Geriatric Trauma with Oxygen Saturations of 94% on Criteria

Emergency Medicine Australasia (2017) 29, 450–455 doi: 10.1111/1742-6723.12785

ACUTE GERIATRICS Major trauma in the older patient: Evolving trauma care beyond management of bumps and bruises

Christopher R CARPENTER ,1 Glenn ARENDTS,2,3 Carolyn HULLICK ,4,5 Guruprasad NAGARAJ,6,7 Zara COOPER8 and Ellen BURKETT9,10

1Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA, 2Department of Emergency Medicine, The University of Western Australia, Perth, Western Australia, Australia, 3Harry Perkins Institute for Medical Research, Centre for Clinical Research in Emergency Medicine, Perth, Western Australia, Australia, 4Emergency Department, John Hunter Hospital, Newcastle, New South Wales, Australia, 5Department of Emergency Medicine, Faculty of Health and Medicine, The University of Newcastle, Newcastle, New South Wales, Australia, 6Department of Emergency Medicine, Liverpool Hospital, Liverpool, New South Wales, Australia, 7Department of Emergency Medicine, School of Medicine, The University of Sydney, Sydney, New South Wales, Australia, 8Department of Surgery, Brigham and Women’s Hospital, Harvard University School of Medicine, Boston, Massachusetts, USA, 9Princess Alexandra Hospital, Brisbane, Queensland, Australia, and 10Department of Emergency Medicine, School of Medicine, The University of Queensland, Brisbane, Queensland, Australia

Two-thirds of female and one-third trauma functional recovery for dec- secondary survey is otherwise unre- of male injury-related deaths occur ades, but age alone is an insufﬁcient markable. She has a history of in those over age 65 years.1 Falls marker for futility because some hypertension and ischaemic heart account for 73% of cases of major ageing trauma victims will beneﬁt disease. trauma in patients over age 65 with from aggressive trauma road trauma constituting the major- resuscitation.1,9,10 ity of the remainder.2 As injurious Triage and initial clinical standing level falls and fall preven- Scenario 1: Pedestrian struck assessment tion will be reviewed later in this – series, this article focuses on major by motor vehicle highlighting Although trauma mortality appears trauma and geriatric management. team-based trauma care, to increase from age 70, older age is Hospitalisations for injury-related geriatric imaging, analgesia associated with under-triage in the issues continue to increase among and prognostication pre-hospital setting and lower rates of ambulance transfer to advanced ageing baby-boomers prompting Ruth, an 85-year-old widow who – trauma care centres.11 13 Then, once increasing focus on these lives independently, is struck by a 3–5 in the ED, elderly patients are again scenarios. After adjusting for car whilst crossing the road. After a more likely to be under-triaged than Injury Severity Score, geriatric short pre-hospital time, she arrives in severity matched younger patients trauma victims have twice the mor- the ED with complaints of left chest and less likely to receive trauma tality of younger patients and signif- pain and left groin discomfort. Your icantly longer intensive care unit team activation despite higher mor- primary survey reveals a patent air- 14,15 6,7 tality. This may be contributed (ICU) and hospital stays. Unfortu- way; a respiratory rate of 24/min to by over-reliance on physiologic nately, even minor geriatric trauma with oxygen saturations of 94% on criteria. In adults ≥70 years, 63% that does not require hospital room air, equal air entry and bruis- with severe injuries and 25% with admission can be associated with ing to her left chest; an initial pulse an injury severity score over 30 do functional decline and preventable rate of 98/min and blood pressure of 8 not meet standard hemodynamic re-presentations to the ED. Increas- 110/50. There is bruising to her left criteria for trauma team activa- ing age has been recognised as one groin and a non-tender abdomen; tion.16 Early trauma team activation determinant of survival and post- she is conscious and alert and the and a low threshold for ICU admission with tissue perfusion monitor- Correspondence: Associate Professor Christopher R Carpenter, Department of Emer- ing decreased geriatric trauma gency Medicine, Washington University School of Medicine in St. Louis, One Brook- mortality by almost 20% in one ings Drive, St. Louis, MO 63130, USA. Email: [email protected] study.17 Christopher R Carpenter, MD, MSc, FACEP, AGSF, Associate Professor; Trauma assessment and manage- Glenn Arendts, MMed, FACEM, Associate Professor; Carolyn Hullick, MBBS, ment in the older person is more FACEM, Staff Specialist; Guruprasad Nagaraj, MBBS, FACEM, Staff Specialist; complex than in younger persons. Zara Cooper, MD, MSc, Assistant Professor of Surgery; Ellen Burkett, MBBS, Geriatric trauma assessment and FACEM, Staff Specialist. management is dependent on an Accepted 19 March 2017 awareness of (Table 1):

