Geriatric Patients Fare Worse After Trauma

LAS VEGAS – Geriatric patients – with their age-related changes, frequent comorbidities, and some unique patterns of injury – "are clearly at risk for poor outcomes with trauma," Dr. Phillip D. Levy said.

Injury severity scores among trauma patients are generally similar across age ranges (J. Trauma 2010;69:88-92). "However, at every injury severity score, the percent mortality for geriatric patients ... is much worse," he said.

Aging leads to a host of anatomical and physiological changes – including reduced cardiac and pulmonary function, altered brain anatomy, and decreased musculoskeletal mass – that play a role in the setting of serious injury, said Dr. Levy, associate director of clinical research in the department of emergency medicine at Wayne State University in Detroit.

"The net effect is that there is a diminished physiological response, and some of these things may also lead to a delayed onset of overt consequences," he said, which may initially mask the extent of injury.

The EAST (Eastern Association for the Surgery of Trauma) guidelines for trauma care in older adults highlight several key concepts, he noted, such as the risk of undertriage and the adverse impact of pre-existing conditions and postinjury complications on outcomes (J. Trauma 2003;54:391-416).

Pre-existing conditions are present in 40% of patients aged 65-74 years, 65% of those aged 75-84 years, and 90% of patients aged 85 years and older, and these patients are often taking medications. For example, trauma patients with heart failure have more than double the risk of death, compared with those without heart failure, and the elevation of risk is even greater for those who are also taking beta-blockers or warfarin (J. Trauma 2010;69:645-52).

Because of these factors, the initial evaluation, secondary survey, and management of geriatric trauma patients have some unique aspects, according to Dr. Levy.

Initial Evaluation

Although the standard ATLS (Advanced Trauma Life Support) protocols still apply in older adults with trauma, "there are some caveats with it," Dr. Levy said.

One caveat is that this population is highly vulnerable to respiratory compromise with chest trauma. "Even one or two rib fractures in an elderly patient has dramatic impact," he noted.

Age-related issues such as nasopharyngeal fragility, the presence of arthritis in the temporomandibular joint, and dentures affect airway management in geriatric patients.

"Probably the most important thing when considering the airway, though, is recognizing that there are pharmacokinetic responses that are different," Dr. Levy said. Because older adults have increased responsiveness to sedatives, the dose should be reduced by 20%-40% to avoid complications.

Hypoperfusion is often occult in the elderly. "You facilitate the search by looking at serum markers of [tissue] oxygen deficit: base deficit and lactic acid," he said. These measures predict mortality in older normotensive adults who have sustained blunt trauma (J. Trauma 2009;66:1040-4). In particular, a base deficit of –6 or less or a venous lactic acid level greater than 4.0 mmol/L is associated with a mortality rate of nearly 40%, independent of injury severity.

He cautioned that specificity is much greater than sensitivity with these markers; hence, "if it’s positive, it’s positive. If it’s negative, well, it may not really be negative; you may be just early in the phase."

Use of pulmonary artery catheters (PACs) may seem an extreme approach for hemodynamic monitoring in geriatric trauma patients, Dr. Levy acknowledged. But "it enables direct measurement of cardiac function and it does improve outcomes if you use a targeted therapeutic approach, either targeting improving cardiac index or improving oxygen consumption."

For instance, therapy using PACs has been associated with a nearly 70% reduction in the risk of death for patients aged 61-90 years with severe injuries (Crit. Care Med. 2006;34:1597-601). "You optimize the patient’s hemodynamic status and their perfusion status, and you may not have even known that it was not optimized before," he said.

Secondary Survey

In blunt head trauma, patients older than 65 years are more likely to sustain traumatic brain injury than are their younger peers, according to one study (Acad. Emerg. Med. 2006;13:302-7).

"What was really interesting was that they found that 26%, about a quarter, of all elderly patients who had an injury had an occult presentation, no symptoms," he noted.

Outward clues, such as decreased alertness, prolonged loss of consciousness, and an abnormal Glasgow Coma Scale score were all less common in the older group, meaning that physical exam findings can’t be relied on to predict whether an older patient has a head injury, he said.

On CT imaging, likely because of different mechanisms of injury, geriatric patients are less likely to have linear skull fractures and epidural hemorrhages, but more likely to have subdural hematomas and subarachnoid hemorrhages.

Cervical spine injuries are also more common in older vs. younger trauma patients, and patterns of injury differ (Ann. Emerg. Med. 2002;40:287-93), again likely reflecting differences in the mechanism, according to Dr. Levy.

"The geriatric patients were at much greater risk for C1 fractures and any fracture at C2 – most specifically, an odontoid fracture," he noted.

And importantly, "you always have to consider central cord syndrome in your elderly patients due to that [hyperextension] type of mechanism. You might have osteophytes that squeeze off the cord."

