QUICK HIT CORE CONCEPTS
***Mortality in trauma increases dramatically with increased age, inc 7% mortality for each year over 65 in trauma
***Liver disease is the worst premorbid condition for trauma
***Standard trauma assessment is inadequate in elderly, particularly vital signs insensitive
***Falls: 10% significant injury, in geraitric population cervical spine fractures common
***Have decreased cardiac output, may not be able to mount adequate tachycardic response, may have occult shock. Have consideration for peri-traumatic MI both prior to trauma or stress of trauma causing MI
***Pulmonary issues: Decreased reserve, increased risk ARDS and atelectasis, CO2 narcosis
***CNS: High risk of subdural, clouded by questionable baseline mental status
***Renal: Often baseline poor GFR, CT Contrast can cause significant injury
***Trauma triage poor in elderly: Age >55 should be at a trauma center
***CMC TRAUMA ACTIVATION for geriatrics
ATC 1:: Age >65: HR>100, SBP<110
ALERT:: Age >65 involved in MVC or fall from height
Airway: Increased aspiration risk. Consider dentures. Consider high cervical spine risk and maintain proper imobilization. Consider increased response to induction agents: decreased your dose.
Breathing: Decreased reserved, rapid desaturation. Use passive oxygenation. Use ETCO2. Consider increased risk of rib fractures.
Circulation: Decreased response to catechols, on beta blockers; may not mount tachycardia appropriately. Consider RELATIVE hypotension.
--Journal trauma study shows HR >90 and SBP <110 significant increased in mortality
Disability: Central cord syndrome more common in elderly, may have "Hand burning", will have upper extremity weakness and capelike paresthesia
HR/Systolic blood pressure
Normal less than 0.6, realistic threshold <0.8
More sensitive than HR or BP alone
Even better: Shock index * Age should be <50
***If concerned about fluids, use repeated small boluses (250ml)
***Anemia: Follow serial hemoglobins and transfuse early. Transfusion threshold controversial, starting thinking about it around 8 or persistent hypotension
***History: Keep in mind precipitating events, syncope in 10-15% of geriatric fall/MVC
***Identify blood thinner use!! Coumadin, plavix, ASA, Anti 10A, anti thrombin
***CAREFUL chest exam: Must identify rib fractures, flail chest; XRAY low sensitivity for these. Traumatic aortic dissection often does not have external signs of injury.
***Abdomen: Geriatric may NOT develop peritonitis despite significant intraabdominal injury
***LABS: Always get lactate; highly predictive of bad outcome
>2 admit, >3 ICU, >4 call chaplain. (40% mortality in lact >4)
Upgrade to ATC 2 if INR >2 or Lactate >2.5
***ECG Routine in geriatric trauma
***Careful with opiates in elderly, start low doses
80% mortality if GCS<8
Any anticoagulation with head trauma = scan
Coumadin, see protocol
Antithrombin: May try FFP but pretty much screwed
Anti Xa: PCCC may be beneficial (see protocol for dosing)
***Rib fractures: Risk of atelectasis, resp faulire, pneumonia
Admit if >3 rib fx. Consult if 1 or more if frail, live alone, any concern really
Eggshell appearance distant from border of aorta may indicate dissection (Egg shell or Halo sign)
***Pelvic fx mortality 50% if hypotension, 90% if open. Eval for hemoperitoneum and aortic rupture
Baux index: Mortality = age + TBSA.
Age >50 with bad burns, = burn center
**BEWARE Cold and quiet, elderly trauma patient!