geriatric trauma - trauma in the elderly

see also:

• trauma
• geriatrics

• most trauma in the elderly are due to:
  • falls
  • motor vehicle accidents, especially as pedestrians
  • burns
  • assaults

• bones more brittle and osteoporotic and degenerative conditions such as OA, rheumatoid arthritis make the joints less flexible
  • fracture neck of femur (#NOF)
  • rib fractures and thus pneumothorax, pulmonary contusion and haemothorax
  • cervical spine injury
    • high risk of Cx spine fracture if elderly fall face first from standing height (“face plant”) - particular type II odontoid fracture is a high risk
    • have a low threshold for ordering a CT Cx spine
  • fracture pelvis
• dura more tightly adherent to skull - subdural haemotoma more likely but extradural less likely

• pre-existing co-morbidities
  • hepatic disease, renal impairment and cancer are among the most important co-morbid factors for mortality
  • decompensated cardiac failure substantially increases mortality
  • an active pre-existing co-morbidity may have been the cause of the trauma (eg. cardiac syncope, occult GIT blood loss, acute stroke, leaking AAA) and these may easily be not assessed with attention focusing on the injuries
• reduced pulmonary reserves
  • lower vital capacity, functional residual capacity and FEV₁
  • thus less able to compensate for metabolic disturbances
• reduced cardiovascular reserves
  • reduced ability to raise cardiac output
  • less sensitive to catecholamines
• current medications may increase risks:
  • anticoagulants increase risk of bleeding, including increased subdural haematoma risk (CHI on warfarin increases risk of intracranial bleed to around 15%! - CT all such patients!)
  • corticosteroids use increase mortality
  • beta adrenergic blockers and calcium channel blockers increase mortality - impair responses to shock
• other risk factors for worse outcomes from the trauma itself:
  • cerebrovascular regulation decreased, increasing risk of secondary brain injury during hypotension periods
  • central cord syndrome from Cx spine injury is more common in the elderly, especially in those with cervical spondylosis who sustain an hyperextension injury (results in motor impairment UL > LL; bladder dysfunction; variable degree of sensory loss below level)
  • more difficult to assess injuries as patient may be less cooperative, less aware, diminished pain sensation, lax abdominal wall musculature or pre-existing conditions impact assessment - eg. Cx spine injury, blunt abdo trauma is difficult to assess clinically.
• more likely to have an adverse medication or infusion event
  • increased Vd of a drug and impaired elimination
  • increased risk of delirium and falls while in hospital and upon discharge
  • higher risk of APO following rapid infusions - consider 500mL boluses instead of 1L, and start early blood transfusion to minimise crystalloid volumes
  • higher risk of over-sedation and respiratory depression
  • higher risk of urinary retention
  • higher risk of adverse effects of non-steroidal anti-inflammatory drugs (NSAIDs)
  • more susceptible to contrast nephropathy
• more likely to have complications from prolonged spinal immobilisation
  • neck pain and injury
  • airway compromise
  • aspiration / impaired respiration
  • decubitus ulcers
  • urinary retention

• more likely to remain within normal RR range despite developing hypoxia or hypercapnia
  • need more aggressive monitoring such as oxygen saturation and end tidal CO₂ if respiratory issues or requiring high levels of analgesics
• less likely to mount a tachycardia response to hypovolaemia or pain
  • a HR > 90/min may be the equivalent of a younger adult's HR being > 140/min in risk terms
  • this is especially problematic if on beta adrenergic blockers which mask the physiologic response to the shocked hypotensive patient and increase mortality - consider using serum lactate and base deficit as markers for occult hypoperfusion
  • slow bleeding haemothorax may not become clinically evident for days - require close monitoring with serial CXRs or CT to detect in patients with rib fractures
  • avoid morphine and use fentanyl instead as shorter acting, less toxic metabolites in the renally impaired, and less risk of hypotension due to histamine release
• baseline BP may be high so a “normal” BP may be misleading
  • a systolic BP < 110mmHg instead of below 95mmHg as with younger adults, becomes more concerning as a marker for mortality
• delayed onset of clinical symptoms and signs of subdural hematoma
  • brain reduces in size by around 30% by age 70yrs leaving extra space for haematoma to occupy
• peritonism not as detectable
  • abdominal wall musculature less and pain sensitivity is less