geriatric trauma - in Indian population

1. GERIATRICTRAUMA
Presented by
Cathrine Diana
PG trainee II
Oral and maxillofacial surgery

2. CONTENT
• Introduction
• Epidemiology
• Demographic content
• Pathophysiology
• Incidence of trauma
• Various Types of fracture &management
• Summary

3. INTRODUCTION
Ageing:
• The normal predictable and irreversible changes of various
organ system over the passage of time which ultimately leads
to death

4. WHAT IS GERIATRIC?
• Dictionaries define 'geriatric' as 'pertaining to old people'
• The World Health Organization (1963) has defined 'middle-
age' as being 45-59 years, 'elderly' as being 60-74 years and
the 'aged' as over 75 years of age
• Most developed countries have accepted the chronological
age of 65 years as a definition of 'elderly' or older person

5. DEMOGRAPHIC DATA
• India’s older population will increase dramatically over the
next four decades. India’s 60 and older population is expected
to encompass 323 million people, a number greater than the
total U.S. population.
• Today’s issue on ageing issue 25, march 2012

6. • Bloom (2011a) calls the share of India’s population ages 50
and older relatively small at 16 %, but notes that India will
experience rapid growth among this age group.
• The United Nations Population Division projects that India’s
population ages 50 and older will reach 34 % by 2050 (UN
2011)
• Today’s issue on ageing issue 25, march 2012

7. >65 years old > 80 years
• 2010 5% 1%
• 2050 14 % 3%
• life expectancy
• In 1774 - 35 years,
2010 - 74 years
2050 - still more
Today’s issue on ageing issue 25, march 2012

8. EPIDEMIOLOGY
• Increased life expectancy due to
• Improved health
• Better nutrition
• Social support
• Improved technology
• Improved medical facilities and awareness

9. GERIATRIC TRAUMA
• A study by Ferrera et al in 2000, 94% of the reported
mechanism of injury (MOI) in the geriatric population
was due to falls, motor vehicle crashes and pedestrian
related accidents
• 55% of the hospitalizations for trauma were due to low-
mechanism falls (LMFs)

10. • Traditionally the geriatric patients with trauma have been
triaged in a similar fashion and by the same guidelines as our
adult population. However, several studies have revealed that
these two populations have different survival rates from
similar trauma.

11. • The most common fractures in elderly population
• rib,
• distal radius,
• pelvic ring, (25%),
• facial bones, 10.1%
• Proximal femur (25%)
• proximal humerus,
• clavicle, (24%),
• ankle, and sacrum.

12. • The injuries associated with the highest mortality rates were
fractures of the cervical spine with neurological deficit (47%),
at the C2 level (44%),

13. PATHOPHYSIOLOGY IN ELDERLY
• 13% -disability that affects at least one activity of daily
living.
• > 1/4th are underweight and
• 1/3rd undiagnosed hypertension.

14. PRE EXISTING CONDITION
• PECs with the strongest effect on mortality
• hepatic disease - 5.1,
• renal disease - 3.1
• Cancer - 1.8.
• Chronic steroid use increased the odds of death after trauma

15. PULMONARY SYSTEM
• functional capacity & lung elasticity.
• breathing effort is mainly depend on diaphragm
• This negatively impacts tidal volume
• chronic obstructive pulmonary disease (COPD) and the
patient's ability to compensate during stress can be severely
impaired.
• Micro aspiration is more common in old age group.
• Therefore, seemingly minor injuries, can cause significant
respiratory compromise.

16. Cardiovascular system
• Impaired cardiac output
• Lower heart rate and stroke volume
• Decreased catecholamine responsiveness
• Decrease circulating blood volume (diuretics)
• Diastolic dysfunction/hypertension
• Lower myocardial cell mass
SBP < 100 mm of Hg consider as a state of shock – one of
the cause for morbidity in elderly injured patients.

17. CENTRAL NERVOUS SYSTEM
Cerebral atrophy shrinkage of the brain
tension on the cerebral veins tear more easily
subdural hematomas.

18. • Due to cerebral atrophy, there is gap between skill box and
the brain, so even a blunt injury , may not cause skull bone
fracture, but cause significant brain damage.
Impairment :
• cognitive function,
• memory,
• hearing and vision,
• perception.

