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Geriatric trauma

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Geriatric trauma

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Geriatric trauma

  1. 1. Geriatric Trauma Aisling Wadden 07/09/2017
  2. 2. Geriatric Trauma • Trauma – any presentation due to or involving an injury or with potential to have an injury… • Geriatric - .........>/= 65 !!
  3. 3. Be wary of the old frail faller • Majority of trauma in elderly is ground level falls/GLF (fall from standing height, fall off bed, fall off chair) – in younger people this mechanism is considered low risk/trivial • Elderly patients high risk for significant morbidity/mortality due to “trivial” falls etc
  4. 4. Falls • The risk of falling is increased by impaired eyesight due to any cause (e.g. glaucoma, macular degeneration, incorrect glasses/lens prescription) balance disorder movement disorders (e.g. Parkinson's disease)  dementia sarcopenia (age-related loss of skeletal muscle). • Collapse/syncope leads to a significant risk of falls/injury; causes may include cardiac arrhythmias vasovagal syncope, orthostatic hypotension and seizures.
  5. 5. Injuries • Intracranial bleed • C-Spine fractures • Hip Fractures • Rib Fracture • Wrist fractures • Internal injuries
  6. 6. Complications • Sepsis • Wound infection • Delerium • Pneumonia • Death
  7. 7. Is being old really that dangerous? • Age itself is not an independent risk factor? • Mechanism of injury • Injury severity score (ISS) • Pre-existing conditions • Anticoagulation use
  8. 8. “Older Age, Comorbid Illnesses, and Injury Severity Affect Immediate Outcome in Elderly Trauma Patients” J Emerg Trauma Shock. 2017 Jul-Sep; 10(3): 146–150. • Currently, traumatic injuries are the fifth leading cause of death in elderly patients. • 1027 patients aged ≥65 years who were admitted to Level I Trauma Centre following blunt trauma*. Patients’ charts were reviewed for demographics, ISS, mechanism of injury, pre- existing comorbidities, Intensive Care Unit and hospital length of stay, complications, and in-hospital mortality.
  9. 9. “Older Age, Comorbid Illnesses, and Injury Severity Affect Immediate Outcome in Elderly Trauma Patients” J Emerg Trauma Shock. 2017 Jul-Sep; 10(3): 146–150. • The mean age of injured patients was 78.8 ± 8.3 years (range 65–109). • The majority of patients had mild injury severity (ISS 9–14, 66.8%) • Falls (all low energy) was a main MOI (907, 88%) followed by motor vehicle crush and pedestrian injury (119, 11.6%). • Orthopaedic trauma followed by head trauma (or combined) was the reason for hospital stay in majority of the cases (68 and 28%, respectively). • 10% of patients had chest trauma (often ribs fractures).
  10. 10. “Older Age, Comorbid Illnesses, and Injury Severity Affect Immediate Outcome in Elderly Trauma Patients” J Emerg Trauma Shock. 2017 Jul-Sep; 10(3): 146–150. • Multiple comorbidities (≥3) were found in 233 patients (22.7%). Hypertension, diabetes mellitus, and coronary artery disease (CAD) were the most frequent comorbidities in the study group • Chronic anticoagulation treatment was recorded in 13% of patients • The addition of a single comorbidity increased the odds of wound infection to 1.29 and sepsis to 1.25.
  11. 11. “Older Age, Comorbid Illnesses, and Injury Severity Affect Immediate Outcome in Elderly Trauma Patients” J Emerg Trauma Shock. 2017 Jul-Sep; 10(3): 146–150. • In-hospital complications were recorded in 209 (21%) survivors (n = 991). • Sepsis and pneumonia were the most common complications (69 patients, 7% and 67, 6.7%, respectively). • Any surgical site infections were found in 49 patients (4.9%). Venous thromboembolic events were detected in 24 patients (2.4%)
  12. 12. Mortality • All study group mortality was noticed in 35 cases (3.4%). • 22 patients (63%) died from severe head trauma on median post-trauma day 8 (range 1–11). • 7 (20%) patients died from sepsis and multi-organ failure; others from severe multi-trauma and haemorrhagic shock and high spinal injury • Mortality increased with age - of 35 deceased, 18 (51%) were above 86 years old. • In the group of patients who passed away during their hospital stay, a statistically significant association was found between death and existence of certain comorbidities (CAD, renal failure, dementia, and warfarin use; P < 0.05). • In 29 mortality cases (83%), at least a single comorbidity was noticed versus no co-morbidities in 705 survivors (71%). • Both age and ISS increased the odds of death as −1.08 and −2.47, respectively.
