CRACKCast E039 – Geriatric Trauma

In CRACKCast, Featured, Podcast by Adam Thomas3 Comments

This episode of CRACKCast cover’s Rosen’s Chapter 039, Geriatric Trauma. We see more and more elderly patients in our trauma bay as our population ages, and there are important distinctions in the management of this growing population.

Shownotes – PDF Link

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Rosen’s in Perspective

  • GERIATRIC trauma is on the rise
  • Have increased morbidity and mortality
  • ATLS recommends that patients older than 55 years old be transferred to a trauma centre regardless of injury severity score
  • Mechanism of injury
    • Falls –  #1
    • MVCs
    • Ped. struck
    • Elder abuse
    • Suicide attempts
    • Burns

Need to think about whether a medical problem CAUSED the crash!

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1) Name 5 risk factors for falls in the elderly

  1. Cognitive impairment
  2. Vision and hearing loss
  3. Impaired thirst mechanism – dehydration, orthostatic hypotension
  4. Reduced respiratory reserve
  5. Cardiac disease – Arrythmias, poor CO, etc.
  6. Osteophyte-arthritis anywhere – joint pain, immobility, decreased ROM
  7. Loss of fine motor skills and sensation
  8. Pharmacy – medications affecting cognition, balance, cardiac function
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2)  What anatomic and physiologic changes in the elderly patient are important for the management of trauma in the elderly patient? (changes in the CVS, CNS, Resp, MSK, skin)

  • Effects of aging:
    • decreased Functional residual reserve [organs have less capacity?]
    • multiple comorbidities
  • Decreased physiologic reserve
    • less able to compensate for hypovolemia and stress
  • Comorbidities
    • Arthritis / CAD / COPD / CVA / DM
  • Effect of medications
    • 30% have  >5 meds including ASA and BB and hypnotics
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Modifications of the Trauma Assessment of older adults

  • Same primary and secondary survey approach
  • Usual vital sign abnormalities are absent:
    • hypotension / tachycardia / pain
  • Normal vital signs should NOT be reassuring

Primary assessment and resuscitation in geriatric trauma

AIRWAY

  • Have multiple predictors of difficult airway
  • Consider early intubation
  • Consider VL rather than DL given reduced C-Spine and jaw mobility
    • “denture-less-ness” will help you out here!!!

At higher risk for hypotension

  • Reduced dosages of RSI meds (3/4 to 1/2 dose) [paralytic should be same?]
  • Careful use (if any at all) of succinylcholine given risk for hyperkalemia
  • Rocuronium 1mg/kg is preferred

BREATHING

  • High flow O2 recommended given reduced FRV
  • more prone to tire easily

CIRCULATION

  • blunted stress response with less physiologic reserve and medications alter normal response to shock
  • normotension may indicate hypotension given baseline hypertension.
  • control bleeding (e.g. scalp)
  • catheter to monitor urine output
  • small 500 ml boluses with reassessments, GIVE BLOOD asap if needed

REVERSAL of anticoagulation

  • PCCs
  • FFP
  • Vit K.
  • Octaplex.

DISABILITY

  • Assessment for TBI / Spinal cord injury / Vertebral fractures
  • Components
    • GCS (any score <15 = likely TBI)
    • Pupils
    • Mental alertness / headache (may have VERY subtle signs of TBI)

At high risk for C-Spine fractures (to be discussed shortly)

  • No rules exist to exclude the elderly from imaging, so imaging should be performed
  • Canadian C-Spine – excludes >65
  • Nexus included all ages, but most elderly people have C-Spine tenderness
  • At increased risk for T, L, S spine fractures which are best imaged on CT
  • AT higher risk for SCIWORA due to spinal stenosis and kyphosis

***high risk for central and anterior cord syndromes***

EXPOSURE

At risk for hypothermia due to:

  • Skin thinning
  • Decreased muscle, increased fat
  • Impaired thermoregulatory mechanisms
  • Prolonged exposure

Remove from backboards ASAP

Tetanus

Secondary assessment

  • Complete history
  • Screen for alcohol and substance abuse or elder abuse

LAB TESTING

  • Trauma labs WITH troponin

IMAGING

  • CT!
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What specific disorders should we watch out for in geriatric trauma?

