Evaluation of Geriatric Trauma

Educational Objectives

The goal of this program is to improve management of older patients with trauma. After hearing and assimilating this program, the clinician will be better able to:

1. Optimize induction of intubation in older patients.
2. Choose appropriate first-line drugs for pain management in older patients.

Summary

Physiologic changes in older patients: include increased susceptibility to trauma because of weaker bones, an increased risk for falls because of less muscle mass, difficulty in recovering from injury, thinner and less vascular skin and connective tissues that make it harder to thermoregulate, increased susceptibility to infections and pressure ulcers, weaker bridging veins in the brain that are prone to bleeding, cerebral atrophy, and a higher incidence of neurologic issues, including decreased reflexes; Parkinson disease, delirium, and dementia are more common chronic neurologic diseases in older patients; they also have decreased pulmonary reserve, brittle rib cages, a higher risk for aspiration and infection, and a decreased adrenal stress response; cardiovascular changes include vessel calcification, decreased ejection fraction, poor cardiac reserve, and poor baroreceptor sensitivity; elderly persons tend to take more medications, which makes them susceptible to falls

Atypical appearance of older adults: do not rely solely on vital signs of older adults, as they often present atypically compared with younger adults; they may delay seeking medical attention due to fear of visiting the hospital, have decreased pain sensitivity, and face several barriers to health care, eg, social isolation, fear of hospitalization, lack of access to transportation, and cognitive impairment (CI); consider occult blood loss in older adults, including retroperitoneal and pelvic bleeding, especially if the patient is taking anticoagulants; undertriaging is common because of their atypical presentation; ground-level falls have mortality rate that is 10 times higher compared with younger patients; even minor trauma can result in poor outcomes; factors contributing to falls include gait instability, poor home safety, vision and hearing loss, cognitive decline, decreased muscle mass, and lack of transportation

Initial management of geriatric trauma: initiate airway breathing, circulation, disability, exposure (ABCDE), and check their extremities; remove the patient from the backboard as quickly as possible to reduce the risk for ulcers; older patients are more prone to hypothermia, so ensure a warm environment and cover them adequately; these patients can have relative hypotension, especially in those with a hypertensive history, so consider a small intravenous (IV) fluid bolus; older adults are more prone to dehydration because of a decreased thirst drive; as soon as clinical or radiographic evidence rules out cervical spine (C-spine) injury, remove the collar

Intubation: consider all patients as potentially difficult airways; induction agents have a faster onset of sedation but slower distribution time and a longer effect; the dosage in older patients is 33% less than the usual adult dose, but the dose of paralytics is increased by 20%; retain dentures during bag-valve mask ventilation to improve seal, but remove them if they obstruct the airway during intubation; older adults have friable mucous membranes that are prone to bleeding, which can be an issue during intubation

Breathing: older adults have changes in ventilation and saturation, as well as decreased respiratory reserve; it is important to correct hypoxia quickly

Circulation: there is a decrease in cardiac output (CO) because of decreased myocyte mass; older patients are more dependent on preload; they have a decreased maximum heart rate and reduced responsiveness of membrane receptors to stress hormones, especially if patients are on β-blockers; they may take diuretics, so they might have a chronic state of volume contraction; address signs of shock early; be vigilant for borderline vital signs, changes in alertness, and mental status

Disability: conduct a thorough neurologic examination on all patients with geriatric trauma; a neurologic event may have caused their trauma; determine the patient’s baseline neurologic status by talking to their family; even with a relatively benign mechanism of injury, the risk for neurologic injury is higher

Imaging: be liberal with imaging, as the injuries may be occult, and patients may not always have pain; the radiation risk with computed tomography (CT) in this population is relatively low

Injuries: the most common traumatic injuries in older adults are lower extremity fractures followed by neck and trunk fractures, intracranial injuries, and upper extremity fractures

Hip fractures: occur more commonly in women, possibly because of postmenopausal hormonal changes and associated osteoporosis and osteopenia; 1-yr mortality is 16%; radiography is 90% to 98% sensitive in detecting hip fractures; 2% to 10% of hip fractures are occult and missed by x-rays; if the x-ray results are negative and the patient continues to experience severe pain and tenderness, is unable to bear weight, and is not ambulatory, follow up with CT; appropriate analgesia is important to reduce the risk for delirium; early surgery is associated with better outcomes; for patients with intractable pain despite opioids and acetaminophen, consider a fascia iliaca block

Head injuries: the Canadian CT rule states that all adults >65 yr of age are at high risk; even minor injuries can cause tearing of the bridging veins, leading to intracranial hemorrhage (ICH); overall mortality for older adults with traumatic brain injury (TBI) is 30% to 80%; half of the deaths from ground-level falls are because of TBI; it is not typically recommended to admit, observe, and repeat imaging in patients who are on anticoagulants unless they have high-risk features, eg, supratherapeutic international normalized ratio; do not advise stopping anticoagulants, but advise caution because of the risk for delayed bleeding

Rib fractures: associated mortality in older patients is ≈5 times that of younger ones; there is an incremental risk for pneumonia and mortality with each additional rib fracture; chest radiography, especially an anteroposterior view, is not accurate in diagnosing rib fractures, while a rib series increases the sensitivity to 70% to 80%; a chest CT is considered the gold standard; analgesia is a crucial part of management; these patients tend to splint, not breathe deeply, causing an increased risk for atelectasis and pneumonia; perform incentive spirometry and provide instructions on its usage; manage pain with acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and opioids as needed; for severe pain, consider epidurals and paravertebral nerve blocks; multiple rib fractures are a marker of polytrauma, particularly intra-abdominal injuries, as fractured ribs can dislodge into the liver and spleen; consider a trauma consultation and admission when there are ≥2 fractures, depending on the patient’s condition; indications for the intensive care unit include flail segments, pulmonary contusions, pneumothorax, and forced vital capacity <1 L

