Evaluation and Management of Geriatric Trauma
1/10/2020
Evaluation and Management of Geriatric Trauma
Michelle Moss NRP, FP-C, BS
Objectives
1 Look at trauma statistics and the impact of elderly trauma on EMS and hospital systems of care
2 Discuss issues related to the assessment and management of elderly trauma patients
3 Discuss how better field assessment, destination determination and ED evaluation can improve mortality for elderly trauma patients
4 Review the benefits of trauma center admission for elderly trauma patients
Is it just me or are we all getting older? 2018 - 5.3 million (14%) Californians are 65 or older.....by 2030 it will increase to 9 million (21%)
42% 26% 50%
2014 CA Trauma Hospital 2017 CA Trauma Deaths S-SV EMS Agency Admissions 20,560 total deaths Percentage of 911 calls for patients 253,000 total admissions 5,423 >65yo >65yo 107,000 >65yo
1 1/10/2020
Significant Mechanisms of Injury
Falls Vehicle Accidents Burns 75% of all geriatric trauma Highest mortality rate = patients struck by Median lethal dose (LD50) 2014 California = 285,355 vehicles 60-70yo = 43.1% TBSA 782 per day 2014 California = 22,662 70-80yo = 25.9% TBSA >80yo = 13.1% TBSA 2014 California = 2,714
Determining Severity of Trauma
ISS Score • Assesses severity of trauma from 0-75 • Six body regions • Abbreviated injury scale (AIS) classifies severity, 1-6 (minor to unsurvivable) • Highest AIS from 3 most injured regions squared and added together • Correlates to mortality, morbidity and length of stay • ISS>15 considered major trauma
Determining Severity of Trauma
Probability of Survival Tools • TRISS (Trauma Severity Score) Evaluates RTS, ISS, age and type of trauma • GTOS (Geriatric Trauma Outcome Score) Considers age, ISS and blood product usage • GTOS II - Looks at probability of unfavorable discharge to SNF, LTAC or hospice
2 1/10/2020
Sierra-Sacramento Valley EMS Agency Major Trauma Review January - June 2018 348 patients with ISS>15 or died of trauma related mechanism prior to hopsital admission 12% 33% 33%
Percentage of trauma patients Percentage of major trauma Major trauma patients >65yo classified as major trauma patients who died 37% of geriatric major trauma was 2734 total admitted or trauma 75 patients died in the field secondary to a ground level fall activated patients 42 died after hospital ED admission
Sierra-Sacramento Valley EMS Agency Major Trauma Review
80% of major trauma patients 81% of geriatric ground level not taken to a trauma center fall patients did not have were >65 documented trauma triage criteria on PCR PCR narratives documented a head strike in 63% of cases but lacked a comprehensive trauma assessment
Effects of Age and Comorbidities on Length of Stay Mean length of stay increases significantly with age and comorbidities 81% of elderly patient have at least one comorbidity Hypertension, heart disease most common... renal insufficiency, liver disease have highest mortality rate
3 1/10/2020
Oral Anticoagulants (OACs)
> 6 million US adults -$27B by 2020 Vitamin K antagonist (VKA) Warfarin - Associated with high mortality in TBI DOACs Direct oral anticoagulants Pradaxa, Xarelto, Elliquis... - Higher efficacy and lower fatal bleeding rates Blunt trauma with ISS>15 -VKA mortality rate 29.5% -DOAC mortality rate 8.3%
Triage tools used to determine the severity of So what's the real trauma are not reliable in problem? the elderly Age-related physiology, comorbidities and medications make trauma assessment challenging
Social and cultural determinants may result in less aggressive evaluation and treatment
Evaluating Degree of Shock
“Normal” respiratory effort
Diminished respiratory reserve and blunted response to hypoxia, hypercarbia and acidosis leads to a normal RR in spite of severe shock