19. • Dementia affects 20% of the elderly above 80 years of age.
• Alzheimer’s diseases,
• depression related cognitive dysfunction

20. RENAL SYSTEM
• Decreased renal function can impact the patient's ability
to survive a protracted recovery period.
• Impaired concentrating ability
• creatinine clearance

21. Loss of nephrons 40- 50% Reduction in GFR
responsiveness to renin-angiotensin-aldosterone
renal blood flow due to changes in vessels (50%)
loss of muscle mass leads to low creatinine level

22. • Immune response
• Production of T-cells, B-cells risk for infection
• Changes in endocrine system
• leads to osteoporosis, diabetes, hypertension

23. Poly pharmacy:
• ability to physiologically compensate for the stress of trauma is
also compromised by the medications
• Some key medications to be concerned about include the
blood thinner Coumadin (warfarin) and
• the antiplatelet agents, such as aspirin and Plavix (clopidogrel),
which can lead to significant bleeding complications.
• OHG
• Anti hypertensive drugs- Beta-blockers and calcium-channel
blockers
• diuretics

24. • Drug PT/INR aPTT TT
• Warfarin
• Dabigatran mild
• Rivaroxaban mild mild

25. SUB OPTIMAL NUTRITION
• Elderly population are mostly in sub optimal nourished
state, due to inaccessibility/ unavailability of nutrients,
age related changes influencing glucose intolerance,
renal clearance, and decreased serum growth hormone
level.
• 45 % – lack of access to “an improved water source.”
• 60% -live in dwellings lacking access to an improved
sewer system

26. INCIDENCE OF TRAUMA IN OLD
AGE
Elderly people are the most rapidly growing demographic in
developed nations. Although they sustain traumatic injury less
commonly than children and young adults, the mortality rate for
trauma in the elderly is higher than in younger people

27. • Trauma is 7th leading cause of death in geriatric patients
• Trauma has 3-fold higher mortality
• – Older patients with pre existing medical conditions = 9.2%
• – Younger patients without pre existing medical conditions =
3.2%

28. 1.FALL (25%)
• Most common injury involves trauma to head, pelvis and
lower extremity.
• Account for 40% of deaths .
• Impaired vision
• hearing and memory,
• postural sway,
• impaired neurosensory coordination
• Indian J Dent Res, 19(2),

29. motor vehicle collision
79.4%
• Most common cause of trauma in developing countries.
• slower reflexes
• error in perception
• impairment of vision and hearing,
• the elderly are more liable to get involved in accidents

30. 3.PEDESTRIAN TRAUMA
• – slow pause, gait imbalance
• ,impaired auditory and visual sense.
• Mortality rate > 25%

31. • Burns
• violence
• occupational accidents
• neglect & suicide

32. Geriatric Trauma Triage
Guidelines:
• The American College of Surgeons Committee on
Trauma(ACS-COT)- patients older than the age 55 should
be “considered” for direct transport to a trauma centre,
apparently without regard to the severity of injury

33. • Glasgow Coma Score < 15 with suspected traumatic brain
injury (TBI);
• Falls with evidence of traumatic brain injury (even from a
standing position);
• Systolic blood pressure < 100 mmHg;
• Geriatric pedestrian struck by motor vehicle;
• Known or suspected proximal long-bone fracture sustained in
a motor vehicle crash (MVC); and
• Multiple body regions injured

34. APPROACHES TO GERIATRIC TRAUMA

35. PRE-HOSPITAL CARE
• Evaluate the past medical history and the event leads to
trauma
• Determine baseline functional status
• Monitor the vitals, elderly patients may go to
decompensating state without warning

36. EVALUATION/MANAGEMENT

37. ABBREVIATED INJURY SCALE ( AIS)
• An anatomically based, consensus derived, global
severity scoring system that classifies each injury by body
region according to its relative importance on a 6-point
ordinal scale (1=minor and 6=maximal).
• AAAM's Abbreviated Injury Scale". Association for the Advancement of
Automotive Medicine. Retrieved 2014-03-27

38. Abbreviated injury Score
AIS-Code Injury Example AIS % prob. of death
1 Minor superficial laceration 0
2 Moderate fractured sternum 1 – 2
3 Serious open fracture of humerus 8 – 10
4 Severe perforated trachea 5 – 50
5 Critical
ruptured liver with tissue
loss
5 - 50
6 Maximum total severance of aorta 100
9 Not further specified (NFS)

39. Initial Care - Airway
• Consider anatomy
• Dentition (dentures), nasopharyngeal fragility,
microstomia, cervical arthritis
• Consider early intubation –
• Decreased cardiopulmonary reserve
• Shock, chest injury, altered LOC
• EAST Practice Management Guidelines Work GroupJ Trauma. 2003;54:391

