Old Age Trauma

2. GERIATRIC TRAUMA
Dr. Adeel Riaz
PGR General Surgery
CPTH, Lhr.

3. PURPOSE
Special considerations in caring for elderly
patients include the effects of age on
physiologic functions, comorbidities, and
concomitant medications. However, the
priorities in evaluation and resuscitation
remain the same.

4. OBJECTIVES
Identify the unique characteristics of elderly trauma
patients, including common types of injury, patterns of
injury, and anatomic and physiologic differences.
Describe the primary management of critical injuries in
geriatric patients, including the following related issues
unique to geriatric patients, emphasizing the anatomic
and physiologic differences from younger patients and
their impact on resuscitation: • Airway management •
Breathing and ventilation • Shock, fluid, and electrolyte
management • Central nervous system and cervical
spine injuries.
Identify common causes and signs of elder
maltreatment, and formulate a strategy for managing
situations of elder maltreatment

5. EFFECTS OF AGING ON ORGAN
SYSYTEMS↓Brain mass Stroke
Eye disease
↓Renal function
↓Total body water
2- to 3-inch loss in height
Impaired blood flow to lower leg(s)
Degeneration of the joints
↓Depth perception
↓Discrimination of colors
↓Pupillary response
↓Respiratory vital capacity
Diminished hearing
Heart disease and high blood pressure
Kidney disease
↓Gastric secretions
↓Sense of smell and taste
↓Saliva production
↓Esophageal activity
↓15%–30% body fat
↓Cardiac stroke volume and rate
↓Number of body cells
↓Elasticity of skin
Nerve damage (peripheral neuropathy)
Thinning of epidermis

6. UNIQUE CHARACTERISTICS OF
GERIATRIC TRAUMA
Patients aged 65 and older are less likely to be injured
than are younger individuals, But older patients are more
likely to have a fatal outcome from their injuries.
decreased physical reserves of the elderly due to the
changes of aging.
comorbidities e.g. arthritis, osteoporosis, emphysema,
heart disease, and decreased muscle mass.
lack of understanding of their needs by many healthcare
providers.

7. MECHANISMS OF INJURY
FALLS are the most common mechanism of injury in
older patients and are mostly caused by aging process
and environmental hazards.Other causes include visual
nd hearing disturbances,gait disturbances,dizziness and
vertigo.
Effects of AGING process have a major influence on the
incidence of injuries in elderly patients leading to
decreased ability to avoid injuries such as arthritis,
osteoporosis, emphysema, heart diseases and decreased
muscle mass.
Thermal injuries is the third leading cause of fatal
outcomes in elderly persons which occurs under the
influence of alchol, or smoking on the bed, exposed to
heat while trapped in fire, and if clothes are ignited.

8. AIRWAY
 Establishing and maintaining a patent airway to provide
adequate oxygenation is the first objective.
 Supplemental oxygen should be administered as soon as
possible, even in the presence of chronic pulmonary disease.
Because of the elderly patient’s limited cardiopulmonary
reserve, early intubation should be considered for elderly
trauma patients presenting in shock and those with chest wall
injury or alteration in the level of consciousness.
 Features that affect management of the airway in the elderly
include dentition, nasopharyngeal fragility, macroglossia
(enlargement of tongue), microstomia (small oral aperture),
and cervical arthritis. Less than full dentition can interfere with
achieving a proper seal on a face mask. Consequently,
whereas broken dentures should be removed, intact well-fitted
dentures are often best left in place until after airway control is
achieved.

9. AIRWAY
 Care must be taken when placing nasogastric and
nasotracheal tubes because of nasopharyngeal friability,
especially around the turbinates.
 The oral cavity may be compromised by either macroglossia,
associated with amyloidosis or acromegaly, or microstomia,
such as the constricted, birdlike mouth of progressive systemic
sclerosis.
 Arthritis can affect the temporomandibular joints and the
cervical spine, making endotracheal intubation more difficult
and increasing the risk of spinal cord injury with manipulation
of the osteoarthritic spine.
 The principles of airway management remain the same, with
endotracheal intubation as the preferred method for definitive
airway control.
 If acute airway obstruction exists or the vocal cords cannot be
visualized, surgical cricothyroidotomy should be considered as
an option.

