Geriatric Trauma - Dr. Colucciello

QUICK HIT CORE CONCEPTS

• Quickly determine if patient is on "blood thinners"
• Do not rely on vital signs to assess risk.
• Consider shock index or age related shock index
• Lactate of 2.5 or greater indicates high risk
• Liberal use of CT scan as opposed to plain films
• Liberal admission policy.
• Use geriatric trauma triage score on admitted patients.
• Many admissions will need to go to ICU because of age and comorbidities
  

More Specifics

***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

***MANAGEMENT

    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


***SHOCK INDEX

    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

***Head trauma:

    80% mortality if GCS<8

    Any anticoagulation with head trauma = scan

***Anticoag reverse>

    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

***Elderly aorta

    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

***Burns..

    Baux index: Mortality = age + TBSA.   

    Age >50 with bad burns, = burn center

**BEWARE Cold and quiet, elderly trauma patient!

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