TABLE 1. Impacts of ageing on trauma assessment and management Impacts of ageing Clinical implications

Airway Increased incidence of: Anticipate potential for difficult airway • Edentulous through reduced mouth opening/ • Arthritis of temporomandibular neck mobility; difficulty in bag- joints and/or cervical spine valve-mask ventilation may be reduced by leaving dentures in situ with removal for laryngoscopy Breathing Reduced respiratory reserve secondary • Early supplemental oxygen and to reduced respiratory muscle respiratory support; apneic strength, vital capacity, compliance oxygenation for intubation of chest wall and increased residual • Early incentive spirometry (if no volume contraindications) to reduce atelectasis • Ensure optimal analgesia to reduce splinting of respirations Circulation • Increased peripheral vascular Increased risk of delays to recognition resistance of shock • Decreased cardiac sensitivity to Early identification of shock through: beta-adrenergic stimuli (intrinsic • Careful physical examination and/or via medications such as beta- • Metabolic markers of tissue blockers) and reduced baroreceptor hypoperfusion (e.g. BD <−6) sensitivity, with resultant blunting • Timely identification of sources of of usual tachycardic response to haemorrhage through above plus hypovolemia extended FAST scan and low • Increased reliance on stroke volume threshold for pan-CT scan for rise in cardiac output • Timely achievement of hemostasis • Reduced pain sensation and increased abdominal wall laxity • Increased incidence of primary or Need for early fluid resuscitation to secondary cardiac ischemia augment ventricular filling • Increased premorbid use of hypotensive, antiplatelet and anticoagulant agents Disability Cortical atrophy with resultant Increased incidence of intracranial increased susceptibility of bridging hemorrhage in setting of normal veins to shearing and subdural GCS haemorrhage Exposure Premorbid malnutrition, Increased risk of: immunosensence • Hypothermia • Pressure injuries • Infection

BD, base deﬁcit; CT, computed tomography; FAST, Focused Assessment with Sonography in Trauma; GCS, Glasgow Coma Scale.

1. Age-related anatomic and physio- significantly impact sensitivity presence of baseline deficits logical changes, including reduced and specificity of clinical findings including cognitive impairment), cardiac and respiratory reserve, in trauma. management and outcome. skin and bone fragility and immu- 2. Increased potential for medical nosenescence, which predispose events inciting or complicating older adults to more severe inju- trauma related to comorbidities. Resuscitation and investigation ries for a given trauma mechan- 3. Functional frailty that may impact Resuscitation of the geriatric trauma ism.4 These changes also trauma assessment (through patient requires modification of