10. BREATHING & VENTILATION
 Many of the changes that occur in the airway and lungs of elderly
patients are difficult to ascribe purely to the process of aging and
may be the result of chronic exposure to toxic agents such as
tobacco smoke and other environmental toxins throughout life.
 The loss of respiratory reserve due to the effects of aging and
chronic diseases makes careful monitoring of the geriatric patient’s
respiratory system imperative.
 Administration of supplemental oxygen is mandatory, although
caution should be exercised with its use because some elderly
patients rely on hypoxic drive to maintain ventilation. Oxygen
administration can result in loss of this hypoxic drive, causing CO2
retention and respiratory acidosis.
 In an acute trauma situation, however, hypoxemia should be
corrected by administering oxygen while accepting the risk of
hypercarbia. In these situations, if respiratory failure is imminent,
intubation and mechanical ventilation is necessary.

11. BREATHING & VENTILATION
 Chest injuries occur in patients of all ages with similar frequency,
but the mortality rate for elderly patients is higher. Chest wall injuries
with rib fractures or pulmonary contusions are common and not well
tolerated. Patients older than 65 years of age with multiple rib
fractures have increased rates of morbidity and mortality.
 Simple pneumothorax and hemothorax also are poorly tolerated,
and geriatric patients with these injuries should be considered for
intensive care unit (ICU) observation, as respiratory failure can be
gradual or precipitous. Respiratory failure may result from the
increased work of breathing combined with a decreased energy
reserve.
 Pulmonary complications—such as atelectasis, pneumonia, and
pulmonary edema—occur in the elderly with great frequency.
Marginal cardiopulmonary reserve coupled with overzealous
crystalloid infusion increases the potential for pulmonary edema and
worsening of pulmonary contusions. Admission to the hospital
usually is necessary, even with apparently minor injuries.

12. CIRCULATION
 A common pitfall in the evaluation of geriatric trauma patients is the
mistaken impression that “normal” blood pressure and heart rate
indicate normovolemia. Early monitoring of the cardiovascular
system must be instituted. Blood pressure generally increases with
age. Thus, a systolic blood pressure of 120 mm Hg can represent
hypotension in an elderly patient whose preinjury systolic blood
pressure was 170 mm Hg.
 Elderly patients with hypertension who are on chronic diuretic
therapy may have a chronically contracted vascular volume and a
serum potassium deficit; therefore careful monitoring of the
administration of crystalloid solutions is important to prevent
electrolyte disorders.
 The optimal hemoglobin level for an injured elderly patient is a point
of controversy. Many authors suggest that, in people over the age of
65 years, hemoglobin concentrations of over 10 g/dL should be
maintained to maximize oxygen-carrying capacity and delivery.
There is little support in the literature for this position.

13. CIRCULATION
 The indication for blood transfusion should be the same as in
younger patients. Early recognition and correction of coagulation
defects is crucial, including reversal of drug-induced
anticoagulation in elderly patients.
 Because elderly patients may have significant limitation in cardiac
reserve, a rapid and complete assessment for all sources of blood
loss is necessary. The focused assessment sonography in trauma
(FAST) examination is a rapid means of determining the presence
of abnormal intraabdominal and pericardial fluid collections.
Nonoperative management of blunt abdominal solid viscus injuries
in elderly patients must be done by an experienced surgeon.
 Retroperitoneum is an often-unrecognized source of blood loss.
Exsanguinating retroperitoneal hemorrhage may develop in elderly
patients after relatively minor pelvic or hip fractures. A patient with
pelvic, hip, or lumbar vertebral fractures who demonstrates
continuing blood loss without a specific source should be
considered for prompt angiography and control with transcatheter
embolization.

14. CIRCULATION
The process of aging and superimposed disease states
make close monitoring mandatory, especially in cases of
injury with acute intravascular volume loss and shock.
 Failure to recognize inadequate oxygen delivery creates
an oxygen deficit from which the geriatric patient may
not be able to recover.
 Because of associated coronary artery disease,
hypotension and hypovolemia frequently results in
impaired cardiac performance from myocardial ischemia.
Thus, hypovolemic and cardiogenic shock may coexist.
Early invasive monitoring with a pulmonary artery
catheter may be beneficial.
 Hemodynamic resuscitation may require the use of
inotropes after volume restoration in these patients.
Prompt transfer to a trauma center may be lifesaving.