4 1/10/2020
Evaluating Degree of Shock
“Normal” blood pressure
Increased vascular resistance leads to baseline hypertension which delays recognition of shock
Evaluating Degree of Shock
“Normal” heart rate
Beta blockers and a stiff myocardium compromise cardiac output and lessen response to catecholamines leading to less profound tachycardia even with profound shock
Evaluating Degree of Shock
Baseline mentation
Memory disorders may complicate establishing reliable baseline
30% reduction in brain size by age 70 may delay signs and symptoms of significant intracranial bleed
5 1/10/2020
Case Study
Patient • 93yo female, 49kg • SNF resident, active in community • Hx: hypothroidism, COPD, “cardiac” • Synthroid, Norvasc, Relafen, Ventolin
Mechanism • Walking on kitchen floor, slipped and fell
Patient Complaints • 10/10 pain to L shoulder, scapula and ribs
Assessment Findings: • No findings noted
Case Study
Initial Vitals @1704 • BP 193/104 HR 89 RR 24 Sat 92% GCS 15
EMS Treatment • C-Collar without board • PIV 20g, 200ml infused • Fentanyl 75mcg • Oxygen 4lpm NC • Transport to non-trauma center
ED Vitals @1745 • BP 148/78 HR 77 RR 18 Sat 99% GCS 15
Case Study
Injuries • Flail segment, L side rib fractures 2-8 • Hemopneumothorax • Pelvic ring fractures (3) • L scapula fracture • Liver laceration • ISS 24 • GTOS - 99% probability of dying • GTOS II - 90% probability of unfavorable discharge
Hospital Course • Acute transfer to trauma center • Ortho consult for fractures • Family made patient DNR/DNI • Palliative care w/focused pain control • LOS - 2 days • Repatriated back to facility of origin
6 1/10/2020
Under Triage in the Elderly Trauma Patient
Factors Contributing to Prehospital/ED Undertriage • Age bias • Inadequate assessment • Masked physiologic response due to age and comorbidities • Difficulty in determining baseline mental status • Not establishing anticoagulant use • Poor historian/unwitnessed event
But Why?
Undertriage of Elderly Trauma Patients to State-Designated Trauma Centers: A Retrospective Analysis • 10 year retrospective review of 26,565 trauma patients resulting in 49% undertriage of patients >65 years old
Providers • 166 providers responded to follow-up surveys • Mean provider age: 41 • Mean number of years of service: 12
Factors causing elderly patients to be transported to non-trauma centers • Inadequate training for managing elderly trauma patients 25.3% • Transport not being worth it because of age 13.4% • Unfamiliarity with protocol 12% • Not being welcomed at the receiving trauma center 9.5% • Transport not being worth it because of poor prognosis 5.4%
Augmented field triage criteria for geriatric patients
Ohio Geriatric Trauma Rules Physiologic Criteria GCS <15 with suspected TBI SBP <100mmHg Anatomic Criteria Any suspected long bone fracture in a MVC Multi-system trauma Mechanism Ground level falls with evidence of TBI Auto vs. pedestrian at any speed
WHAT CAN WE DO ABOUT IT?
7 1/10/2020
What can we do about it? Prehospital
Advocate
Assess
Ask
What can we do about it? Prehospital
- What were you doing when you fell? - Do you remember what happened?
- Medications? Ask Patient and Bystanders
- Do you see a doctor regularly?
- Pain? Pain scale for EVERY trauma patient
What can we do about it? Prehospital
- Head to toe assessment: AND - Assess the scene
- Landing surface? Assess - What could they have hit on the way down? - How long have they been down?
- Does the scene match the story?
8 1/10/2020
What can we do about it? Prehospital
- Considerations 1. SBP < 110 might represent shock 2. Use of anticoagulation or antiplatelet medication, or history of bleeding disorder 3. Paramedic Judgment Advocate