CT is indicated as the primary imaging modality in cervical spine injuries among adults older than 65 years (J. Emerg. Med. 2009;36:64-71).

"The most likely [cervical spine] area for an elderly individual to have an injury is at C2 and, coincidentally, the most likely area to be missed on plain films is C2," Dr. Levy explained. "Additionally, the elderly are at a tremendous risk of false-positive findings [on plain films]. They have a lot of arthritis."

As for chest injuries, half of all older adults who sustain rib fractures do so during simple falls from a standing position (J. Trauma 2003;54:478-85), likely from hitting something on the way down. Hence, the index of suspicion should be high even after seemingly minor spills.

"As the number of rib fractures increases, mortality increases in both elderly and nonelderly, but it increases disproportionately in the elderly," he observed.

The take-home message is early airway management: "When you see a patient with three or four rib fractures, they are not taking good deep breaths in, their saturations are hovering around 90% or 92% – that’s a patient you are probably going to want to consider intubating very early on."

Geriatric patients can get an injury unique to this age group: the sacral insufficiency fracture. "Suspect it if somebody has persistent hip pain, persistent back pain, [and] they can’t get up and walk," he advised. "The elderly person who fell, there is nothing on x-ray, you don’t see much on the CT scan, you may need to go ahead if the index of suspicion is high and make this diagnosis." In addition, relative to their younger counterparts, older adults are less likely to get open-book pelvic fractures and more likely to get acetabular and pubic rami fractures, according to Dr. Levy.

Management

Fluid resuscitation is often challenging in geriatric trauma patients because of underlying cardiac dysfunction and concerns about precipitating heart failure, Dr. Levy observed.

"You can facilitate this by using central venous pressure [CVP] guidance," he said. "If you can see what their CVP is, you can titrate their fluids to their CVP, recognizing that that might not be the best marker of preload in an elderly individual and it might not be the best marker of fluid response, but it may help."

Early consideration of blood products is important in geriatric trauma patients with hemodynamic instability, and their use has the advantages of administration of a smaller fluid volume (compared with saline) and a colloid effect.

"Rapid reversal of anticoagulation is not something a lot of us do routinely, but you should consider it in every elderly patient who comes in, especially those with traumatic head injuries. [Use] vitamin K and fresh frozen plasma," he recommended.

In a study of geriatric patients with head trauma taking warfarin, mortality was 48% in historical controls who developed intracranial hemorrhage but just 10% with use of a rapid imaging and, when indicated, reversal protocol including vitamin K and fresh frozen plasma (J. Trauma 2005;59:1131-7).

Proactive management for patients with chest trauma should include both pain control and early ventilatory support, Dr. Levy said.

"Pain control is huge," he commented. "If they are more comfortable, they are more apt to take big deep breaths in and less likely to suffer from the adverse consequences of their chest trauma."

Although strategies for ventilatory support may include intubation, "in some of these older folks with COPD [or] heart failure, when you intubate them, you may never extubate them. That’s always a concern," so a trial of bilevel pulmonary airway pressure is probably warranted if started early, he said.

Additional Considerations

Dr. Levy cautioned physicians not to forget to remove cervical collars once geriatric trauma patients have been medically cleared. "The longer they stay in that collar, the longer they stay on their back, the greater the risk they have of decubiti," he explained.

Prompt orthopedic consultation for patients with hip fracture is also key, as the time to intervention influences outcomes after this injury.

Be alert for rhabdomyolysis, especially in patients who have been immobile for a prolonged period, he said. In this setting, creatine kinase is more sensitive than urine myoglobin.

If "somebody comes in and they have multiple long bone fractures, multiple upper extremity fractures, a lot of bruising," consider the possibility of elder abuse or neglect, Dr. Levy further advised.

"And always, always, always look for medical causes in trauma," he stressed, as a patient’s accident may have been precipitated by a stroke or myocardial infarction that can be overlooked in the rush to treat their injuries.

Geriatric trauma patients are potential candidates for being discharged home if they had minor closed head trauma and are not on anticoagulation, they had a simple fall and do not have ambulatory difficulties, or they have isolated extremity fractures, provided they have adequate mobility and home support. "I would say pretty much consider admissions for most if not all others," he said.

A final consideration to be aware of is end-of-life issues in patients with little potential for recovery, Dr. Levy noted. Risk stratification tools can help physicians and families make treatment decisions in this context, he said. For example, the combination of age, base deficit, and head injury severity assessed on arrival in the emergency department can help predict if care is likely to ultimately be futile in geriatric trauma patients (J. Trauma 2004;57:37-41).

"We can consider that within the context of everything else: Are they demented, living in a nursing home, on a feeding tube? Or are they a fully functional individual in the community?" Dr. Levy said. "Certainly, these are all factors in the equation to consider when you are making that decision."

