The Changing Face of Trauma Care
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Presentation on Geriatric Trauma for the Hong Kong Hospital Authority delivered on February 22, 2019.
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The Changing Face of Trauma Care
- 1. The Changing Face of Trauma Care severe injury in older adults February 22, 2019 Hong Kong Hospital Authority Dr. Camilla Wong, MD FRCPC MHSc Geriatrician, St. Michael’s Hospital Associate Professor, University of Toronto
- 2. To recognize the demographic shifts in trauma care: mechanism of injury, injury patterns, sequelae of severe injury To discuss implications of aging physiology, co-morbidities, and frailty in managing the older adult with severe injury To understand how current pre-hospital, hospital, and post-hospital systems are not designed for the changing demographic
- 3. Demographic Shift mechanism, patterns, sequelae 01 To recognize the demographic shifts in trauma care: mechanism of injury, injury patterns, sequelae of severe injury
- 4. The Hong Kong population is aging.
- 5. BJS Open. 2018;2(5):310-318. The incidence of major trauma is increasing in the old.
- 6. U.S. National Trauma Data Bank Falls now surpass MVCs as leading mechanism of trauma.
- 7. U.S. National Trauma Data Bank 2016 In older adults, by far the most common mechanism of severe injury is falls.
- 8. In older adults, the evaluation is not only on diagnosing the injury, but also includes a search for the underlying reason for the mechanism of injury.
- 9. Multitude of interacting, age- related underlying causes for falls. Med Clin N Am; 2006;90(5)807–82.
- 10. Prince Philip, 97, gives up driving license. Motor Vehicle Collisions: cognitive impairment, delayed reaction time
- 11. Penetrating Injuries: high index of suspicion for depression
- 12. Pedestrian Injuries: slower gait speed, gait aids, sensory impairment
- 13. Worse 1-year functional outcomes with age. BJS Open. 2018;2(5):310-318.
- 14. Sharp increase in poor outcomes in older adults. BJS Open. 2018;2(5):310-318.
- 15. Curr Opin Crit Care 2015;21:520-6. Growing scholarly interest in geriatric trauma.
- 16. Implications of Aging physiology, frailty, co-morbidities 02 To discuss implications of aging physiology, co-morbidities, and frailty in managing the older adult with severe injury
- 17. Am Surg. 2010;76(1):65-9. Vital Signs Occult hypotension is common and normal vital signs do not exclude hypoperfusion.
- 18. Decreased Lung Function More complications including pneumonia and pulmonary contusions.
- 19. Brain Atrophy The Glascow Coma Scale (GCS) is an unreliable clinical tool.
- 20. Declining GFR Beware of contrast dye, NSAIDs. Dose-adjust.
- 21. Decreased Bone Density More fractures (hip, forearm) and lateral compression pelvic fractures.
- 22. Degenerative Cervical Spine High cervical spinal cord injuries are more common.
- 23. Proportion of Canadians aged 65 and older with zero to four self- reported major chronic diseases (cancer, cardiovascular disease, chronic respiratory disease, diabetes) Canadian Community Health Survey, 2014
- 24. Public Health Reviews. 2010;32:451-74. COMORBIDITY MULTIMORBIDITY
- 25. Anticoagulant use is associated with progression of known intracranial hemorrhage and development of new foci of hemorrhage on repeat head CT. J Trauma Acute Care Surg. 2014;76:431-6.
- 26. Warfarin Dabigatran Rivaroxaban Apixaban Endoxaban Mechanism of Action Vitamin K antagonist Thrombin inhibitor Factor Xa inhibitor Normal Half-life 20-60 hours 7-17 hours 7-11 hours 8-12 hours 10-14 hours Laboratory measurement PT/INR aPTT, thrombin clotting time PT/INR, Anti-factor Xa assay PT/INR, Anti-factor Xa assay Anti-factor Xa assay Emergency reversal Vitamin K PCC Idarucizumab PCC (Andexanet alfa)
- 27. Polypharmacy Altered hemodynamics. Drug-drug interactions. Adverse drug events. Withdrawal.