4. Manage pain appropriately 5. Treat as if they were your family!
What can we do about it? ED
Employ an “aggressive” approach to elder trauma Use elevated base deficit and lactate as indicators of shock Prioritize c-spine clearance
Consider chest and pelvis x-rays for mild trauma
Screen for antiplatelet and anticoagulant medications
What can we do about it? ED
Pain management and sedation
Minimize use of Use muti-modal benzodiazepines in pain therapy non-intubated Limit opioids when appropriate patients Consider Tylenol, NSAIDS for Increased body fat + decreased acute pain lean body mass = prolonged Evaluate for hypoxia, duration of effect hypoventilation before sedation Contributes to ICU delirium and Consider PCA, epidurals and ongoing cognitive impairment blocks for long-term Increases risk of falls management
9 1/10/2020
Fluid Resuscitation
Volume overload associated with higher mortality Chronic diuretic therapy in the elderly = decreased vascular volume and low serum K+ Dillutional coagulopathy and diffuse edema Worsens renal, hepatic and cardiac function and increases extravascular fluid volume in lungs Assessment Monitor fluid status in the ED hourly Lactate and base deficit are better shock indicators than HR and BP Operative intervention or transfer should be considered for ongoing shock Non-invasive and invasive monitoring are essential in guiding resuscitation
Fluid Resuscitation What's the difference?
Balanced salt for hemorrhage and saline for heads
0.9% Saline - Crystalloid Solution
Chloride can worsen acidosis and contribute to kidney injury. Associated with longer mechanical ventilation time
Hypertonic Saline
Only animal studies demonstrate a benefit in hemorrhage resuscitation May be of benefit as a bridge to neurosurgery in head injured patients
Ringers Lactate - Balanced Salt Solution
Minimal effect on PH. Hypotonic - may exacerbate cerebral edema. May interact with citrate in blood products
When should we transfer?
Advanced age should not be a sole criterion in denying or limiting care or transfer Consider early transfer or EMS diversion for major geriatric trauma Generally an initial aggressive approach should be pursued, unless.. - Persistent GCS<8 in spite of aggressive resuscitation, AND - Significant comorbidities (especially previous MI), AND - Advancing age Up to 85% will return to pre-injury level of function
10 1/10/2020
Benefits of Trauma Center Admission
Specialist advocates recommend all trauma patients 70 or older be trauma activated regarless of mechanism One study - 16% mortality rate in 660 “stable” patients 70 or older who did not meet any standard trauma activation criteria
Another study - Elderly trauma patients with an ISS score >15 had nearly twice the mortality rate when admitted to a non trauma center
Level I and II Trauma Centers
Level I - must admit 1200 24/7 Anesthesia, IR, MRI in trauma patients annually or house 240 admissions with ISS>15 OR staffed and available Level I - ICU Director must within 15 minutes be a board certified surgeon ICP monitoring capability ICU MD coverage in house (LI) or within 15 minutes (LII) Protocolized trauma management 24/7 Neurotrauma, orthopedic, radiology at bedside in 30 minutes All ED MDs - 16 hours/yr of trauma CE
Benefits of Trauma Center Admission
Established criteria for full/partial trauma team activation
Mitigates late recognition of significant injuries Typically age >65 elevates level of activation by one tier
Standard protocols for anticoagulation reversal At minimum, partial trauma team activation
Emergency Trauma Specialty Services
11 1/10/2020
Benefits of Trauma Center Admission
Geriatric Trauma Services Standard criteria for early geriatric consultation on the trauma care team
Comprehensive geriatric assessment (CGA) by geriatrician Evaluates medical, psychosocial and functional capabilities and limitations in developing follow-up plans Increases likelihood of being alive and at home one year following discharge by 25%
Emergency Trauma Specialty Services
Benefits of Trauma Center Admission
Palliative Care Specialists Aimed at improving quality of life and well-being Person (rather than patient) centered, family-oriented