LAS VEGAS – Geriatric patients – with their age-related changes, frequent comorbidities, and some unique patterns of injury – "are clearly at risk for poor outcomes with trauma," Dr. Phillip D. Levy said.

Injury severity scores among trauma patients are generally similar across age ranges (J. Trauma 2010;69:88-92). "However, at every injury severity score, the percent mortality for geriatric patients ... is much worse," he said.

Aging leads to a host of anatomical and physiological changes – including reduced cardiac and pulmonary function, altered brain anatomy, and decreased musculoskeletal mass – that play a role in the setting of serious injury, said Dr. Levy, associate director of clinical research in the department of emergency medicine at Wayne State University in Detroit.

"The net effect is that there is a diminished physiological response, and some of these things may also lead to a delayed onset of overt consequences," he said, which may initially mask the extent of injury.

The EAST (Eastern Association for the Surgery of Trauma) guidelines for trauma care in older adults highlight several key concepts, he noted, such as the risk of undertriage and the adverse impact of pre-existing conditions and postinjury complications on outcomes (J. Trauma 2003;54:391-416).

Pre-existing conditions are present in 40% of patients aged 65-74 years, 65% of those aged 75-84 years, and 90% of patients aged 85 years and older, and these patients are often taking medications. For example, trauma patients with heart failure have more than double the risk of death, compared with those without heart failure, and the elevation of risk is even greater for those who are also taking beta-blockers or warfarin (J. Trauma 2010;69:645-52).

Because of these factors, the initial evaluation, secondary survey, and management of geriatric trauma patients have some unique aspects, according to Dr. Levy.

Initial Evaluation

Although the standard ATLS (Advanced Trauma Life Support) protocols still apply in older adults with trauma, "there are some caveats with it," Dr. Levy said.

One caveat is that this population is highly vulnerable to respiratory compromise with chest trauma. "Even one or two rib fractures in an elderly patient has dramatic impact," he noted.

Age-related issues such as nasopharyngeal fragility, the presence of arthritis in the temporomandibular joint, and dentures affect airway management in geriatric patients.

"Probably the most important thing when considering the airway, though, is recognizing that there are pharmacokinetic responses that are different," Dr. Levy said. Because older adults have increased responsiveness to sedatives, the dose should be reduced by 20%-40% to avoid complications.

Hypoperfusion is often occult in the elderly. "You facilitate the search by looking at serum markers of [tissue] oxygen deficit: base deficit and lactic acid," he said. These measures predict mortality in older normotensive adults who have sustained blunt trauma (J. Trauma 2009;66:1040-4). In particular, a base deficit of –6 or less or a venous lactic acid level greater than 4.0 mmol/L is associated with a mortality rate of nearly 40%, independent of injury severity.

He cautioned that specificity is much greater than sensitivity with these markers; hence, "if it’s positive, it’s positive. If it’s negative, well, it may not really be negative; you may be just early in the phase."

Use of pulmonary artery catheters (PACs) may seem an extreme approach for hemodynamic monitoring in geriatric trauma patients, Dr. Levy acknowledged. But "it enables direct measurement of cardiac function and it does improve outcomes if you use a targeted therapeutic approach, either targeting improving cardiac index or improving oxygen consumption."

For instance, therapy using PACs has been associated with a nearly 70% reduction in the risk of death for patients aged 61-90 years with severe injuries (Crit. Care Med. 2006;34:1597-601). "You optimize the patient’s hemodynamic status and their perfusion status, and you may not have even known that it was not optimized before," he said.

Secondary Survey

In blunt head trauma, patients older than 65 years are more likely to sustain traumatic brain injury than are their younger peers, according to one study (Acad. Emerg. Med. 2006;13:302-7).

"What was really interesting was that they found that 26%, about a quarter, of all elderly patients who had an injury had an occult presentation, no symptoms," he noted.

Outward clues, such as decreased alertness, prolonged loss of consciousness, and an abnormal Glasgow Coma Scale score were all less common in the older group, meaning that physical exam findings can’t be relied on to predict whether an older patient has a head injury, he said.

On CT imaging, likely because of different mechanisms of injury, geriatric patients are less likely to have linear skull fractures and epidural hemorrhages, but more likely to have subdural hematomas and subarachnoid hemorrhages.

Cervical spine injuries are also more common in older vs. younger trauma patients, and patterns of injury differ (Ann. Emerg. Med. 2002;40:287-93), again likely reflecting differences in the mechanism, according to Dr. Levy.

"The geriatric patients were at much greater risk for C1 fractures and any fracture at C2 – most specifically, an odontoid fracture," he noted.

