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Geriatric Trauma

Geriatric Trauma. Christopher B. Powe, Ph.D., ACNP-BC Associate Professor, Trauma & Surgical Critical Care. Background. Elderly people account for 12-15% of U.S. population 10-14% of all trauma victims are >65 33% of all trauma $ is spent on elderly patients

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Geriatric Trauma

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  1. Geriatric Trauma Christopher B. Powe, Ph.D., ACNP-BC Associate Professor, Trauma & Surgical Critical Care

  2. Background • Elderly people account for 12-15% of U.S. population • 10-14% of all trauma victims are >65 • 33% of all trauma $ is spent on elderly patients • Trauma care cost 3x as much for an elderly person compared to a younger person

  3. Definitions • Elderly >65 years • Young old and Old old • Chronological age is actual # of years lived • Physiologic age is actual functional capacity of patient’s organ systems

  4. Mechanisms • Falls • Motor Vehicle Crashes (MVC) • Pedestrian vs. Motor Vehicle • Burns • Assaults

  5. Falls • Most common injury - 40% elderly trauma • 25% who fall sustain “serious injury” • Falls M=F but females are more likely to be injured • Postural instability, vision and hearing, reaction time, meds • Syncope vs Fall • Standing height falls

  6. MVC • 2 cars • Daytime • Intersections • Close to home • 2nd Highest fatal crash rate • Time to stop driving

  7. Auto-Ped • 46% elderly trauma occurs at crosswalk • Average crosswalk speed is 4ft/sec • Parking lots

  8. Pathophysiology of Geriatric Trauma • Pre-existing diseases lead to more severe injuries • Co-morbid diseases complicate recovery • Medications alter “normal” function and vital signs • Physiologic Age • Less dramatic physiologic response • Narrow limit of physiologic tolerance

  9. Cardiovascular • Myocardial cells are replaced by fatty infiltration and amyloid deposits; heart becomes “stiff” • Decreased Beta receptor # and sensitivity to catecholamines (decreases rate and contractile force) • Not able to increase cardiac output at important times

  10. Cardiovascular • Atherosclerotic disease is prevalent in elderly and can lead to “secondary injury” • Myocardial oxygen demand is increased during trauma and stress • Loss of elasticity of arteries decreases compliance and increases resistance • Cardiac medications • Pacemakers

  11. Chest wall and lungs not as compliant Respiratory muscles are weaker Loss of alveolar surface area leads to impaired gas exchange Spinal immobilization (collar and supine) Impaired cough Rib fractures double mortality Pulmonary

  12. “There are three signs of old age. The first is your loss of memory and the other two I forget.” Unknown

  13. Central Nervous System • Subdurals - Most common • Atrophy • Delayed accumulation of blood • Warfarin • Pre-existing dementia or strokes makes evaluation and recovery difficult

  14. Renal • By age 65 lose 40% of glomeruli • Diminished renal blood flow • Creatinine is misleading because of decreased muscle mass (CrCl is better) • Chronic dehydration • Hypotension leads to ATN • Nephrotoxic agents (IV contrast and NSAIDS)

  15. Metabolic, Nutrition and Immunity • Caloric requirements decrease with age but nutrient demands remain constant • Elderly have less nutritional reserve • Glucose intolerance and diabetes • Catabolic response is same as with young people but catabolic protein loss is more significant with elderly • Increased risks of infection

  16. Injuries • Subdurals • Hip fractures • Wrist fractures • Compression fractures • Rib fractures • Central cord syndrome • Scalp lacerations

  17. Subdurals • Tear in bridging veins because of atrophy • Crescent shaped clot between the dura and arachnoid • Judicious use of CT for falls • Warfarin • Aggressive reversal of coagulopathy

  18. Central Cord Syndrome • Cervical stenosis and spondylosis • Hyperextension injuries • Central corticospinal and spinothalamic tracts • Upper extremities more commonly involved • Good prognosis

  19. Outcomes • Mortality • Young is 4-8% • Elderly is 15-30% • Improve survival by early invasive monitoring • Prevention most important • Withholding Care

  20. Outcomes • Occult hypotension and early recognition • High Risk • TBI • Multiple long bone fractures • Auto vs. Pedestrian • Initial systolic BP < 130

  21. Prevention • Safe environment (rugs, cords, lighting, etc) • Home modifications (tubs, rails, etc) • Medications (benzos and narcotics) • Driving Safety • Not driving • Strength and balance therapy

  22. How to Help Seniors Drive Safely Longer- 8 Functional Areas (AAA) • Working Memory (directions and traffic rules) • Visualization of missing info (recognize hazards) • Visual search (find signs) • Useful field of vision (peripheral threats) • Leg strength and flexibility • Head and neck flexibility • High contrast visual acuity (signs/marks) • Low visual acuity

  23. “An ounce of prevention is worth a pound of cure.” Benjamin Franklin

  24. Summary • Poor prognosis for old people with traumatic injuries • Significant injuries with minor accidents • Warfarin is bad in trauma • Judicious use of CT scans • Early invasive monitoring • Prevention is the key

  25. “Age is strictly a case of mind over matter. If you don’t mind then it doesn’t matter.” Jack Benny

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