Geriatric Trauma.
Robert S. Anderson, Jr, M.D.
Assistant Professor of Emergency Medicine
Assistant Professor of Internal Medicine
Tufts University School of Medicine
Maine Medical Center
Robert.Anderson@tufts.edu
Disclosures
 No company is paying me.
 I am not selling you anything.
 A note for learners.
Notions of the Elderly.
Transformation.
3 Concepts.
 1. Our conception for the mechanism of
trauma does not match the reality for our
older patients.
 2. Our understanding of geriatric physiology
has not translated into action.
 3. Our systems approach to injured older
adults is not meeting their needs.
MVC
Licensed Drivers and Number in Accidents by Age: 2009. From:
http://www.census.gov/compendia/statab/2012/tables/12s1114.pdf. Accessed 27
September 2014
Geriatric Trauma = Falls.
FALLS
Clin Geriatr Med 29(2013) 137-150
Falls: the face of geriatric trauma.
Falls: why the suits care.
 By 2020, annual cost $50 billion.
 High prevalence in community:


30% over age 65 fall
50% over age 75 fall
 Higher prevalence in LTC:

1.5 falls per bed per year
http://www.cdc.gov/ncipc/factsheets/fallcost.htm, accessed 12/10/2010
Finlayson ML. Falls, aging, and disability. Phys Med Rehabil Clin N Am
2010;21:357-373
Falls: why we care.
 Falling kills people:

#6 cause of death in elderly people.
 Falling hurts people:

#2 cause of brain/spinal injury in older adults.
 Falling scares people:

18% of restricted activity days, highest for any
health condition.
Hazzard WR, et al, eds. Principles of Geriatric Medicine and Gerontology. 5th ed. New York: McGraw-Hill; 2003.
Cassel CK, et al, eds. Geriatric Medicine: an evidence based approach. 4th ed. New York: Springer-Verlag; 2003.
Three reasons for every fall:
 1. Age related condition/disease and/or
 2. Medications (or ETOH) and/or
 3. Nonspecific manifestation of

An acute illness (10%)*.
*Cassel CK, et al, eds. Geriatric Medicine: an evidence based approach. 4th
ed. New York: Springer-Verlag; 2003.
Falls: atypical presentation examples.
 Pneumonia
 Cholecystitis
 Delirium
 Ruptured AAA
Suggested work up for fallers:
 1. Hit head, AMS, AC = STAT head CT.

Low threshold for C-spine CT
 2. Concerning history = proceed as usual.
 3. Respect rib fractures.
 4. High risk features:


Age over 85.
RA, steroids, anticoagulants.
What about the rest of them?
 80 year old, first fall.
 80 year old, falls frequently.
2. Our understanding of geriatric
physiology has not translated into action.
 EMS protocols don’t fit, under triaged.
 Physiologic changes underappreciated.
 Markers of illness can be missed.
 Markers of resuscitation may be helpful.
Triage.
 Under triage/ under activation well
documented.
Demetriades D, et al. Old age as a criterion for trauma team activation. J
Trauma 2001;51:754-757.
Why?
 “It is clear…good outcomes can be
achieved..”
J Trauma. 2003;54:391-416.
2011
National Guidelines on Field Triage.
 Step One: Physiologic Criteria.
 Glasgow Coma Scale ≤13, or
 SBP of <90 mmHg, or
 RR of <10 or >29 breaths per minute (or support)
 Step Two: Anatomic Criteria.
 Step Three: Mechanism of Injury.
 Step Four: Special Considerations.
 older adults
 risk for injury/death increases after age 55 years
 SBP <110 might represent shock after age 65 years
 low impact mechanisms (e.g., ground-level falls) might
result in severe injury
Sasser SM, et al. Guidelines for the field triage of injured persons.
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6101a1.htm, accessed 10/3/13.
A geriatric trauma victim is a person >70
years of age exhibiting one or more:
 Physiologic conditions


GCS</= 14 with known/suspected TBI
Systolic BP < 100 mmHg ( <110 mmHg!)
 Anatomic conditions