  13. 13. “Older Age, Comorbid Illnesses, and Injury Severity Affect Immediate Outcome in Elderly Trauma Patients” J Emerg Trauma Shock. 2017 Jul-Sep; 10(3): 146–150. • *Any types of blunt trauma mechanism were included: falls and car accidents including both inside car injured and pedestrian. • Conclusion: age alone in elderly trauma population is not a robust measure of outcome, and more valuable predictors such as injury severity, pre-existing comorbidities, and medications are accounted for adverse outcome. Trauma care in this population with special considerations should be tailored to meet their specific needs.
  14. 14. “Differences in Mortality between Elderly and Younger Adult Trauma Patients: Geriatric Status Increases Risk of Delayed Death” Perdue, Philip W. MD, MPH; Watts, Dorraine D. RN, PhD; Kaufmann, Christoph R. MD, MPH; Trask, Arthur L. MD Journal of Trauma-Injury Infection & Critical Care: October 1998 - Volume 45 - Issue • Records from 5,139 adult patients from a Level I trauma centre were retrospectively reviewed. Injury Severity Score (ISS), Revised Trauma Score (RTS), early mortality (<24 hours), and late mortality (>24 hours) were determined for elderly (>or=to65 years) and younger (16-64 years) patients. • Mortality in elderly patients was twice that in younger patients despite equivalent injury severity (p < 0.001), and elderly patients were more likely to suffer later death than younger patients (p < 0.005). • The prevalence of pre-existing disease was greater in the elderly, as was the incidence of complications. Using logistic regression, ISS, RTS, pre-existing cardiovascular or liver disease, the development of cardiac, renal, or infectious complications, and geriatric status were all independently predictive of late mortality (p < 0.05).
  15. 15. Scghed.com
  16. 16. • Cervical Spine injury
  17. 17. J Clin Med Res. 2013 Apr; 5(2): 75–83. “Geriatric Trauma Patients With Cervical Spine Fractures due to Ground Level Fall: Five Years Experience in a Level One Trauma Center” Hao Wang,a,c et al. • From 2006 - 2010, a total of 12,805 trauma patients were included in trauma registry, of which 726 (5.67%) had sustained C-spine fracture(s). • Among all C-spine fracture patients, 19.15% (139/726) were geriatric patients. • Of these geriatric patients 27.34% (38/139) and 53.96% (75/139) had C1 and C2 fractures compared with 13.63% (80/587) and 21.98% (129/587) in young trauma patients (P < 0.001). • Of geriatric trauma patients 13.67% (19/139) and 18.71% (26/139) had C6 and C7 fractures compared with 32.03% (188/587) and 41.40% (243/587) in younger ones separately (P < 0.001). • Furthermore, 53.96% (75/139) geriatric patients had sustained C- spine fractures due to GLF with more upper C-spine fractures (C1 and C2).
  18. 18. J Clin Med Res. 2013 Apr; 5(2): 75–83. “Geriatric Trauma Patients With Cervical Spine Fractures due to Ground Level Fall: Five Years Experience in a Level One Trauma Center” Hao Wang,a,c et al. • ICP associated with C-spine fractures were only found in geriatric patients in this study. Seven different clinical variables could potentially be independent risk factors associated with C-spine fractures and ICP in trauma patients due to GLF or less. The results of our multivariate regression showed only age (OR 1.17) and male gender (OR 91.57) were two independent risk factors.