ACS-COT Recommendation for Geriatrics Palliative care should be initiated and advance directive status should be determined within 24h of admission
Palliative care is not hospice
Palliative care Hospice care begins at begins when diagnosis treatment ends Pain management Patient is considered Nutritional guidance terminal Explain complex terms Usually provided at home and treatment options or hospice residence Counseling for patient and Pain management family Spiritual support aimed at Spiritual guidance and moving toward assistance with family acceptance and peace needs
12 1/10/2020
Case Study
Patient • 78yo male, 79kg • History of HTN • Unknown meds, denies blood thinners
Mechanism • 1970's pickup truck, lap belt only • Oncoming vehicle headlights obstructed vision • Off the road @55mph head-on into tree • 2 feet of engine compartment intrusion • Deformity to steering wheel
Patient Complaints • 10/10 chest, face, leg pain • Pain with breathing
Case Study
Assessment Findings EMS Treatment • 2 inch laceration and edema to • C-Collar without long board nose, bleeding from nares • Warming measures • Crepitus to right chest with • PIV 14g @TKO decreased breath sounds • EKG monitor • Deformity, shortening, outward • O2 @15lpm NRBM rotation to left leg • Transport to trauma center - Met • Contusions and swelling to bilateral mechanism and paramedic lower legs judgment criteria
Initial Vitals @0127 Repeat vitals @0139 • BP 124/76 HR 90 RR 20 Sat 98% • BP 96/70 HR 90 RR 20 Sat 98% GCS 15 GCS 15 • 250ml NS for drop in SBP
Case Study
ED Vitals @0155 Severity Scores • BP 108/70 HR 84 RR 19 Sat • ISS 22 100% GCS 15 • GTOS - 99% probability of dying • GTOS II - 87% probability of Injuries unfavorable discharge • Spleen laceration • Pneumothorax Hospital Course • Femur fracture • IR - splenic embolization • Sternum fracture • OR - Open reduction and internal • 3 rib fractures fixation of femur, chest tube, facial repairs • Multiple facial fractures • 2 units RBCs • Facial laceration • LOS 10 days • Discharge to rehab
13 1/10/2020
Summary
Ask, assess, advocate for all elderly trauma patients
Vital signs may not be reliable in determining degree of shock
Elderly patients deserve aggresive trauma care too
Questions?
Additional Case Studies
14 1/10/2020
Case #1 Fall Pre-arrival alert
Case #1 Fall Pre-arrival alert
Case Study
What we know from initial report • 62yo male • Fall 6-8ft from ladder onto head • +LOC • A/Ox4 with repetitive questioning • CC: headache, nausea/vomiting • 4mg IM Zofran • BP 142/81 HR 80 RR 18 Sat 98% • BS 79
What we know after MICN prompting • Patient is on blood thinners • GCS 14 • Unwitnessed event
Pertinent information we don't know • What did he land on? • Baseline mental status?
15 1/10/2020
Case Study
What we know from the PCR but not reported • “Pt. states he was about 6-8ft up on 10ft ladder when he tripped and fell” • “Minor abrasions to L lateral head, L elbow and L knee, bleeding controlled prior to EMS arrival” • “Patient with decreasing GCS and unable to obey simple commands” • “Pelvis stable” • “No other signs of trauma noted” • Pt. is actually 72 not 62 • BS is actually 173 not 79 Diagnosis • R comminuted, depressed skull facture • Brain contusion of R temporal lobe • R parietotemporal SDH and SAH • R sphenoid wing fracture • R orbit fracture
Case Study
Trauma Triage Criteria Hospital Course • Anatomic - skull fracture • Transferred to L2 trauma center (which was within catchment area Severity Scores from scene) • Medically induced coma for • ISS 16 refractory ICP • GTOS - 97% predicted probability of • ICP Monitor placed dying • Developed ICU myopathy, • GTOS II - 63% probability of pneumonia, and CHF exacerbation unfavorable discharge • Discharged to SNF 20 days after admission
Discussion
Did the patient get a head to toe assessment? Can you palpate a depressed skull fracture and have no assessment findings?
What was he doing when he fell? Did he land on the garage floor? The lawn? Carpet?
Injuries on both sides of the head. Did he hit something on the way down? Did the ladder fall on him?
Pain scale? No pain meds given
Did the medic have a high enough index of suspicion?
Would you have advocated to take this patient to a trauma center?
Ask? Assess? Advocate?
