CXR: 0.001 radsCT abdo/pelvis: 0.6-5.0 rads Teratogenicity: Fetal exposure to 10 – 50 rads in first 6 weeks of gestation Oncogenicity: Increased risk of childhood leukemia's (RR 1.5-2.0) Other: Mental retardation with 5 – 15 rads at 8-15 weeks No increase in fetal anomalies or pregnancy loss if < 5 rads exposure (American College of Obstetrics & Gynecology) Therefore exposure to < 5 rads is safe Therefore exposure to < 5 rads is safe

56. Diagnostic Imaging  Foetus most vulnerable during 1 st 15 weeks of gestation  Risk of radiation is small compared to risk of missed or delayed diagnosis of trauma  X-rays of extremities, CT scan of head and neck should be undertaken if necessary  USS can assess solid organ injury, intraperitoneal fluid, gestational age, fetal activity, foetal presentation, placental location and amniotic fluid volume  USS is not as reliable an indicator in recent placental abruption

57. CT scan

58. Fetomaternal haemorrhage Mixing of fetal blood into maternal circulation Complications: ◦ Maternal isoimmunization ◦ Mother Rh (-), fetus Rh (+) ◦ Fetal exsanguination KB test to detect fetal Hb in maternal circulation ◦ All pregnant women > 12 weeks gestation ◦ Watch false positives with sickle cell trait RhoGAM® RhoGAM® if KB test positive 300  g IM (72 hr. window), repeat in 12 weeks + 300  g for each 30ml of fetal-maternal transfusion

59. Medication Concerns A) Direct risk of teratogenicity or death to the foetus SAFE  Tetanus toxoid  Fentanyl, morphine  LMW Heparins  Propofol  Cephalosporins  Penicillins

60. AVOID  Benzodiazepines  Metronidazole  Warfarin  Pancuronium  Furosemide  Prednisone

61. Direct risk of placenta vasoconstriction and hypoxia  Most vasoconstrictors

62. Caesarean Delivery  Urgent delivery if imminent maternal death  CPR not successful within 4 minutes  Stable mother, non-reassuring CTG  During laparotomy, gravid uterus prevents adequate surgery for injuries  Perimortem Caesarean section for optimum survival of foetus an mother if within 4 min - irreversible brain da,mage after 4 – 6 min - pregnant patient anoxia sooner - Effective resuscitation with empty uterus - Improved fetal survival with shorter time to delivery

63. Summary In pregnant trauma usual ABC management principles apply BUT need to be more vigilant In pregnant trauma usual ABC management principles apply BUT need to be more vigilant Oxygen and IV fluids for all If mom >20 weeks, tilt left side down Best chance for fetus is to treat mother well Best chance for fetus is to treat mother well If mom Rh (–) think of Rhogam Don’t defer important imaging Give appropriate medications Involve obstetricians early in the trauma Involve obstetricians early in the trauma Estimate fetal age Prevention is best medicine Prevention is best medicine

64. References  Queensland Clinical Guidelines Trauma in pregnancy 2014  Guidelines for the management of a pregnant trauma patient by Society of Obstetricians and Gynaecologists of Canada June 2015  Imaging of the Trauma in a pregnant patient (Seminars in USS CT and MRI 2012)  Trauma management of the pregnant patient Critical Care Clinics 32 (2016) 109-117  Blunt Trauma in Pregnancy American Family Physcian 2004 (70) 7 1303 – 1310  Trauma in the pregnant patient: an evidence based approach to management EBMEDICINE.Net April 2013 (15) 4

65. Trauma in the elderly patient

66. What are the issues in trauma in this group  Mechanisms of trauma  Are the injuries different than in the younger age group?  Should you use a different diagnostic approach?  Do therapeutic options differ for these patients?  Are they often under triaged because of their age?