- 28. Fluid Resuscitation Not too much. Not too little. Just right.
- 29. Aging Physiology and Co-Morbidities Management Implications Occult hypoperfusion • Serum lactate • Close hemodynamic monitoring Decrease lung function • Incentive spirometry • Aggressive rib fracture pain management Brain atrophy • Low threshold for head imaging Declining GFR • Adjust renaly excreted medications • Contrast dye precautions Decreased bone density • Early fixation and rehabilitation • Angiography to control bleeding in lateral pelvic compression fractures Cervical degeneration • Early spine evaluation Anticoagulation • Low threshold for repeat head imaging • Traxemic acid, reversal agents Polypharmacy • Early medication reconciliation • Early, frequent pharmacist expertise Volume status • Frequent evaluation
- 32. J Am Coll Surg. 2017;225(5):658-665. Pre-admission frailty is associated with adverse discharge destination. • moderate to severe frailty, OR=5.3; 95% CI 2.1-13.5; P<.001 • age OR=1.1; 95% CI 1.0-1.1; P=0.006 • ISS ≥ 25, OR 2.3 ; 95% CI 0.7-6.1 P<.001 • three or more comorbidities OR=2.8; 95% 1.1-7.3, P=0.04
- 34. JAMA Surg. 2014;149(8):766-72. Pre-admission frailty is associated with adverse discharge destination. • OR, 1.6; 95% CI, 1.1- 2.4; P=.001) Pre-admission frailty is associated with in- hospital complications • OR, 2.5; 95% CI, 1.5- 6.0; P=.001
- 36. System Failure pre-hospital, hospital, post-hospital 03 To understand how current pre-hospital, hospital, and post-hospital systems are not designed for the changing demographic
- 37. Geriatric trauma IS different. Pre-existing conditions, altered responses, atypical signs, and more serious injuries for same mechanism of injury.
- 38. Geriatric trauma IS different. falls death LOS mean of 13.5 vs 18.0 days adults aged 65+ account for 51% of trauma deaths account for 74% of major injury hospitalizations in adults aged 65+ Canadian National Trauma Registry 2013 Report
- 39. Geriatric trauma IS different. adverse discharge Frailty in-hospital complications Odds ratio 2.5, 95% CI 1.5-6.0 Better predictor than age or injury severity. Odds ratio 1.6, 95% 1.1-2.4 JAMA Surg. 2014;149(8):766-72.
- 40. CURRENT TRAUMA SYSTEMS WERE NOT DEVELOPED FOR THE OLDER ADULT IN MIND.
- 41. Undertriage is increased in older adults, reaching 60% for those older than 90 years old. Ann Emerg Med. 2012;60(3):335-45. Current trauma systems were not developed for the older adult in mind.
- 42. physiological anatomical mechanism special consideration GCS SBP < 90 mmHg National Trauma Triage Protocol, 2011 36.6% sensitivity No c-spine fractures or closed head injury Only high-level falls Age criteria sBP < 110 mmHg Coagulopathy Head injury Low impact falls
- 43. Hong Kong Trauma Patients Diversion Protocol physiological anatomical
- 44. N Engl J Med 2006;354:366-78. The risk of death is lower among older patients treated at trauma centres than among those treated at non-trauma centres, but this is only a trend. • death in hospital RR 0.94 (0.56-1.61) • death at 365 days RR 0.92 (0.67–1.28) Current trauma systems were not developed for the older adult in mind.
- 45. Differences in trauma centre-specific mortality are most pronounced in geriatric trauma patients. median odds ratio = 1.40 CMAJ Open. 2014; 2(3): E176–E182. Current trauma systems were not developed for the older adult in mind.
- 46. Treatment at hospitals with higher geriatric trauma proportion is associated with lower hospital mortality. HR 0.71 (95% CI 0.54 to 0.94) Current trauma systems were not developed for the older adult in mind. J Am Coll Surg. 2016;223(1):32-40.