[1] Traumatic brain injury

  • Common, may be asymptomatic (more space for blood to go)

Pathophysiology:

  • Frequent anticoagulant use
  • Brain size decreases by 10%
  • Less tortuous bridging veins and increased intracranial free space –> mobile brain –> ICH
  • Pre-existing cognitive impairment

Assessment and Diagnosis:

CT, INR

***clinical variables alone are insufficient to rule out injuries***

  • all excluded from the new orleans or CT head rule (<65)

Treatment:

  • Supportive care; reversal of anticoagulation; surgical decompression

Avoid

  • Cerebral hypoxia
  • Hypoperfusion

Ensure to:

  • Get early invasive hemodynamic monitoring
  • Get early neurosurgery consultation to inquire re: ICP monitoring and decompression
  • Reverse coagulopathy

Prognosis and disposition:

  • Morbidity increased with comorbidities, anticoagulation, low GCS, etc.
  • If normal INR and CT may be discharged to a reliable home for observation

[2] Thoracic trauma

  • higher risk for rib, sternal #, pulmonary contusions,  pneumothorax (due to COPD)
  • risk for pneumonia
  • due to pain, and splinting –> atelectasis
  • need admission for pain control and chest physio/incentive spirometry

[3] Abdominal Trauma:

  • Goal is early dx and close monitoring
  • Physical exam is UNRELIABLE
  • > grade III splenic injuries usually fail nonoperative management
  • May have a role for angiography for blush or extravasation

[4] Extremities

In order of fracture frequency:

Upper extremity: distal radius > proximal humerus > elbow

Lower extremity: ankle # > hip and pelvic > tibial plateau

Pelvis # : usually lateral compression – > at higher risk for hemorrhage

  • 80% mortality rate if open
  • Need resuscitation, binding, blood, angiography

Hip fractures

  • 15% 1 yr mortality
  • Plain xray : 90% sensitive

[5] End of life decisions

Grave prognosis if:

  • GCS < 8 with anticoagulation
  • GCS 3

Initial injury in the ED does not accurately predict long term prognosis. We need to have discussions with family members re: goals of care, life support, life support measures, etc.

SUMMARY:

  • OCCULT injuries with low force are the norm : [ J- so image like hell?]
  • Vital signs are unreliable
  • Look for other indicators
    • mental status, urine output, skin perfusion
  • Use invasive monitoring
  • Low threshold for imaging
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3) What are the most common c-spine injuries in the geriatric trauma patient?

Vertebral fractures and spinal cord injuries

  • Age changes put seniors at higher risk : OA; spinal stenosis:
    • Symtoms of spinal stenosis: myelopathy, impaired coordination, gait, bowel/bladder dysfunction, abnormal motor/sensory function
  • More likely to have partial neurologic injuries

Three main types of injuries:

[1] Central cord syndrome: “hyperextension injury”

  • J- Mechanism is buckling of flava flav….  [yea boii] .. i mean ligamentum flavum
    • weakness in Arms > legs
    • often have NO fracture, but have pre-existing spinal stenosis
    • painful hyperesthesias
    • usually stable, need immobilization
    • may need surgery

[2] Cervical extension-distraction injuries: “hyperextension: face or forehead trauma” 

  • Caused by reduced ROM — degenerative spondylolysis/disk space collapse/osteophyte formation
  • pt. may report that they are able to extend their neck more than they used to =  “open book” fracture
  • UNstABLE

[3] Odontoid fractures:

  • Fall with impact to head
  • <10% cause neuro deficits
  • ****Type II (base of the dens) are the most common***
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This post was uploaded by Riley Golby (@RileyJGolby).

Adam Thomas

CRACKCast Co-founder and newly minted FRCPC emergency physician from the University of British Columbia. Currently spending his days between a fellowship in critical care and making sure his toddler survives past age 5.

Chris Lipp

Chris Lipp is one of the founding Fathers for CrackCast. He currently divides his time as an EM Physician in Calgary (SHC/FMC) and in Sports Medicine (Innovative Sport Medicine Calgary). His interests are in paediatrics, endurance sports, exercise as medicine, and wilderness medical education. When he isn’t outdoors with his family, he's brewing a coffee or dreaming up an adventure…..