40. –Breathing/Ventilation
• Decreased vital capacity/respiratory reserve
• Chest injuries (rib fractures, pulmonary contusion,
pneumothorax, hemothorax)
• Increased mortality
• High risk of atelectasis, pulmonary edema, pneumonia, and
acute respiratory failure
In patients 65 years of age and older, an admission respiratory
rate < 10 is associated with a 100% mortality
EAST Practice Management Guidelines Work GroupJ Trauma. 2003;54:391

41. • Liberal use of supplemental oxygen
• CXR and ABG
• Analgesia
• Tidal Volume status
• Pulmonary toilet
• Maintain SPo2 > 90 %
• EAST Practice Management Guidelines Work GroupJ Trauma. 2003;54:391

42. • Head CT – in case of LOC, neurologic deficit, dementia, head and
neck injury, multisystem injury, h/o anticoagulant therapy
• Less force is enough to cause cervical spine fracture (C2)
• Need rigid collar/halo while transportation
• EAST Practice Management Guidelines Work GroupJ Trauma. 2003;54:391

43. Circulation:
• Criteria were developed to select patients for invasive
hemodynamic monitoring.
• These criteria included
• pedestrian–motor vehicle mechanism,
• initial blood pressure < 100 mm Hg,
• acidosis,
• multiple fractures,
• and head injury

44. • Patients were moved to the intensive care unit as quickly as
possible.
• Pulmonary artery catheters and arterial lines were inserted in
all patients.
• Volume infusion and inotropes were used to augment
hemodynamic parameters.
• Attempts were made to optimize patients to a cardiac index >
4 L/min/m2 or an oxygen consumption index of 170
mL/min/m2.

45. ICU RECOMMENDATION:
• Pelvic fracture
• hemoperitonium - significant mortality rate.
• Geriatric patients with a TS <15
• AIS > 3
• Shock
• Chronic cardio vascular or renal disease are at high risk for
complications and should be admitted to the ICU and treated
aggressively.
EAST Practice Management Guidelines Work GroupJ Trauma. 2003;54:391

46. Prescribing guidelines (Beers
Criteria ACS 2012)
• Discontinue nonessential medications
• Continue medications with withdrawal potential (, beta
blockers, clonidine, statins, corticosteroids)
• Adjust doses for renal function (GFR)
• Monitor narcotic use closely
• Consider non narcotic alternatives

47. • Plasma, FFP or cryoprecipitate can be given to reverse the
anticoagulant effects of warfarin and admitted to ICU for close
neurologic monitoring and pulmonary care

48. • Enteral feeding is the clear choice for most effective
physiologic route for providing nutrition.
• other consideration for enteral route feeding site is decrease
in septic complication and improvement of nitrogen balance,
and maintenance of gut mucosa.

49. DISTRIBUTION OF INJURIES INEDPOPULATION

50. • In elderly population trauma involves more than one fracture
• Brain injury - (63.0)
• Cervical spine - (5.3)
• Other spinal injury - (20.9)
• Upper extremity - (43.4)
• Lower extremity (33.0)
• Thoracic injury - (31.0)
• Abdominal injury - (15.0)
• J Oral Maxillofac Surg 72:352-361, 2014

51. • soft tissue injuries - 46%
• maxillary fractures- 30%
• mandibular fractures-18%
• zygomaticomaxillary complex fractures, 30%
• nasal bone fractures - 43.2%
• orbital floor – 27%
• dentoalveolar fractures, and cranial bone fractures. 5%
• Appropriate radiographic imaging should be performed for final
diagnosis
• J Oral Maxillofac Surg 72:352-361, 2014

52. HEAD INJURIES

53. • Traumatic insult to the head that may result in injury to soft
tissue, bony structures, and/or brain injury
• Blunt Trauma
• Penetrating Trauma

54. • Scalp laceration or avulsion -Most common injury
• Vascularity = diffuse bleeding
• Skull fracture – linear or depressed

55. Signs
• Hemotympanum or bloody ear discharge
• Rhinorrhea or otorrhea
• Battle’s sign
• Raccoon’s eyes
• Cranial nerve palsies

56. Sub Dural hematoma
• common in elderly trauma population- Between Dura
mater and arachnoid.
• Usually venous Bridging veins between cortex and Dura.
Causes increased intracranial pressure.
• Pressure exerted downward on brain, compress Cerebral
cortex -- Altered level of consciousness
Hypothalamus --- Vomiting