67. Epidemiology  People have a longer life expectancy ( 82 years by 2050)  Rapid increase in “older” adult population  By 2030 1 in 5 people will be > 65  They are more independent and have a more active lifestyle than in previous generations  Result: more injuries

68. The realities of growing old

70. Mobility scooter racing

71. Geriatric marathons

72. General  The elderly account for 10 to 12% of all trauma victims  They consume a significant amount of health care resources ( up to 255 of trauma related)  They have higher mortality rates  Higher complication rates

73. Definitions  Elderly = over age 65 years  Young- old = 65 – 80 years  Old old = over age 80 years  ATLS Recommendations: - all traumatized patients > 55 should be considered for evaluation in a trauma centre - physiological age more important than chronologic age

74. “Joys” of growing old: Physical realities  Loss of hearing  Deteriorating vision  Weakening of musculoskeletal system  Breakdown of skin hydration/replacement cycle  Body becomes less efficient  Existence of multiple chronic diseases  Multiple medications

75. Cardiovascular  Less cardiovascular reserve  Less vascular compliance  Less cardiac compliance  Diminished catecholamine response ( less beta receptor activity)  Poor AV conduction/loss of pacemaker cells  Decline in cardiac index linearly with age ( CO(SV x HR)/BSA  Respond to hypovolaemia with increased SVR vs increased CO  Unable to tolerate and respond to fluctuations in blood volume

76. CVS continued  Underlying CAD increases risk of myocardial infarction ( 50% pts> 65 have CAD) - hypoxia - anaemia - hypotension  Medications affect response to trauma - beta-blockers - calcium channel blockers - diuretics

77. CVS  Hypertension - ? Baseline BP, may mask early shock - 110 the new SBP not 90  CHF  Dysrhthmia  PVD

78. Respiratory  Lung less compliant  Increased dead space - hypoventilation/illness/immobility  VC, FEV1, PaO2 decrease with age  Increased residual volume  Respiratory muscle weaker in the elderly  Airway management may be affected by changes in the aging  Chest wall more rigid and brittle - result more prone to traumatic injuries

79. Respiratory continued  Diminished alveolar surface - diminishes max O2 uptake by as much as 55%  Less responsive to hypoxia  Less cilia  Chromic lung disease - Restrictive/obstructive - hypoxia/hypercarbia

80. Neurological  Dura adherent to inside of skull  Brain atrophies - more tendency to move inside skull during trauma - more likely to develop CNS bleeds  Spinal stenosis can complicate evaluation  Cognitive impairment increases with age  Decreased reaction times

81. Musculoskeletal  Osteoporosis - more prone to fractures  Decreased joint mobility - spinal column problematic  Vertebral compression  Kyphosis/lordosis

82. Medications  Anticoagulants - increased risk of bleeding  Cardiac medications - beta and calcium-channel blockers - affect response to volume loss  Diuretics - volume contraction - potassium depletion

83. Predisposing factors for trauma  Diminished sight  Problems with gait/coordination - impaired sensation/proprioception - muscle weakness - degenerative joint disease - neuromuscular disorders - dementia  Diminished hearing

84. Renal/urinary  Renal perfusion decreases by 10% per decade  Hormonal response decreases (vasopressin) - impaired sodium retention  Less bladder capacity/compliance  Chronic renal failure/impairment  Nephrotoxic medications/infusions  Hydration status

85. Characteristics of injury in the elderly  Mores severe response to any given mechanism  Decreased ability to respond to trauma  Trauma can trigger/exacerbate pre-existing medical problems  Patterns of injury differ in the elderly

86. Mechanisms of Injury  What is the most common mechanism of injury in the elderly?  What is the most common LETHAL mechanism of injury in the elderly?

87. Mechanisms  Falls  MVA  Car vs pedestrian  Elder abuse/assault/burns  Penetrating trauma

88. Falls  Most common mechanism  40% of elderly trauma  3.8% of elderly have a significant fall each year  Ground falls most common  Usually occur at home  28% of falls due to an underlying medical condition  MUST determoine cause of fall

89. Injuries sustained from falls  Fractures 8%  Major injuries 10%  Peri-injury fatality rate from falls 12%  50% will die within one year of fall  Head injuries a significant problem - 1 in 50 may require neurosurgery - up to 16% will have n abnormal CT ( contusion 36%, Subdural 33%) - highest risk fall on stairs or from height - fall from a standing position still a significant risk