16 1/10/2020
Case #2 Auto vs. Pedestrian Destination Consultation
Case Study
What we know from initial report • 79yo female • Crossing street, struck by 2dr sedan at approx. 10-15mph • Vehicle struck pt. on her side, up on to hood then to ground • -LOC • Shoulder pain with abrasions to back, L shoulder • Hematoma to R parietal area • Groin pain when moved • BP 152/106 HR 106 RR 15 GCS 15 • C-spine precautions • Pre-existing neck pain What we know after MICN prompting • Patient is not on blood thinners • Scene is 5 minutes to closest ED and 35-40 minutes to L2 trauma center Pertinent information we don't know • History and medications
Case Study
What we know from the PCR but not reported • “Car did not run over patient” • “Pt complains of 7/10 L posterior shoulder pain • Abrasion to L elbow • ”Groin pain feels better when knees are bent. No shortening or rotation“
Trauma center directed patient to non-trauma center
Diagnosis • L clavicle fracture • L humerus fracture • Pelvic fracture • Multiple spinal fractures
17 1/10/2020
Case Study
Trauma Triage Criteria Hospital Course • Anatomic - pelvic fracture • Patient went to OR for humerus • Mechanism - Auto vs Ped; thrown fracture • Admitted to ICU for 4 days Severity Scores • Discharged home w/care and scheduled to return to OR for repair • Not calculated at non-trauma center of spinal fractures
Discussion
Did the patient get a head to toe assessment?
Did the report paint a clear picture of the mechanism and injuries?
Given the report and mechanism, do you think this patient should have been accepted by the trauma center?
Should this patient have been offered pain management for 7/10 pain?
Ask? Assess? Advocate?
18 Airway Management and Ventilation Dynamics David Nicholson, CRNA Who am I and why am I here? A: Yes Q: “Will this be on the test?” Why would one need to intervene to open a patient’s airway and/or insert an artificial oral or nasal airway? Airway Obstruction What is the most common cause of airway obstruction? The tongue.
But really it’s because of airway laxity and crowding.
Opening an obstructed airway • Keep it simple
• Millimeters matter: try a chin lift first
• Lift the oral floor with a chin lift
• Head tilt with chin lift - it may be overrated
• Slight turn of the head
• Fingers on the edge of the mandible provide control
• Jaw thrust, best method by far Movable joints effecting the airway • Neck: flexion and extension
• Atlanto-occipital joint: flexion and extension
• Temporomandibular joints: excursion, opening and closing, side to side movement
• All of these movements have the potential to open an obstructed airway and are described in crude terms like “head tilt” etc.
• “Sniffing position” who knows what that is? We will come back to this soon. Artificial “airways” Oropharyngeal (oral) airway and nasal pharyngeal (nasal) airway
Picking the correct size! The corner of the mouth to the angle of the jaw?
The nose to the earlobe?
How about the distance from the orifice to the glottis?
NO ish Yes From: The Three Axis Alignment Theory and the “Sniffing Position”: Perpetuation of an Anatomic Myth? Anesthes. 1999;91(6):1964.
Figure Legend: Fig. 1. Intubation in sniffing position. LA = laryngeal axis; MA = mouth axis; PA = pharyngeal axis.
Date of download: 1/5/2020 Copyright © 2020 American Society of Anesthesiologists. All rights reserved. Don’t forget that the goal of intervening to relieve airway obstruction is to create space. Extreme positions can do the exact opposite. Tone is good. Tension not so much. Placing airways
• Do what works for you.
• Tip: the floor of the nasal cavity does not correspond to the apparent direction of the nares.
Robertazzi Soft material, fixed flange Fixed flange Stiffer, PVC material (epistaxis - let’s discuss contraindications to a nasal airway) Adjustable flange Softer material, allows for more precise positioning The wooden tongue blade is like glue on the tongue. Allows for a less traumatic insertion. Keep a few in your pocket. Guedel Berman My favorite! Now what?
Ventilation
Let’s talk about mask ventilation. If you are struggling to ventilate the patient with a mask and bag something is wrong. Why is mask ventilation difficult.
• The airway is still obstructed
• The mask seal is insufficient
• The bag is inadequate
• Inexperience Tips
• Do the maneuvers we discussed to open the airway
• Choose a different size airway
• Make sure you have a good mask seal
• Don’t be so aggressive squeezing the bag
• Ask for help
• Practice
• Why? The scenario of securing an airway changes radically if you cannot adequately ventilate a patient Questions?