© 2017 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine 452 CR CARPENTER ET AL. commonly used values for identifica- utilised as an initial approach in the knocked unconscious. Upon his arri- tion of hemodynamic or neurologi- ED setting, we prefer opioid sparing, val in the ED he is awake and com- cal compromise.18,19 Venous lactate multimodal shared decision-making municative with a Glasgow Coma (≥2.5 mmol/L) or base deficit (≤−6) approaches to analgesia including Scale (GCS) score of 15, but very may better predict hemodynamic regular paracetamol and regional concerned about the woman that he compromise than traditional vital anaesthesia.30,31 struck and emotionally distraught. signs.20,21 In conjunction with early Pelvic fractures in geriatric trauma You note a golf ball size hematoma engagement of trauma surgery, lac- are common, with lateral compres- over his forehead. Your primary and tate monitoring for occult hypoper- sion fractures the most common.32 secondary trauma surveys are other- fusion could reduce mortality.22 Rates of clinically significant hae- wise unremarkable, but you note Age has not been identified as an morrhage associated with pelvic that he takes apixaban for atrial independent predictor of outcome in fractures are significantly higher in fibrillation. He is otherwise robust patients undergoing massive transfu- elderly.33 Sensitivity of plain trauma and well. sion, and massive transfusion proto- series pelvic films for posterior pelvic By virtue of their common cortical cols should be activated equivalently ring fractures is unacceptably low atrophy and high use of antiplatelet/ for an older person.23 Use of a per- with up to 97% of posterior pelvic anticoagulant medications, older permissive hypotension with a systolic ring fractures missed when pubic sons are at higher risk of intracranial target of <90 mmHg, as a compo- rami fractures are present.34,35 injury despite normal GCS.41 While nent of damage control resuscitation Central to management of the ger- the incidence of traumatic intracra- in older persons, is controversial. iatric trauma patient is the evolving nial bleeds is extensively researched Although mortality rises with lower concept of shared decision-making, for warfarin,42–44 new oral anticoa- admission systolic blood pressure, with the cognitively intact patient or gulation (NOAC) therapies include there was no synergistic effect of age with alternate health decision-makers direct thrombin (dabigatran) or Fac- and blood pressure on mortality in in those patients lacking decision- tor Xa (rivaroxaban and apixaban) one retrospective study.24 making capacity.36 Informed deci- inhibitors.45 Traditional measures of The increased incidence of severe sion-making in this setting requires anticoagulation (PT, PTT) do not injury and mortality and the reduced an understanding of likely prognosis provide information about the sensitivity of clinical findings, sup- with respect to survival and func- degree of anticoagulation with port a liberal approach to pan-CT tional outcomes. Trauma-related NOACs. Furthermore, their effective scanning in geriatric trauma. ED mortality for geriatric victims with reversal requires a shift away from physicians adopting this approach severe injuries has been declining in fresh frozen plasma with vitamin K need to be aware of and prepared to Australia for the last decade.37 A and towards prothrombin concen- manage the high rates of incidental study of 38 707 older trauma trate complex or activated Factor findings.25 Though the risk of patients showed that 90% of seri- VII.46 Researchers and pharmaceuti- contrast-induced nephropathy is ously injured older adults survived to cal manufacturers continue to often raised, a retrospective study of hospital discharge, with 52% dis- explore safe, effective and costly non-ionic iso-osmolar intravenous charged directly home, 20% dis- reversal agents for NOACs, such as contrast in older trauma patients charged to rehabilitation and 25% andexanet alpha (factor Xa inhibitor demonstrated no association discharged to a residential aged care reversal agent).47 Idarucizumab, a between intravenous contrast media facility.38 The presence of pre-existing monoclonal antibody to reverse administration and acute kidney comorbidities increased the odds of dabigatran, is currently the only injury.26 complications three fold. Frailty also NOAC reversal agent registered in increases risk, but objective measures Australia.48 of frailty are not widely accepted TheCanadianHeadCTRuleiden- Injury management across surgical or medical tifies age 65 or older as an independ- Post-trauma pain management in specialities.39,40 entriskfactorfor‘high-risk’ head older trauma victims is often sub- injuries that require CT imaging.49 A optimal.27 Rib fractures are a com- normal brain CT does not eliminate mon cause of morbidity and mortal- Scenario 2: Motor vehicle the risk of a delayed intracranial ity in the older trauma patient, with accidents – assessing beyond bleed, but from that point manage- one study identifying that mortality ment and the decision to admit or dis- increased (odds ratio for death of the acute injuries charge is mired in controversy. The 1.19) for each additional rib frac- Alfred is a 92-year-old Veteran of incidence of delayed intracranial hae- ture.28 Appropriate analgesia for rib World War II who arrives to the ED morrhage among traumatic brain fractures is critical to reduce splint- via ambulance, after the vehicle he injury (TBI) victims taking warfarin ing of the chest wall and optimise was driving accidentally struck one and/or antiplatelet agents ranges from vital capacity.29 Although intrave- of his neighbours while she was 0.6% to 6%, and most delayed bleeds nous opioid analgesia (in cognitively crossing the street. When he are clinically inconsequential and intact persons ideally via patient- slammed on his brakes, his forehead require no surgical intervention.50–53 controlled analgesia) is generally struck the steering wheel and he was Bleeding presentations can be delayed