Proximal long bone fracture via MVC
 Mechanism of injury


Pedestrian struck by motor vehicle
Fall from any height, including standing falls,
with evidence of TBI
Werman HA, et al. Development of statewide geriatric patients trauma
triage criteria. Prehosp Disaster Med 2011;26(3):170-179.
J Trauma Acute Care Surg.
2012;73:S345-S350.
Under Triage.
 13,000 elderly patients.
 ½ as likely to have trauma team activation.
 Under triaged elders had 4 times the:


Mortality rate.
Discharge disability.
Lehman R, et al. The impact of advanced age on trauma triage decisions
and outcomes: a statewide analysis. Am Jour Surgery. 2009;197:571-575.
Under Triage.
 4,500 elderly patients
 90% were falls.
 Under triaged patients almost twice as likely
to die, even when adjusted for RTS, GCS,
Coumadin use, >1 complication.
Rogers A, et al. Old and undertriaged: a lethal combination. Am Surg.
What is Aging?
 “Aging is characterized by a failure to
maintain homeostasis under conditions of
physiologic stress.”
 Inability to keep it together.
Davies, I. (2003). Cellular mechanisms of aging. In R.C. Tallis, H.M. Fillit (Eds.) Brocklehurst’s
Textbook of Geriatric Medicine and Gerontology(6th Ed, p. 31). Churchill Livingstone, London.
“Keeping it together” curve.
Acquired disease
Medications
Cook D J , Rooke G A Anesth Analg 2003;96:1823-1836
“Breathing”
 Increased work of breating.
 “Senile” emphysema.
 Impaired reflexes
“Circulation”
 Stiff vessels.
 Stiff ventricle.
 Impaired beta response.
 Conduction problems.
“Falling apart” line.
Taffett, G.E.(2002). Physiology of Aging. In C.K. Cassell, et al.(Eds.), Geriatric
Medicine, an evidence-based approach(4th Edition, pp.27-31). Springer-Verlag, NY.
Triage Vitals:
 BP = 90/50 mmHg
 BP = 90/50 mmHg
 HR = 120 bpm
 HR = 120 bpm
 RR = 30 bpm
 RR = 30 bpm
Triage Vitals:
 BP = 90/50 mmHg
 BP = 90/50 mmHg
 HR = 120 bpm
 HR = 120 bpm
 RR = 30 bpm
 RR = 30 bpm
Markers of illness:
 Do not miss “occult hypoperfusion”:

Hypotension starts at 110 mmHg.
 Do not misinterpret the heart rate:

Tachycardia starts at 90 beats per minute.
 Do not ignore respiratory rate and/or effort:

Important prognostic marker.
Markers of resuscitation;
2,4,6,(8).
 2 = Lactate >2
~ 20 % mortality
 4 = Lactate >4
~ 40% mortality
 6 = BD < - 6mEq/L ~ 60% mortality
 (8 = GCS < 8 at 72 hr ~ poor)
**Trauma Literature of NON fallers
Take home points – age related
changes.
 Aging is loss of reserve.
 Markers of illness:


BP less than 110mmHg.
HR greater than 90 bpm.
 Markers of resuscitation:


Base deficit.
Lactate.
3. Our systems approach to injured older
adults is not meeting their needs.
 “Among academic trauma surgeons, a
substantial difference of opinion seems to
exist on whether falls from standing or hip
fractures qualify as a ‘geriatric trauma’ worthy
of admission to a dedicated trauma service.”
J Trauma Acute Care Surg. 2012;73:S345-S350.
Examples.
 Head trauma:

2 yo second story v. 92 yo fall.
 Chest trauma:

30 yo motorocyle v 83 yo fall.
 Extremity trauma:

30 yo fall v 83 yo fall.
Team Sport
 In the emergency department.
 In the hospital.
 Home care.
Case: 85 year old, fall off toilet.
 CC: Right Flank Pain
 Vitals: BP 110
 Exam: Right SI tenderness
“Self…”
 A fall could be an atypical presentation.
 A blood pressure of 110 mmHg could be bad.
 Flank pain + hypotension = ultrasound.
Mrs. Murray’s aorta.
Trauma care:
 Triage – early recognition.
 Altered marker of illness recognized.
 Decision/ability to image was rapid.

(Interpretation was immediate.)
 Immediate surgical care.
Take home Points
 Falls.
 Unique physiology.
 Systems.
Thoughts?
Robert.Anderson@tufts.edu