Trauma in the elderly population

1. Trauma in the Elderly
Nicola Batrick FRCS FRCEM
Consultant Emergency Medicine
Director NWL Trauma Network

2. The London Trauma
System
Centralisation of trauma services

3. 3
Co-ordinated Pan-London
Pre-hospital Pathways

4. Elderly Trauma

5. Causes of trauma in the older patient
• Elderly have different injury pattern
• 25% RTC (road traffic collision) driver or pedestrian
• 75% falls - 90% Ground level or low height
• Why do the elderly fall? Causes include weakness, visual loss, balance/gait
problems, cognitive impairment
• Consider elder abuse

6. Trauma Call Criteria
• Modify call criteria to include elderly fall from standing
• 2 tiered trauma system
• Find what works in your Trust for your patient population

7. Older persons trauma proforma
St Mary’s MTC Older Adults (≥65 years) Major Trauma Proforma
Assign member of team to communicate with and orientate patient
Primary Survey
1. Medications (Check Summary Care Record if possible)
Ask about the following medications specifically which effect initial management
Anticoagulation/Antiplatlets agents (bleeding
risk)
Asprin
Clopidogrel (Plavix)
Warfarin
Coumadin
Rivaroxiban (Xarelto)
Dabigatrin (Pradaxa)
Apixiban (Eliquis)
Cardiac Meds (mask physiological response/ indicated altered baseline physiology)
ACE inhibitors
Beta Blockers
Other antihypertensives/ antiarrhythmic
Bisphosphonates or other treatments for osteoporosis (high risk fractures)
Alcohol (higher risk of concealed injury, coagulation disturbance)
Alter drug doses if needed
Reference Drug Doses for common medications used in Trauma
Paracetamol 15mg/kg (if under 50kg, to max 1g)
Morphine 0.2-0.4 mg/kg
Fentanyl 25-100mcg titrated (1mcg/kg)
TXA 1st
dose 15mg/kg (up to 1g), then infusion 2mg/kg/hr
Tetanus Status
Consider Immune Status
( ≥5 vaccinations in lifetime? If born in the UK before 1961 or the rest of the developed world before 1965-70 unlikely to
have had a full course, if born in a developing world country is likely to need full primary course)
Consider need for full course primary vaccination (follow-up on ward or via GP needs to be arranged)
Consider need for Immunoglobuin (tetanus prone wound in someone without a full course primary vaccination)
2.Imaging .
Fragility Fractures Have a low threshold for imaging in those with risk factors for osteoporosis even in low
energy mechanism of injury as fracture risk is high
Renal Function Don’t delay imaging if it is needed
Do consider using IV fluids after the procedure
Do consider holding diuretics for 24 hours after CT
Do monitor renal function for 48 hours
Actions
Consider doing TEG where history of
anticoagulants/antiplatelet is unclear/unknown
Follow Trust guidance on reversal
Secondary survey
1. Consider the cause of fall .
Treat dehydration
Exclude UTI
Exclude Pneumonia
Exclude CVA
Exclude Cardiac Syncope
- Do an ECG
- Exclude murmur
- Is the history suspicious for cardiac syncope?
Consider Elder Abuse
- Complete safeguarding form if suspected
2. Key Information .
Estimated Weight (Kg)
Allergies
Next of Kin
Contacts
3. Patient Communication .
Known cognitive impairment Y N
Usually Wear Hearing Aids?
(if yes try to reduce noise and put bairhugger at foot of bed)
Y N
Usually Wear Glasses? Y N
Usually Wear Dentures? Y N
Mouth Care (as early as possible – for comfort and to facilitate communication) Y N
Try to clear neck as soon as possible
– if any delay consider early use of MiamiJ collar and removal of blocks to facilitate communication

8. Admission Policy
• Pressure area assessment
• VTE assessment
• Bone health and falls
assessment
• Delirium / dementia screen
• Cognitive assessment

9. Admissions policy
• Medicines reconciliation
• Collateral history
• Mental health
• Falls prevention
• Orthogeriatrics review/ care of the elderly input
• Discharge planning

10. Imaging in the elderly
• Radiation dose is not a concern
• Contrast induced nephropathy - anticipate but don’t change imaging
• All adults with blunt major trauma and suspected injuries should have
whole body CT – NICE

11. Blunt Thoracic Injuries
• Early recognition of injuries
• Rib fractures most common manifestation
• Age related demineralisation increased risk rib fractures with low
energy mechanisms
• What is your pathway for multiple rib fractures?
• Imaging consider CT
• Pain relief
• Underlying lung disease
• Management of small pneumothoraces

12. Blunt Abdominal Trauma
• Follow high energy trauma
• Same prevalence as in younger population
• When it occurs 5x mortality increase compared with younger
population
• Diagnosis of shock can be difficult
• Poor resilience to volume loss
• Interventional radiology or surgical intervention

13. Pelvic Fractures
• Up to 4 x increase in mortality compared with young
• Pelvic XR
• Early CT if any concerns
• Pelvic binders – care with skin integrity if left in place for a long period
• Age over 60 years significant risk factor for active bleeding
• Early interventional radiology essential for embolisation

14. TBI
• Increased risk of haemorrhage all compartments particularly subdural
• NICE guidance
• Protocolised CT – avoid prolonged discussions
• High chance of significant abnormality on CT
• Unsurvivable
• No NS operative input needed or neuro ICU – remain in a TU
• NS intervention or risk of significant deterioration transfer to an MTC

15. Anti coagulation
• Anticoagulated patients 4-5 x mortality of non anti coagulated
• What protocols are in place for patients on Warfarin and DOACS?
• How quickly can you get Octaplex for a warfarinised TBI?
• Octaplex protocol
• Watford “grab bag”
• Low threshold for repeat CT if patient deteriorates
• Monitor for 12-24 hours due to risk of delayed haemorrhage

16. Spinal Injuries
• Increased risk eg demineralisation and rigidity of spine
• Patients with kyphosis/ degenerative spine may not tolerate cervical
collar
• Plain XR poor diagnostic value in the elderly
• Low threshold for advanced imaging with CT and MRI
• Cervical spine fractures – commonest site C1 and C2
• 30-40% non contiguous spinal fractures v 10% younger patients

17. Extremity Injuries
• Fracture severity increases with osteporosis
• Osteoporotic periarticular fractures – proceed to joint replacement
• Diagnostic value of CT may be limited if bone density poor so consider
MRI as well
• Soft tissue injuries – complicated by arterial disease and venous
insufficiency

18. Pain management
• Care with elderly who have cognitive impairment – look for non
verbal manifestations of pain
• Care with drug dosages eg paracetamol
• Regular analgesia avoid NSAIDs
• Thoracic epidural – check absolute CI including clopidogrel
• Alternative blocks
• Lidocaine patches

19. Any questions?
Thanks to Dr Elizabeth Dick Consultant Radiologist St Mary’s MTC for providing
some of the images used in the lecture