57. • Signs:
• Slower onset
• Increased ICP - Increased BP,Decreased pulse, Irregular
respiratory pattern (Cushing’s triad)
• Headache, decreased LOC, unequal pupils
• Hemiparesis, hemiplegia

58. Management:
• Consider - Airway, breathing and circulation first, followed by
drug therapy
• IV diazepam 5mg in case of seizure, may mask signs LOC.
• IV mannitol 1g/kg - decrease cerebral edema
• IV lignocaine 1.5mg/kg – prevents increase in ICP
• IV glucose in case of hypoglycemia

59. • Traumatic Coma Databank, , defined severe brain injuries as
GCS score < 8. But other studies suggested that admission GCS
<11 associated with 100% mortality rate in elderly population
>80 yrs. of age

60. • Kotwica and Jakubowski, in a study of head-injured patients
70 years of age and older, noted a 90% mortality in patients
with a GCS score <9 when craniotomy was required and 76%
when craniotomy was not required. On the basis of this
finding in 136 patients, they recommend aggressive treatment
for 24 hours only for those patients without space occupying
lesions. Aggressive treatment, then, is continued only in those
patients who show “significant” improvement within this time
frame

61. • Consider with holding of primary treatment for craniofacial
injuries that will not result in substantial functional loss.
• In medically compromised cases, consider secondary repair of
facial injury.

62. CRANIOMAXILLARY FRACTURE

63. • Primary concerns
• Airway compromise secondary to bleeding
• FB aspiration secondary to broken or avulsed teeth
• Management:
• ABCs
• Suction
• Stabilize impaled object
• Collect tissue: tongue or tooth

64. • In elderly population craniofacial fractures are usually managed by
conservative methods
• In case of undisplaced fractures, it can be managed with closed
reduction- MMF, suspension wirings, external pin fixations.

65. • If it is displaced or affect the functional status , ORIF can be
performed based on the medical condition of the patient.
• ORIF of cariniomaxillary fractures can be approached through
existing laceration, hemi coronal or bi coronal approach

66. Gunning splint:
• Gunning splint was initially fabricated by Thomas brain
gunning for the immobilization of edentulous ridges.
• In edentulous patient due to the absence of teeth it is difficult
to reduce and immobilize the fracture.

67. • A gunning splint resembles a mono block consists of two bite
block fixed to the maxilla by per alveolar wiring and to the
mandible by circumferential wiring. Then interconnecting the
both with wire loop and elastics
• Existing denture can also be used as splint

68. Fabrication of gunning splint
• Impression materials
1. Impression compound
2. Alginate hydrocolloids
Impression tray:
Preformed trays
Sectional trays
Cast fabrication – type 2 plaster or stone

69. • Challenges:
• bleeding
• Trismus
• pain
• Fractured / mobile teeth
• Disoriented occlusion
• Posterior occlusal gag
• Gag reflex

70. • Wax bite is fabricated with appropriate VD
• In case of any retaining firm teeth , that can be used to
maintain VD
• 3 hooks per quadrant has to be fixed followed by acrylization
• Reverse hooks has to be attached in molar region if
suspension wiring was planned

71. • Maxillary gunning splint - per alveolar wiring, circumpalatal
wiring,
• Mandibular splint – circummandibular wiring
• MMF – elastics, tie wires
• Suspension wires, external pin fixators can also be attached
with it

72. NASAL BONE FRACTURE

73. • Epistaxis
• Anterior bleeding from septum- Usually venous
• Posterior bleeding- Often drains to airway
• May be associated with Sphenoid and/or ethmoid fractures
Basilar skull fracture
• Direct pressure over septum
• Upright position, leaning forward or in lateral recumbent
position
• Anterior and/ posterior nasal pack
• Fractured segments can be reduced either by closed or open
method
• Immobilization can be done by external splints or internal
plate fixation

74. Atrophic mandibular fractures

75. • Long edentulous period leads to atrophy of mandible
• The remaining bone is markedly diminished in height
and often width, and is frequently entirely cortical (and
brittle) in nature.
• The highest degree of atrophy is seen typically in the
lateral body of the mandible, an area without major
muscle attachment. There is no effective endosteal blood
supply

76. • Depends mainly on periosteal blood supply.
• Because of the risk of non-union resulting from interference
with periosteal blood supply, reduction should be
accomplished with minimal exposure.
• many undisplaced fracture require no active treatment