- 47. Most institutions do not have established protocols for the management of geriatric trauma patients. Current trauma systems were not developed for the older adult in mind. J Trauma Acute Care Surg. 2015;78(6):1197-209.
- 48. Under triage in the field. Treatment at a trauma centre may not be associated with reduced risk of death. Differences in trauma centre- specific mortality are most pronounced in older adults. Most trauma centres do not have geriatric-specific protocols. Current trauma systems were not developed for the older adult in mind.
- 49. Geriatric trauma IS different.Geriatric trauma IS different. It is complicated. • Atypical presentation • Frailty • Processes suboptimal • System variability
- 50. TRAUMA protocols extrication subdural hematoma vasopressors third degree burns REBOA intubation injury severity score FAST falls Glascow coma scale (GCS) transfusion retroperitoneal bleeding resuscitation anxiety gun shot wound oxygenation seizure npo facial fractures cardiac arrest Aspen collar agitationsplenic laceration traumatic brain injury log roll precautions reperfusion sedation subarachnoid hemorrhage crystalloids fentanyl plasma liver laceration ischemia transexamic acid Octaplex shock
- 51. multi morbidity evidence dementia depression hypertension diabetes mellitus stroke parkinsons osteoporosis pain falls benign prostatic hypertrophy incontinence prostate cancer polypharmacy anxiety osteoarthritis colon cancer seizurecirrhosis cataracts macular degeneration presbycusis glaucoma insomniaconstipation functional decline chronic kidney disease hypothyroidism hip fracture myelodysplastic syndrome
- 52. GERIATRIC TRAUMA Stay tuned for part 2 ...
- 54. Thank you. Dr. Camilla Wong, MD FRCPC MHSc Geriatrician, St. Michael’s Hospital Associate Professor, University of Toronto
Editor's Notes
- While this is Australian data, most developed nations are following a similar demographic trend.
- Mechanism of injury in 2005 compared with 2014. National Data Bank report. In 2004, MVC was majority of trauma admission for all ages. In 2014, falls surpassed MVC as leading mechanism, even with all ages combined.
- Underlying causes for the mechanism of injury in older adults are often medical or age-related physiologic changes, rather than behavioural or psychosocial in younger adults.
- Whereas in the young, the underlying mechanisms for MVC are usually risk taking behaviour or substance use, in older adults, there needs to be a good examination of reaction times and cognition.
- Whereas in the young, gang violence. In older adults, it’s depression.
- In the young – distracted (texting, headphones). In older adults: slower gait speed, sensory impairment
- BJS Open. 2018;2(5):310-318. doi: 10.1002/bjs5.80. eCollection 2018 Sep. Major trauma in older persons. Beck B1, Cameron P1,2, Lowthian J1,3, Fitzgerald M4,5, Judson R6,7, Gabbe BJ1,8.
- BJS Open. 2018 Jun 23;2(5):310-318. A sharp increase and consistent increase in poor outcomes in patients older 65 years. Over 50% dead at 1 year and over 80% not living independently at one year.
- We have entered a new era. Increasing publications on ‘geriatric trauma’ over 40 years reflects this demographic shift. PubMed query for ‘geriatric trauma’.
- Occult Hypoperfusion Arterial stiffening, decreased baroreceptor sensitivity – may not manifest tachycardia Forty-two per cent of patients had abnormal BD or LA in the emergency room indicating OH Serum lactate levels and base deficit have been demonstrated to be markers for hypoperfusion and predictive of outcomes in geriatric trauma patients. The above data emphasize the importance of close hemodynamic monitoring and careful trending of vital signs rather than relying on a single set of normal vital signs Scalea et al. documented the impact that early invasive monitoring and aggressive hemodynamic optimization had on outcomes in mild to moderately injured geriatric trauma patients
- Decreased lung function Pneumonia Pulmonary contusion Early incentive spirometry Multimodal pain control – aggressively manage rib fractures
- Low threshold for head imaging with injury
- Impaired creatinine cle.arance Contrast dye
- Early surgical repair and rehabilitation to prevention functional decline. Lateral compression fractures – bleeding in need of angiography.
