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Home , Geriatric trauma

10/22/19

Conflict of Interest Disclosure

• Bryan E. Bledsoe, DO, FACEP, FAEMS • No conflicts of interest to disclose Assessment of Geriatric Trauma

Bryan E. Bledsoe, DO, FACEP, FAEMS Professor and Surgery (Trauma) UNLV School of Medicine Las Vegas, Nevada

Geriatric Trauma Assessment Geriatric Trauma Assessment

• Percentage of the population over • Falls are the most common 60 years of age is growing faster cause of trauma in patients than any other age group: >65 (48-72%): • Longer life expectancy • Morbidity and mortality • Lower birth rates correlates with frailty and age. • Identified risk factors: • Trauma population getting older: • Previous falls • Active lifestyle (predisposes to • Living alone ) • Walking aid • Advances in medical care in • Depression general • Cognitive deficit • Use of >6 medications

Geriatric Trauma Assessment Geriatric Trauma Assessment

• MVCs are the second most • Auto-pedestrian trauma in the common type MOI in geriatric elderly: trauma and the most common • Geriatric patients secondary to cause of mortality. children in the incidence of auto- pedestrian trauma. • Chest trauma most common • Highest mortality rate in (23%): geriatric trauma is an auto- • Rib fractures (24%) pedestrian mechanism. • (10%) • Sternum fracture (6%)

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Geriatric Trauma Assessment Geriatric Trauma Assessment

• Anticoagulants increase risk of • Under- in geriatric trauma hemorrhage in the elderly. assessment common (49% in one study). • Anticoagulants: • Direct oral anticoagulants (DOACs): • Traditional physiologic criteria • Dabigatran (Pradaxa) may not truly detect the unstable • Rivaroxaban (Xarelto) geriatric trauma patient. • Apixaban (Eliquis) • CDC recommends any trauma • Edoxaban (Savaysa) patient >65 years with systolic BP • Vitamin K antagonists (VKAs): <110 mmHg should go to a trauma • Warfarin (Coumadin) center. • DOACs appear safer than VKAs. • Pulse rate ≥90 may indicate tachycardia and • Most patients do well. transport may be beneficial.

Evolving conventional wisdom is that all trauma patients >70 years of age should be transported to a trauma center.

Geriatric Trauma Assessment Geriatric Trauma Assessment

• Airway • Circulation: • Mouth opening may be limited. • Normal vital signs may be abnormal in the geriatric trauma patient. • High cervical fractures (e.g., odontoid) are more common in the elderly and • Shock is more difficult to detect (normal BP in an older patient may actually manipulation of the head for airway care may compromise cervical spine. be hypotension). • Medication usage (more common in the elderly) can alter the normality of • Breathing vital signs. • Diminished respiratory capacity in the elderly. • Trending vital signs more important than a single set in determining impending shock. • Be alert for hypoxia and treat. • Mortality increases when systolic BP falls below 110 mmHg and/or heart • BVM ventilation easier if dentures (if present) are left in place. rate rises above 90. • Respiratory rate <10 is associated with great risk of death. • Tachycardia (heart rate >90) in a geriatric patient must be explained. It is • Consider CPAP/NIPPV before intubation. shock until proven otherwise.

Geriatric Trauma Assessment Geriatric Trauma Assessment

• Circulation: • Secondary Assessment: • Look for more subtle signs and symptoms of shock in a “normotensive” geriatric • Look for not readily apparent. trauma patient: • Systematic survey essential. • Confusion • Agitation • Common injuries (can occur with even minor MOI): • Head injuries (especially on anticoagulants) • Somnolence • Delayed capillary refill • Cervical spine injuries (Canadian C-Spine vs. NEXUS) • Mild tachypnea • Chest injuries (rib fractures, flail chest, /) • Decreased urinary output • Abdominal injuries (bruising, tenderness) • Disability: • Extremities (fractures more common) • Hip, pelvis, clavicle • Difficult. Inquire about anticoagulant usage. • Spine (compression fractures, wedge fractures) • Inquire about baseline mental status (e.g., dementia, confusion). • Skin (greater propensity to tear, lacerate, avulse)

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Geriatric Trauma Assessment Geriatric Trauma Assessment

• Summary: • Determine the mechanism of injury (often subtle) • Primary assessment: • ABCDE • Secondary assessment: • Systematic examination • Review of medications • Determine baseline health and functional status • Assess cognition • Determine priority/destination • Err on the side of caution (avoid undertriage) • Virtually all geriatric trauma should to a designated trauma center (especially >70 years of age)

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