© 2017 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine GERIATRIC TRAUMA 453 weeks, especially subdural bleeding. threshold to image the cervical department visits by older adults in Routine admission for every warfarin- spine.63–65 CT is more sensitive than the United States. Acad. Emerg. anticoagulated victim with a normal plain films for detecting spine frac- Med. 2012; 19: 821–7. brain CT would cost over $1 million tures at the cost of preventable over- 7. Taylor MD, Tracy JK, Meyer W, per life saved, which is neither practi- diagnosis and over-treatment of Pasquale M, Napolitano LM. cal nor cost-effective.54 insignificant fractures or incidental Trauma in the elderly: intensive Our approach is again based on findings unrelated to the trauma.66,67 care unit resource use and outcome. shared decision-making and a risk- J. Trauma 2002; 53: 407–14. fi ’ bene t analysis. With the patient s Conclusions 8. Carpenter CR. Deteriorating func- agreement, families and carers are tional status in older adults after educated about the risks and signs of Managing major trauma in geriatric emergency department evaluation delayed brain bleeding. We do not adults requires a low clinical thresh- of minor trauma–opportunities and recommend routine repeat CT scan- old for advanced imaging and multi- pragmatic challenges. J. Am. Ger- ning. It is prudent for the patient to disciplinary assessment, recognising iatr. Soc. 2013; 61: 1806–7. see their General Practitioner in the that mechanism and physical exami- 9. Day RJ, Vinen J, Hewitt-Falls E. days after discharge for clinical nation can be deceiving. Physiologi- Major trauma outcomes in the eld- review and re-evaluation of the indi- cal and anatomical changes of erly. Med. J. Aust. 1994; 160: cation for anticoagulation. Admis- ageing increase trauma-related mor- 675–8. sion is offered where safe home tality. Efficient laboratory, imaging 10. Aitken LM, Burmeister E, Lang J, observation or certainty of follow up and disposition decisions require an Chaboyer W, Richmond TS. Char- cannot be established AND it is felt understanding of typical injuries and acteristics and outcomes of injured the risks of discharge exceed those common resuscitation pitfalls, as older adults after hospital admis- risks of hospitalisation we have dis- well as recovery trajectories and pre- sion. J. Am. Geriatr. Soc. 2010; 58: cussed elsewhere in this series.55 ventative strategies to reduce short- 442–9. Operative management of TBI in term functional decline or further 11. Caterino JM, Valasek T, patients over age 75 is associated with injury. Werman HA. Identification of an higher mortality. A GCS of 8 or less age cutoff for increased mortality in patients with elderly trauma. Am. implies a 70% overall mortality in Competing interests geriatric TBI victims and survival over J. Emerg. Med. 2010; 28: 151–8. the age of 85 with this severity of None declared. 12. Grant PT, Henry JM, brain injury is extremely rare.56,57 The McNaughton GW. The manage- dismal outcomes in very old TBI vic- References ment of elderly blunt trauma victims led to the Eastern Association for tims in Scotland: evidence of the Surgery of Trauma (EAST) Guide- 1. Joseph A. Trauma in the elderly: ageism? Injury 2000; 31: 519–28. line recommendation of ‘discussions burden or opportunity? Injury 13. Lane P, Sorondo B, Kelly JJ. Geriat- regarding the goals of care if no 2015; 46: 1701–2. ric trauma patients-are they receiv- improvement in GCS is seen after the 2. NSW Agency for Clinical Innova- ing trauma center care? Acad. initial phase of care and after with- tion. Major Trauma in NSW 2015 Emerg. Med. 2003; 10: 244–50. drawal of sedatives’ following 72 h of in NSW Institute of Trauma and 14. Lehmann R, Beekley A, Casey L, aggressive trauma management.58 Injury Management. 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