- C1-2 more common due to degenerative changes and stiffening of the cervical spine. Early spine evaluation. Implications of immobilization. The Aspen collar – every geriatricians’ nightmare.
- Conceptual Diagram of Comorbidity: Index Disease, With One or More Comorbid Condition or Diseases Affecting Its Course and Treatment. Comorbidity has often been studied and treated in clinical practice from the perspective of an index disease, and one or more comorbid diseases may typically be considered. These diseases may affect the course and treatment of the index disease to varying degrees (varied weight of connecting bars). This framework may create disjointed treatment plans for each of the diseases and become cumbersome in patients with several co-existing diseases. Conceptual Diagram of Multimorbidity within an Individual Person’s Circumstances and Preferences. The perspective of multimorbidity may be useful for treating patients with multiple conditions. Conditions include traditional diseases, but also may reflect conditions such as disability, falls, hearing impairment, and sarcopenia that fall outside the traditional disease model. These conditions may overlap to varying degrees. The intersecting conditions exist within a context of biological health and reserves, as well as the psychological circumstances of a person (i.e., positive affect). The multimorbid conditions also unfold for given people within their social, educational, cultural, economic and environmental circumstances, and these will affect management of the multimorbid conditions. The person with multimorbidity also has individual values and priorities for their life and healthcare, which need to be elicited and factored into treatment plans. Comorbidity: index disease as centre of interest, different importance of conditions, only interaction with index disease assumed Multimorbidity: no index disease, all conditions equal, chronic conditions, interaction between conditions
- Low threhold for repeat brain imaging
- Don’t even know if they are on a DOAC. May have preserved GCS. Need for urgent imaging, especially head injury. Identify and control source of bleeding. Tranexamic acid. Discontinue anticogulants/antiplatelet Reversal (no antidotes for antiplatelets) – platelet transfusion is < 50 Discussion of risk, benefit, patient values in resuming. Full Study Report of Andexanet Alfa for Bleeding Associated with Factor Xa Inhibitors, ANNEXA-4 Investigators
- Early medication reconciliation. Early pharmacist involvement.
- Challenging in setting of occult hypoperfusion, heart failure.
- Frailty is broadly considered as decreased physiologic reserve across multiple organ systems leading to an impaired ability to withstand physiologic stress. Frailty makes it difficult for individuals to respond to the acute stress of trauma.
- We capture the Clinical Frailty Scale prospectively in our trauma registry database. It is easy to use and may readily be administered in a clinical setting. It was validated in the CSHA.
- While we have developed very robust transport, referral, management protocols for trauma in tertiary care centres, there was one factor more strongly associated with adverse following traumatic injury in older than age or even injury severity, and that is frailty – and we were completely ignoring it in our current systems. In fact, large data sets were also confirming that transfer to a tertiary care centre did not necessarily confirm benefit.
- More often than not, we’re not just dealing with multimorbidity, but frailty. When an individual has many diseases and have limited reserve
- Trauma-Specific Frailty Index (15 items)
- Frailty matters
- The elderly are not just older adults. It’s like comparing apples to oranges. The elderly have: more pre-existing conditions altered responses to apparently minor injuries atypical physiologic signs of injury more serious injuries for same mechanism of injury “My subdural hematoma hasn’t expanded enough yet to really affect my level of consciousness.” “I respond poorly to too much or too little fluid.” “My injuries weren’t accidental.” “A little medication goes a long way with me.”
- The elderly are not just older adults. It’s like comparing apples to oranges. For any given ISS, older patients are more likely to succumb to their injuries than their younger counterparts. Elderly trauma patients have long lengths of stay, on average by four days, suggesting there are processes inherent in hospital care (that address co-morbidities, functional status, hazards of hospitalization) that can be optimized. Across Canada, the causes of major injury hospitalizations for cases age 65 and older (n = 3,969). The leading causes of major injury were falls (74%, n = 2,941) followed by motor vehicle collisions (20%, n = 774) at a distant second. Based on these data, it is increasingly important to identify systems and processes of care to improve outcomes for older injured patients
- The elderly are not just older adults. It’s like comparing apples to oranges. Unlike younger adults, age and injury severity are not great predictors of outcomes. Rather, frailty performs better in predicting in-hospital complications and adverse discharge destination.