  19. 19. J Clin Med Res. 2013 Apr; 5(2): 75–83. “Geriatric Trauma Patients With Cervical Spine Fractures due to Ground Level Fall: Five Years Experience in a Level One Trauma Center” Hao Wang,a,c et al. • Conclusion: • Geriatric patients tend to sustain more upper C-spine fractures than non-geriatric patients regardless of the mechanisms. • GLF or less not only can cause isolated C-spine fracture(s) but also lead to other significant injuries with ICP as the most common one in geriatric patients. • • Advanced age and male are two risk factors that can predict this co-injury pattern. In addition, it seems that alcohol plays no role in the cause of GLF in geriatric trauma patients.
  20. 20. Rib Fractures • “Elderly Trauma Patients with Rib Fractures Are at Greater Risk of Death and Pneumonia” Bergeron et al Journal of Trauma-Injury Infection & Critical Care: March 2003 • Results: Among 4,325 blunt trauma admissions, there were 405 (9.4%) patients with rib fractures; 113 were aged ≥ 65. • Injuries were severe, with Injury Severity Score (ISS) ≥ 16 in 54.8% of cases, a mean hospital stay of 26.8 ± 43.7 days, and 28.6% of patients requiring mechanical ventilation. • Mortality (19.5% vs. 9.3%;p < 0.05), presence of comorbidity (61.1% vs. 8.6%;p < 0.0001), and falls (14.6% vs. 0.7%;p < 0.0001) were significantly higher in patients aged ≥ 65 despite significantly lower ISS (p = 0.031), higher Glasgow Coma Scale score (p = 0.0003), and higher Revised Trauma Score (p < 0.0001). • After adjusting for severity (i.e., ISS and Revised Trauma Score), comorbidity, and multiple rib fractures, patients aged ≥ 65 had five times the odds of dying when compared with those < 65 years old.
  21. 21. Scghed.com • “With regard to patients with chest injury, the earlier pain is controlled, the less likely patients will suffer complications from inadequate pain control, splinting OR excessive narcotisation. This is especially the important in elderly patients and patients with significant comorbidities. There is an agreement at SCGH between Pain Service, Trauma Service and the ED, that any patient with the following criteria should be referred to the Acute Pain Service: • Criteria for urgent referral to acute pain team: • > 65 years old • OR • significant comorbidities • OR • no enteral route available • AND • > 2 rib fractures.”
  22. 22. • Relevant pre-existing conditions: • Frailty! • Advanced age • Osteopenia , osteoporosis, Degenerative joint disease • Anticoagulant use • CAD/CKD/DM/COPD
  23. 23. Osteoporosis • It is estimated that 200 million people worldwide have osteoporosis. • About 15% of caucasians in their 50s and 70% of those over 80 are affected. • It is more common in women than men. • There are 8.9 million fractures worldwide per year due to osteoporosis. • Globally, 1 in 3 women and 1 in 5 men over the age of 50 will have an osteoporotic fracture.
  24. 24. Osteoporosis – Risk Factors • Non-modifiable: Increasing age Female sex Oestrogen deficiency (menopause/oopherecto my) Family History Ethnicity – European and Asian highest rates. • Modifiable: Excess alcohol Smoking Vitamin D deficiency Malnutrition ?Soft drinks – displace calcium Immobilisation Steroids/AEDs/Lithium/PP Is/Anticoagulants/Thiazoli dinediones/L-Thyroxine
  25. 25. Osteoporosis • Treatment: modify risk factors Vitamin D/Calcium Bisphosphonates – after first fracture
  26. 26. Osteoporosis • Hip fractures  The most serious consequences of osteoporosis. A 50- year-old caucasian female is estimated to have a 17.5% lifetime risk of fracture of the proximal femur • Vertebral fractures smaller impact on mortality, can lead to a severe chronic pain of neurogenic origin, which can be hard to control, as well as deformity. • Wrist fractures  In the United States, 250,000 wrist fractures annually are attributable to osteoporosis. Wrist fractures are the third most common type of osteoporotic fractures. By the time women reach age 70, about 20% have had at least one wrist fracture. • Rib fractures Cause of significant morbidity in the elderly, secondary to pain, secondary pneumonia, over-sedation from analgesia etc
  27. 27. Anticoagulation • Warfarin: The commonest side effect of warfarin is bleeding. The risk of severe bleeding is small but definite (a typically yearly rate of 1-3% has been reported) • This risk increases greatly once the INR exceeds 4.5(atraumatic bleed) and INR of >1.5 (traumatic) • Aspirin: Some studies show increased risk of traumatic IC bleeding but overall risk is not increased. (?) • Other antiplatelet agents, especially Clopidogrel associated with significant increased risk of traumatic ICB • NOACS -- Increased risk but not as much as Warfarin………….?