Cervical spine: older patients are more prone to C-spine injuries; if the patient has trauma above the clavicles and if head CT is being ordered, consider C-spine CT; these patients are also at a higher risk for anterior and central cord syndrome because of the loss of intravertebral discs, more fragile bones, and a higher incidence of underlying issues; if they have neurologic symptoms or persistent pain, consider magnetic resonance imaging; replace C-collar with a soft collar as soon as the C-spine is cleared

Intra-abdominal injuries: mortality is ≈4-fold higher in older patients; poor abdominal examination reliability is because of diminished musculature and sensory nerves; ≈33% of patients with polytrauma have substantial abdominal injuries; if the patient is unstable or has an acute drop in hemoglobin, search for occult bleeding that may be missed on a FAST examination

Falls: 78% of geriatric trauma admissions are related to falls, particularly among women; fall mortality is the leading cause of trauma mortality in older adults; 1-yr mortality after a fall-related injury can be ≤58%; falls are the second most common reason for emergency department (ED) visits by older patients; 40% of new skilled nursing facility (SNF) admissions are related to falls and gait instability; falls account for 95% of hip fractures among older adults; often, these patients do not present because of increased stoicism; patients and family members often lack awareness of modifiable risk factors and associated fall symptoms; it is important to intervene, identify associated issues, and educate patients and family members during health visits

Predisposing factors for falls: include changes in muscle mass and strength, neurologic changes, slowed nerve conduction and reflexes, sensory and CI, incontinence, and nocturia (increases the risk for falls during the night), comorbidities affecting balance, and cardiac issues that cause arrhythmias, lightheadedness, and syncope; extrinsic factors include the environment, poor lighting, cluttered walkways, loose carpets, uneven surfaces, no handrails, lack of appropriate footwear, assistive devices, medications, especially those that cause volume contraction, orthostasis, or dizziness, nutritional deficiencies that cause osteoporosis and osteopenia, and alcohol and drug use

Evaluation: perform ABCs and a thorough physical and neurologic examination; get collateral information; assess their hydration status; consider whether the patient is hypoglycemic or bleeding; obtain basic laboratory tests and ECG, consider troponin levels, urinalysis, or an infectious workup; review medications and ask about any recent medication changes; check orthostatics, and image them liberally; while obtaining the patient’s history, inquire about any preceding or prodromal symptoms and symptoms during and after the fall (eg, loss of consciousness, ability to ambulate, neurologic symptoms); patients can be unreliable historians, especially if they have underlying CI, so seek out collateral information

Polypharmacy: includes anticholinergic medications, benzodiazepines, hypoglycemics, antihypertensives, diuretics, antipsychotics, opiates, muscle relaxants, antidepressants, antiepileptics, drugs, and alcohol; every medicine added beyond 4 increases the fall risk by 14%; acetaminophen (eg, Aceta, Paracetamol, Tylenol) is the first-line therapy for pain management; a combination of acetaminophen and NSAIDs is the second line of treatment; limit the use of NSAIDs to a few weeks because of the risk for gastritis, ulcers, gastrointestinal bleeding, renal injury, and hypertension; if the patient is taking NSAIDs for a while, prescribe a proton pump inhibitor; opiates are appropriate for severe pain, but opiates carry risks for sedation, delirium, constipation, and increased falls; they are more effective in combination with acetaminophen and NSAIDs; to mitigate constipation, advise a bowel regimen

Safe disposition: assess the patient’s balance and gait before discharge from the ED; consider whether they need a cane or a walker; enquire about home safety and tripping hazards; encourage hydration, consider a small fluid bolus, and advise compression stockings if the patient is orthostatic; discuss their vision and hearing issues; ask if they have appropriate footwear or if they need a podiatrist consultation, and adequate wound care; check their lower extremity strength to rule out spinal issues as a cause for a fall; review their medications; provide ways to prevent falls, eg, sit for 1 or 2 min before standing from bed or always use a walker; ensure appropriate follow-up with their specialists; encourage them to stay active, maintain strength activities, and utilize resources in the ED, eg, pharmacists, a geriatric nurse expert, and a geriatric care coordinator

Readings

Borsheski R, Johnson QL. Pain management in the geriatric population. Mo Med. 2014;111(6):508-511; Cascella M, Bimonte S, Di Napoli R. Delayed emergence from anesthesia: What we know and how we act. Local Reg Anesth. 2020;13:195-206. doi:10.2147/LRA.S230728; Parlak S, Çıvgın E, Beşler MS, et al. Ground level falls: computed tomography findings and clinical outcomes by age groups. Zemin seviyesinden düşmeler: Yaş gruplarına göre bilgisayarlı tomografi bulguları ve klinik sonuçlar. Ulus Travma Acil Cerrahi Derg. 2023;29(6):710-716. doi:10.14744/tjtes.2023.28741; Shelmerdine SC, Langan D, Hutchinson JC, et al. Chest radiographs versus CT for the detection of rib fractures in children (DRIFT): A diagnostic accuracy observational study. Lancet Child Adolesc Health. 2018;2(11):802-811. doi:10.1016/S2352-4642(18)30274-8.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Noorvash was recorded at the 21st Annual Emergency Medicine Symposium: A Practical Update, held on December 8, 2023, in Beverly Hills, CA, and presented by Cedars-Sinai Medical Center. For information about upcoming CME activities from this presenter, please visit Cedars-sinai.edu. Audio Digest thanks the speakers and Cedars-Sinai Medical Center for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.00 CE contact hours.

Lecture ID:

EM412002

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.