- Trauma systems and the trauma experience traditionally and historically centers on the needs of young, otherwise healthy patients (this is what those of us who work in the trauma field are used to seeing….young healthy patients sustaining injuries in the pursuit of risk taking behavior, car crashes) – all oranges. But really, we are seeing more elderly trauma patients coming in to our trauma bays – the apples, but our trauma systems are not designed for this.
- In this retrospective cohort study of 260,027 patients evaluated and transported by EMS during the 3-year study period. Definition of undertriage: Patients with Injury Severity Score greater than or equal to 16 and not meeting any field triage criteria, regardless of transport destination; and patients with Injury Severity Score greater than or equal to 16 and initial transport to a non–Level I or II hospital (ie, Level III, IV, and V trauma centers and nontrauma centers), regardless of triage criteria. The incidence of undertriage increased non-linearly after the age of 60, and reaching 60% for those older than 90 years old.
- Step 1: missing occult hypoperfusion; GCS not reliable marker of brain injury in older adults (high level trauma centres) Step 2: missing common injuries in older adults (high level trauma centres) Step 3: low level falls can still result in severe injury in older adults (trauma centre, not high level) Step 4: special considerations are just considerations (trauma centres, not high level) Current field triage practices still only 36.6% sensitive for high-risk patients older adults (ISS ≥ 15 or need for major non-orthopedic surgery)
- Anatomical and physiological criteria for primary trauma diversion in Hong Kong – patients are transported directly to a trauma centre.
- In this NEJM, prospective cohort study of 18 Level I trauma centres and 51 large non-designated centres with extensive data collection to allow for risk adjustment. Follow-up of 1 year. Specialized trauma centres may improve outcomes … but this is only a trend. The risk of death is lower among older patients treated at trauma centres than among those treated at non-trauma centres. death in hospital RR 0.94 (0.56-1.61) death at 365 days RR 0.92 (0.67–1.28)
- In this Ontario Trauma Registry data, data on 26 421 admitted to a trauma centre between 2005 and 2011 were used to calculate in-hospital mortality over time and hierarchical models to estimate trauma centre–specific mortality. Differences in trauma centre-specific mortality are most pronounced in geriatric trauma patients. The outcomes across similarly accredited trauma centres are not equivalent, even after adjusting for case-mix. The median odds ratio = 1.40. That is, the odds of dying could be 1.40-fold greater if the same elderly patient was admitted to one randomly selected trauma centre as opposed to another. A possible explanation that may explain such inter-hospital differences in risk-adjusted mortality include differences in structures and processes of care for these older patients. And perhaps therein lies opportunity.
- Highest tertile compared to lowest tertile. A possible explanation that may explain such inter-hospital differences in risk-adjusted mortality include differences in structures and processes of care for these older patients. And perhaps therein lies opportunity.
- Surveys distributed to the membership of AAST. 143 survey respondents.
- The elderly are not older adults. It’s like comparing apples to oranges. Things are not crystal clear on how trauma systems should best care for elderly individuals. Atypical presentation Frailty Protocols suboptimal System variability How to identify atypical presentations and anticipate atypical responses to standard treatments. How to operationalize frailty in trauma decision making How to develop trauma systems that do not under or over triage How to disseminate the structures and processes of care of the higher performing centre that may account for the inter-hospital differences in risk-adjusted mortality.
- Trauma care is complex.
- The older patient is complex even before the traumatic injury.
- Complexity of trauma. Complexity of frailty. How do we manage the complexity of trauma without losing sight of the complexity of frailty? This may seem an unlikely collaboration..
- Of course, Atul Gawande said it much more eloquently in his book, Being Mortal.