  28. 28. “Preinjury warfarin, but not antiplatelet medications, increases mortality in elderly traumatic brain injury patients.” Grandhi R1, Harrison G, Voronovich Z, Bauer J, Chen SH, Nicholas D, Alarcon LH, Okonkwo DO • Preinjury use of warfarin, but not antiplatelet medications, influences survival and need for neurosurgical intervention in elderly TBI patients with intracranial haemorrhage; haemorrhage progression and morbidity are not affected. The importance of antithrombotic therapy may lie in its impact on initial injury severity.
  29. 29. “Antiplatelet therapy and the outcome of subjects with intracranial injury: the Italian SIMEU study” Andrea Fabbri et al Italiana di Medicina d'Emergenza Urgenza Study Group • Conclusions: pre-injury antithrombotic therapy is associated with an increased risk of short-term radiological worsening and six-month unfavourable outcome in subjects with a positive head CT scan, particularly in subjects treated by clopidogrel. The results should be considered in predictive algorithms of future guidelines of diagnosis and treatment of head injury.
  30. 30. References • Scghed.com • J Emerg Trauma Shock. 2017 Jul-Sep; 10(3): 146–150.”Older Age, Comorbid Illnesses, and Injury Severity Affect Immediate Outcome in Elderly Trauma Patients”Dvora Kirshenbom, Zila Ben-Zaken, Nehama Albilya, Eva Niyibizi, and Miklosh Bala • “Antiplatelet therapy and the outcome of subjects with intracranial injury: the Italian SIMEU study” Andrea Fabbri,corresponding author1 Franco Servadei,2 Giulio Marchesini,3 Carolina Bronzoni,2 Danilo Montesi,4 and Luca Arietta4, of the Società Italiana di Medicina d'Emergenza Urgenza Study Group • J Clin Med Res. 2013 Apr; 5(2): 75–83. “Geriatric Trauma Patients With Cervical Spine Fractures due to Ground Level Fall: Five Years Experience in a Level One Trauma Center” Hao Wang,a,c Marco Coppola,a Richard D. Robinson,a James T. Scribner,a Veer Vithalani,a Carrie E. de Moor,a Raj R. Gandhi,b Mandy Burton,a and Kathleen A. Delaneya • “Elderly Trauma Patients with Rib Fractures Are at Greater Risk of Death and Pneumonia”Bergeron, Eric MD; Lavoie, Andre PhD; Clas, David MD; Moore, Lynne MSc; Ratte, Sebastien MD; Tetreault, Stephane MD; Lemaire, Jacques PhD; Martin, Marcel MD. Journal of Trauma-Injury Infection & Critical Care: March 2003 - Volume 54 - Issue 3 - pp 478-485
  31. 31. References • “Differences in Mortality between Elderly and Younger Adult Trauma Patients: Geriatric Status Increases Risk of Delayed Death” Perdue, Philip W. MD, MPH; Watts, Dorraine D. RN, PhD; Kaufmann, Christoph R. MD, MPH; Trask, Arthur L. MD; Journal of Trauma-Injury Infection & Critical Care: October 1998 - Volume 45 - Issue 4 - pp 805-810 • “Preinjury warfarin, but not antiplatelet medications, increases mortality in elderly traumatic brain injury patients.” Grandhi R1, Harrison G, Voronovich Z, Bauer J, Chen SH, Nicholas D, Alarcon LH, Okonkwo DO.

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