15. DISABILITY: BRAIN & SPINAL
CORD INJURY
CHANGES WITH AGING:
 Brain mass decreases approximately 10% by 70 years of age.
This loss is replaced by cerebrospinal fluid. Concomitantly, the
dura becomes tightly adherent to the skull. Although the increased
space created around the brain may serve to protect it from
contusion, it also causes stretching of the parasagittal bridging
veins, making them more prone to shear injury.
 Cerebral blood flow is reduced by 20% by the age of 70 years.
This is further reduced if atherosclerotic disease occludes cerebral
arteries. Visual and auditory acuity declines, vibratory and position
sensation is impaired, and reaction time increases.
 In the spine, the most dramatic changes occur in the intervertebral
disks. Loss of water and protein affect the shape and
compressibility of the disks. This risk is increased in the presence
of osteoporosis, whether or not it is apparent radiographically.
Finally, osteoarthritis may cause canal stenosis and segmental
immobility, making cord injury more likely.

16. DISABILITY: BRAIN & SPINAL
CORD INJURY
 The elderly have a higher incidence of subdural and
intraparenchymal hematomas. Subdural hematomas are
nearly three times as frequent in the elderly, in part because
elderly individuals are more likely to be taking anticoagulant
medications for cardiac or cerebrovascular disease. Rapid
screening for anticoagulant use and subsequent correction
with blood component therapy may improve outcomes.
 A computed tomography (CT) scan of the head provides
rapid, accurate, and detailed information on structural
damage to the brain, skull, and supporting elements.
 Cervical spine injuries appear to be more common in elderly
patients, although they may be occult and difficult to diagnose
if osteoporosis and osteoarthritis are present. Magnetic
resonance imaging (MRI) is particularly useful in these
patients for diagnosing ligamentous injuries.

17. EXPOSURE & ENVIRONMENT
 The skin and connective tissues of elderly individuals undergo
extensive changes, including a decrease in cell numbers, loss of
strength, and impaired function.
 The dermis loses as much as 20% of its thickness, undergoes a
significant loss of vascularity, and has a marked decrease in the
number of mast cells.
 These changes result in the loss of thermal regulatory ability,
decreased barrier function against bacterial invasion, and
significant impairment of wound healing.
 Injured elderly patients must be protected from hypothermia.
Hypothermia not attributable to shock or exposure should alert the
physician to the possibility of occult disease—in particular, sepsis,
endocrine disease, or pharmacologic causes.
 The potential for invasive bacterial infection through injured skin
must be recognized. Appropriate care, including assessing tetanus
immunization status, to prevent infection, must be instituted early.

18. OTHER SYSYTEMS
Other systems that warrant special attention with regard
to the treatment of elderly trauma patients include the
musculoskeletal system,
nutritional status,
altered metabolism,
and the immune system

19. MUSCULOSKELETAL SYSTEM
 Disorders of the musculoskeletal system are frequently the cause
of presenting symptoms in the middle-aged and geriatric
population. These disorders cause restrictions in daily activities
and are key components in the loss of independence.
 Osteoporosis results in a decrease of histologic normal bone with
a consequent loss of strength and resistance to fractures.
 The consequences of these changes on the musculoskeletal
system are frequently disabling and at times devastating. Injuries
to ligaments and tendons affect joints and adjacent soft tissues.
Osteoporosis contributes to the occurrence of spontaneous
vertebral compression fractures and the high incidence of hip
fractures in the elderly.
 The most common locations of fractures in elderly patients are the
ribs, proximal femur, hip, humerus, and wrist. Neurovascular
integrity should be assessed and compared with that of the
opposite extremity.
 The aim of treatment for musculoskeletal injuries should be to
undertake the least invasive, most definitive procedure that will
permit early mobilization. Prolonged inactivity and disease often
limit the ultimate functional outcome and impact survival.

20. NUTRITION & METABOLISM
Caloric needs decline with age, as lean body mass and
metabolic rate gradually decrease. Protein
requirements actually may increase as a result of
inefficient utilization.
There is a widespread occurrence of chronically
inadequate nutrition among the elderly, and poor
nutritional status contributes to an increased
complication rate.
 Early and adequate nutritional support of injured
elderly patients is a cornerstone of successful trauma
care.

21. IMMUNE SYSTEM & INFECTIONS
Mortality from most diseases increases with age. The
loss of competence of the immune system with age
certainly plays a role.
Elderly patients have an impaired ability to respond to
bacteria and viruses, a reduced ability to respond to
vaccination, and a lack of reliable response to skin
antigen testing.
Elderly individuals are less able to tolerate infection and
more prone to multiple organ system failure.
The absence of fever, leukocytosis, and other
manifestations of the inflammatory response may be
due to poor immune function.

22. SPECIAL CIRCUMSTANCES
Special circumstances that require consideration
in the treatment of elderly trauma patients
include
medications,
elder maltreatment,
and end-of-life decisions.