77. • The most common site of fracture is bilateral body region
(bucket handle fracture)- which may compromise the airway
and mandibular angle

78. METHODS OF IMMOBILIZATION

79. • 1.intermaxillary fixation with gunning splints
• 2. indirect skeleton fixation :
• Pin fixation, bone clamps
• 3.direct osteosynthesis:
• Bone plates (mini plates)
• Trans osseous wiring,
• Trans fixation with K-wires
• Bone grafting

80. • Rigid internal fixation (RIF) has been more effective in these
complex injuries
• Modern locking reconstruction plates anchored by at least
three screws on either side of the fracture or defect allow for
undisturbed healing
• If wound complications occur, the internal fixator stabilizes the
segments during further debridement, grafting, etc, with the
patient continuing to function in general
• A reconstruction plate (locking or nonlocking) with bicortical
screw placement (mostly only possible in chin and angle
region) must bear the functional load in an atrophic mandible

81. SOFT TISSUE INJURIES

82. • Age related immunological changes appear to play a critical
role in wound repair and healing.
• The inflammatory, proliferative response are decreased.
• There is a measurable change in fibroblast function, collagen
formation, migration and cross linkage

83. • This affects the patient’s ability to resists infections and
delayed wound healing
• Most of the soft tissue lacerations can go for primary closure,
also skin turgor, rhytids do not adversely contribute to
outcome.

84. SUMMARY
• Advanced patient age is not an absolute predictor of poor
outcomes following trauma and, therefore, should NOT be
used as the sole criterion for denying or limiting care in this
patient population
• An initial aggressive approach should be pursued for
management of the elderly patient unless in the judgment of
an experienced trauma surgeon it seems that the injury
burden is severe and the patient appears moribund

85. • The preponderance of available literature, however, suggests
more favourable long-term outcomes, with up to 85% of
survivors functioning independently at home at follow-up
intervals as long as 6 years post injury

86. • Geriatric trauma care presents unique challenges
• •Aggressive care is generally warranted
• •Consider pre-existing conditions
• •Anticipate complications
• •Don’t minimize discharge planning
• Premorbid status has to be consider more than the chronological
age
• Consider early transport to trauma centre
• Vital and urine output are not absolute values to consider
• Physical examination may underestimate the injury, use of
radiographic studies indicated

87. Reference:
1. Killey’s fractures of mandible
2. Rowe and williams
3. Oral and maxillofacial trauma - fonseca
4. Geriatric Trauma: Demographics, Injuries, and Mortality Journal of
Orthopaedic Trauma: September 2012 - Volume 26 - Issue 9 - p e161–
e165
5. State of Ohio State Board of Emergency Medical Services Trauma
Committee: "Geriatric Trauma Task Force Report and Recommendations."
6. A Simple Fall in the Elderly: Not So Simple
7. Journal of Trauma-Injury Infection & Critical Care: February 2006 -
Volume 60 - Issue 2 - pp 268-273
8. .AAAM's Abbreviated Injury Scale". Association for the Advancement of
Automotive Medicine. Retrieved 2014-03-27
9. .Maxillofacial intervention in trauma patients aged 60 years and older
Indian J Dent Res, 19(2), 2008Journal of Trauma-Injury Infection & Critical
Care: February 2002 - Volume 52 - Issue 2 - pp 242-246

88. 10. . ACS-TQIP gediatric trauma management guideline
Today’s issue on ageing issue 25, march 2012
11 AO Principles of Internal Fixation of the Craniomaxillofacial Skeleton
12. Defining Predictable Patterns of Craniomaxillofacial Injury in the Elderly:
Analysis of 1,047 Patients J Oral Maxillofac Surg 72:352-361, 2014
13. Practice Management Guidelines for Geriatric Trauma: The
EAST Practice Management Guidelines Work Group
J Trauma. 2003;54:391–
14.Two Piece Gunning Splint In Edentulous Patient With Fractured Maxilla
Indian Journal of Dental SciencesSakshi Malhotra Kaura
Jugraj Singh. October 2014 Supplementary Issue Issue:4, Vol.:6
15. Conservative Splint Therapy For Atrophic Edentulous Mandible Fracture
In A Geriatric Patient M Rathee, M Goel, A Hooda, A Kumar, R
KunduConservative Splint Therapy For Atrophic Edentulous Mandible
Fracture In A Geriatric Patient M Rathee, M Goel, A Hooda, A Kumar, R
Kundu