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S13049-021-00922-1.Pdf Eichinger et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2021) 29:100 https://doi.org/10.1186/s13049-021-00922-1 REVIEW Open Access Challenges in the PREHOSPITAL emergency management of geriatric trauma patients – a scoping review Michael Eichinger1* , Henry Douglas Pow Robb2, Cosmo Scurr3, Harriet Tucker4, Stefan Heschl5 and George Peck6 Abstract Background: Despite a widely acknowledged increase in older people presenting with traumatic injury in western populations there remains a lack of research into the optimal prehospital management of this vulnerable patient group. Research into this cohort faces many uniqu1e challenges, such as inconsistent definitions, variable physiology, non-linear presentation and multi-morbidity. This scoping review sought to summarise the main challenges in providing prehospital care to older trauma patients to improve the care for this vulnerable group. Methods and findings: A scoping review was performed searching Google Scholar, PubMed and Medline from 2000 until 2020 for literature in English addressing the management of older trauma patients in both the prehospital arena and Emergency Department. A thematic analysis and narrative synthesis was conducted on the included 131 studies. Age-threshold was confirmed by a descriptive analysis from all included studies. The majority of the studies assessed triage and found that recognition and undertriage presented a significant challenge, with adverse effects on mortality. We identified six key challenges in the prehospital field that were summarised in this review. Conclusions: Trauma in older people is common and challenges prehospital care providers in numerous ways that are difficult to address. Undertriage and the potential for age bias remain prevalent. In this Scoping Review, we identified and discussed six major challenges that are unique to the prehospital environment. More high-quality evidence is needed to investigate this issue further. Keywords: Prehospital care, Triage, Geriatric trauma, Traumatic injuries, Trauma Introduction the UK [2]. Frailty, multi-morbidity and advanced age By 2030 one in four people in the United Kingdom (UK) are widely accepted as risk factors for adverse outcomes are expected to be older than 65 with those over 80 be- [3]. Anatomic and physiologic changes make assessment ing the most rapidly growing demographic in our society more challenging [2, 4]. Adapting care for this vulner- [1]. In the last decade, national and international trauma able cohort is recognised as a key goal within the NHS systems have witnessed a shift in the type of trauma long term plan [5]. This extends to the prehospital mechanism and age of patient admissions. Older people emergency setting where care systems differ across Eur- (≥65 years old) falling from a standing height now con- ope, but the challenge of adapting to an older population stitute the largest share of major trauma presentations in remains [6]. Research specific to trauma in older people is far outweighed by that in younger cohorts, especially * Correspondence: [email protected] in the prehospital setting. This Scoping review aims to 1Major Trauma and Cutrale Perioperative and Ageing Group, Imperial College Healthcare NHS Trust, London, UK summarise the challenges in providing prehospital care Full list of author information is available at the end of the article to older trauma patient. © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Eichinger et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2021) 29:100 Page 2 of 12 Methods (n = 71/131) used a threshold of more than 65 years to Search strategy define an older trauma patient, but there was no univer- We performed a scoping literature review according to sal cut-off for older age (see Fig. 2). 93 of the 131 studies PRISMA-ScR guidelines [7]. Searches were conducted were conducted in the United States. using PubMed, Google Scholar and Medline from Janu- ary 2000 until April 2020 for articles written in English. Challenge 1: understanding of mechanism of injury (MOI) The following search terms were included: prehospital, Low-energy falls (used synonyms: ground-level falls/low- emergency, management, geriatric trauma. These terms level falls/same-level falls) were used rather than specific age cut-offs to ensure that An understanding of high- and low-energy mechanisms all patients/papers were included, no matter what the in- of injury and subsequent relative energy transfer is cru- dividual paper inclusion criteria was. The terms were ad- cial for effective injury detection and trauma triage. In justed for the requirements of the different databases to older adults low-energy falls are much more common, maximise the search results (Additional File 1). Search- with most injuries being caused by blunt force [8]. In ing of references of included studies yielded additional the presence of frailty, osteoporosis, sarcopenia and material. Studies addressing prehospital and emergency other comorbidities, these perceived low energy mecha- department settings were included, regardless of the In- nisms can result in severe injuries [9, 10]. Falls are the jury Severity Score (ISS). This scoping review did not most common reason (~ 60%) for severe traumatic in- fulfil the registration criteria of PROSPERO. jury and death in older adults [10–13], with over two- thirds of patients presenting more than once after a fall Study selection [14]. These events usually happen indoors [15, 16]. Mus- Two independent authors (ME and HR) repeated the culoskeletal weakness, poor balance and slower response initial literature identification process independently times to protect vital areas lead to more direct impacts from each other using identical search terms. Title and to the hip or head [11]. Other frequent significant injur- abstract screening were performed followed by full-text ies include rib fractures, which are associated with in- screening. Articles were organized using the online plat- creased mortality in older people [17]. Patients who have form©2020 Covidence, and any conflicts were discussed already had a fall may fear another, and therefore reduce and evaluated according to the inclusion criteria before their activities, leading to a downward spiral of rapid consensus was reached. A third author (GP) was tasked physiological decline [18]. A thorough evaluative falls as- to resolve any conflicts to limit selection bias. Articles sessment is crucial to prevent future falls and subse- were removed if they were updated within the set time quent injury, especially in patients that are not frame, and the most recent version was included. transported to hospital [19], and an appreciation of the potential harm of relatively low impact falls on an older Data extraction and processing person with altered physiology and anatomy is crucial Two authors (ME and SH) performed data extraction in- when assessing patients. dependently. Study characteristics and relevance towards the review were evaluated and extracted. Extraction data Road traffic collisions (RTCs) included information and origin of the author(s), study Older people, and especially females, more commonly type, study aims, age threshold number of participants. suffer from severe thoracic injuries after RTCs, even at A formal quality assessment of included studies is not low speed [11]. If involved as a pedestrian, older people performed in Scoping Reviews, but the results are pre- are overrepresented in fatalities [11, 20, 21], and blunt sented in tables with a narrative (see Additional File 1). aortic injuries are three times more common in this A narrative synthesis of included studies was per- group [11]. Compared to younger patients that die on formed. Statistical analysis of age cut-offs, and the distri- the scene, older patients are more likely to suffer from bution of included published studies over time was severe thoracic and pelvic injuries, in addition to trau- established using IBM® SPSS® Statistics (Version 26). matic brain injury and spinal cord injuries [20, 22–24]. Severe injuries are associated with the mobility status of Results the occupant after the crash, the angle of impact and the After 29 duplicates were excluded, 1034 publications number of injured people [25] and ideally, these variable were identified (see Fig. 1). Reasons for exclusion can be should be included into triage pathways [26]. Older mo- viewed in supplemental material. Additional File 1 torcyclists sustain
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