90. MVA second most common mechanism  28-30% of all trauma in the elderly  Fatality rate 21%

91. Accident Characteristics MVA  Occur in daytime  Close to home  At an intersection  Usually involve 2 cars  Frequently due to a syncopal episode  Less likely due to alcohol, excessive speed or reckless driving

92. Auto vs Ped  Third most common mechanism  Accounts for 9 to 25% of trauma case  Fatality rate - 30 -55% - most common lethal mechanism

93. Specific Injuries  Spinal  Head  Chest  Aortic  Abdominal  Extremity  Soft tissue

94. Spinal  Aging predisposes to spinal injury  Most common mechanism is falls  Requires extreme caution  Low threshold to image spine  Bony injuries - most commonly occur C1 – C3 - type II odontoid fracture most common  Spinal cord injuries - often from hyperextension - central cord syndrome

95. Spinal  Mortality rate 26%  Thoracic and lumbar spine - compression fractures most common - may occur with minimal trauma - common in osteoporotic patients -

96. Head Injury  Most common mechanism is falls  Types of injury - Cerebral contusion - lower incidence than younger patients - epidural haematomas - dura adheres to inside of skull - subdural haematomas - more common with age - stretching of bridging veins - greater movement of atrophied brain - more likely to be on anticoagulants

97. Head Injury  Assessment difficult - history may be difficult to obtain - subtle alterations in baseline mental status difficult to evaluate - may mimic dementia  Low threshold to get head CT - isodense SDH at 7 – 20 days after injury - may need iv contrast - often undertriaged

98. Head injury  High mortality and morbidity - survival to discharge 21% - favourable outcome 11% - mortality higher still if patient over 80 ( 4x

99. Chest Injuries  Chest Wall injuries - Highly morbid and mortal injuries - predisposing factors chest wall more rigid osteoporosis less pulmonary reserve

100. Chest Injuries  Rib Fractures - more common injury - more prone to complications ( pneumonia, hypoventilation) - Lap-shoulder belts do not prevent these injuries - actually may cause them - check for rib fractures, sternal fractures, flail chest

101. Aortic injuries  Suspect if mediastinum > 8 cm  Low threshold to perform CT chest or aortogram

102. Abdominal Injuries  Seen in up to 30% of elderly trauma victims  Abdominal USS unreliable  CT if haemodynamically stable  Mortalit rte 4 – 5 times higher than in younger patients

103. Management of Elderly Trauma patient  Pre hospital - rapid transportation - early assessment - information from witnesses/prehospital personnel key  Watch closely for rapid deterioration

104. Airway/breathing  All need supplemental oxygen  Airway management maybe difficult  BMV - cachexia, edentulous  Intubation - decreased mouth opening - decreased neck mobility - RSI drugs choices maybe limited by pre-existing medical conditions

105. Circulation  Fluid/ blood resuscitation may be complicated by pre-existing medical conditions  Medications alter response to resuscitation

106. History  What happened BEFORE the trauma  Fall - consider syncope, hypovolaemia, CV or CVA, alcohol  Single Car MVA - consider acute medicl event

107. Traps  BP - may be deceivingly normal - many patients have underlying hypertension - increasing SVR is response to hypovolaemia  Pulse - maybe falsely normal - medication effects - decreased catecholamine response

108. Imaging  Spine plain plus CT  CXR  Echocardiography  FAST  Head CT

109. References  ACS TQIP Geriatric Trauma Management Guidelines American College of Surgeons 2014  Evaluation and management of geriatric trauma An eastern association for the Surgery of Trauma practice management guideline J Trauma Acute Care Surg (73) 5 supplement 4 S345 –S369  The Changing face of major trauma in the UK Emerg Med J 2015;32:911-915  Polytrauma in the elderly: predictors of the cause and time of death Scandinavan Journal of Trauma, Resuscitation and Emergency Medicine 2010 18-26  Injury in the aged: Geriatric Trauma at the crossroads Review Trauma Acute Care Surg (78) 6 2015 1197-1209  Systolic Blood pressure criteria in the national Trauma Triage Protocol for geriatric trauma 110 is the new 90 J Trauma Acut Care Surg 78 (2) 352-359