23. MEDICATIONS
Due to concomitant disease elderly patients are often taking several
pharmacologic agents even before an injury occurs.Adverse reactions to
some medications may even contribute to the injury-producing event.
 ß-adrenergic blocking agents may limit chronotropic activity, and
calcium-channel blockers may prevent peripheral vasoconstriction and
contribute to hypotension.
 NSAIDs may contribute to blood loss because of their adverse effects
on platelet function.
 Steroids and other drugs may further reduce the inflammatory and
immune response.
 Long-term anticoagulant use may increase blood loss and increases
the incidence of lethal brain injury.
 Long-term diuretic use may render elderly patients chronically
hypovolemic and lead to total body deficits of potassium and sodium.
 Hypoglycemic agents may contribute to difficulty in control of serum
glucose.
 Psychotropic medications, commonly prescribed for elderly patients,
may mask injuries or become problematic if discontinued abruptly.

24. MEDICATIONS
Pain relief in geriatric trauma patients should not be
neglected after resuscitation. Narcotics are safe and
effective and should be given in small, titrated
intravenous doses.
Antiemetic agents should be given with caution to
avoid extrapyramidal effects.
Potentially nephrotoxic drugs (e.g., antibiotics and
radiographic dyes) must be given in doses that reflect
the elderly patient’s decreased renal function,
contracted intravascular volume, and comorbid
conditions.

25. ELDER MALTREATMENT
 When evaluating an injured elderly patient, consider that the injury
may have been inflicted intentionally.
 Maltreatment of the elderly may be as common as child
maltreatment.
 Maltreatment is defined as any willful infliction of injury,
unreasonable confinement, intimidation, or cruel punishment that
results in physical harm, pain, mental anguish, or other willful
deprivation by a caretaker of goods or services that are necessary
to avoid physical harm, mental anguish, or mental illness.
 Elder maltreatment can be classified into six categories:
1.Physical maltreatment
2.Sexual maltreatment
3.Neglect
4.Psychological maltreatment
5.Financial and material exploitation
6.Violation of rights

26. PHYSICAL MALTREATMENT
 Contusions affecting the inner arms, inner thighs, palms, soles, scalp,
ear (pinna), mastoid area, buttocks, or multiple and clustered
contusions
 Periorbital ecchymoses
 Oral injury
 Unusual alopecia pattern
 Untreated fractures
 Nasal bridge and temple injury (eyeglasses)
 Untreated pressure ulcers or ulcers in nonlumbar/sacral areas
 Injuries in various stages of evolution
 Injuries to the eyes or nose
 Contact burns
The presence of these findings should prompt a detailed history that
may be at variance with the physical findings and may uncover an
intentional delay in treatment. These findings should prompt reporting to
appropriate authorities and further investigation. If maltreatment is
suspected or confirmed, appropriate action should be taken, including
removal of the elderly patient from the abusive situation.

27. END-OF-LIFE DECISIONS
 Many geriatric patients return to their pre-injury level of function
and independence after recovering from injury.
 Age significantly increases mortality from injury, but more
aggressive care, especially early in the evaluation and
resuscitation of elderly trauma patients, has been shown to
improve survival.
 Certainly there are circumstances in which the doctor and patient,
or family member(s), may choose to withdraw life-sustaining
treatment and provide palliative care.
 This decision is particularly clear in the case of elderly patients
who have sustained extensive burns or severe brain injury or when
survival from the injuries sustained is unlikely.
 The trauma team should try to determine the patient’s wishes as
evidenced by a living will, advance directive, or similar document.

28. SUMMARY
 Knowledge of the changes that occur with aging, an appreciation
of the injury patterns seen in the elderly, and an understanding of
the need for aggressive resuscitation and monitoring of injured
geriatric patients are necessary for improved outcome.
 Anatomic and physiologic changes in the elderly are associated
with increased morbidity and mortality following trauma.
Comorbidity increases with age. Frequent use of medications
including beta blockers and anticoagulants complicate assessment
and management.
 Treatment of the geriatric trauma patient follows the same pattern
as that for younger patients, but caution and a high index of
suspicion for injuries specific to this age group are required for
optimal treatment. Careful volume resuscitation with close
hemodynamic monitoring should guide treatment.
 Increased awareness of elder maltreatment, including the patterns
of injury, is necessary so that reporting can be improved. This
should lead to earlier diagnosis and improved treatment of elderly
injured patients.