And importantly, "you always have to consider central cord syndrome in your elderly patients due to that [hyperextension] type of mechanism. You might have osteophytes that squeeze off the cord."

CT is indicated as the primary imaging modality in cervical spine injuries among adults older than 65 years (J. Emerg. Med. 2009;36:64-71).

"The most likely [cervical spine] area for an elderly individual to have an injury is at C2 and, coincidentally, the most likely area to be missed on plain films is C2," Dr. Levy explained. "Additionally, the elderly are at a tremendous risk of false-positive findings [on plain films]. They have a lot of arthritis."

As for chest injuries, half of all older adults who sustain rib fractures do so during simple falls from a standing position (J. Trauma 2003;54:478-85), likely from hitting something on the way down. Hence, the index of suspicion should be high even after seemingly minor spills.

"As the number of rib fractures increases, mortality increases in both elderly and nonelderly, but it increases disproportionately in the elderly," he observed.

The take-home message is early airway management: "When you see a patient with three or four rib fractures, they are not taking good deep breaths in, their saturations are hovering around 90% or 92% – that’s a patient you are probably going to want to consider intubating very early on."

Geriatric patients can get an injury unique to this age group: the sacral insufficiency fracture. "Suspect it if somebody has persistent hip pain, persistent back pain, [and] they can’t get up and walk," he advised. "The elderly person who fell, there is nothing on x-ray, you don’t see much on the CT scan, you may need to go ahead if the index of suspicion is high and make this diagnosis." In addition, relative to their younger counterparts, older adults are less likely to get open-book pelvic fractures and more likely to get acetabular and pubic rami fractures, according to Dr. Levy.

Management

Fluid resuscitation is often challenging in geriatric trauma patients because of underlying cardiac dysfunction and concerns about precipitating heart failure, Dr. Levy observed.

"You can facilitate this by using central venous pressure [CVP] guidance," he said. "If you can see what their CVP is, you can titrate their fluids to their CVP, recognizing that that might not be the best marker of preload in an elderly individual and it might not be the best marker of fluid response, but it may help."

Early consideration of blood products is important in geriatric trauma patients with hemodynamic instability, and their use has the advantages of administration of a smaller fluid volume (compared with saline) and a colloid effect.

"Rapid reversal of anticoagulation is not something a lot of us do routinely, but you should consider it in every elderly patient who comes in, especially those with traumatic head injuries. [Use] vitamin K and fresh frozen plasma," he recommended.

In a study of geriatric patients with head trauma taking warfarin, mortality was 48% in historical controls who developed intracranial hemorrhage but just 10% with use of a rapid imaging and, when indicated, reversal protocol including vitamin K and fresh frozen plasma (J. Trauma 2005;59:1131-7).

Proactive management for patients with chest trauma should include both pain control and early ventilatory support, Dr. Levy said.

"Pain control is huge," he commented. "If they are more comfortable, they are more apt to take big deep breaths in and less likely to suffer from the adverse consequences of their chest trauma."

Although strategies for ventilatory support may include intubation, "in some of these older folks with COPD [or] heart failure, when you intubate them, you may never extubate them. That’s always a concern," so a trial of bilevel pulmonary airway pressure is probably warranted if started early, he said.

Additional Considerations

Dr. Levy cautioned physicians not to forget to remove cervical collars once geriatric trauma patients have been medically cleared. "The longer they stay in that collar, the longer they stay on their back, the greater the risk they have of decubiti," he explained.

Prompt orthopedic consultation for patients with hip fracture is also key, as the time to intervention influences outcomes after this injury.

Be alert for rhabdomyolysis, especially in patients who have been immobile for a prolonged period, he said. In this setting, creatine kinase is more sensitive than urine myoglobin.

If "somebody comes in and they have multiple long bone fractures, multiple upper extremity fractures, a lot of bruising," consider the possibility of elder abuse or neglect, Dr. Levy further advised.

"And always, always, always look for medical causes in trauma," he stressed, as a patient’s accident may have been precipitated by a stroke or myocardial infarction that can be overlooked in the rush to treat their injuries.

Geriatric trauma patients are potential candidates for being discharged home if they had minor closed head trauma and are not on anticoagulation, they had a simple fall and do not have ambulatory difficulties, or they have isolated extremity fractures, provided they have adequate mobility and home support. "I would say pretty much consider admissions for most if not all others," he said.

A final consideration to be aware of is end-of-life issues in patients with little potential for recovery, Dr. Levy noted. Risk stratification tools can help physicians and families make treatment decisions in this context, he said. For example, the combination of age, base deficit, and head injury severity assessed on arrival in the emergency department can help predict if care is likely to ultimately be futile in geriatric trauma patients (J. Trauma 2004;57:37-41).

"We can consider that within the context of everything else: Are they demented, living in a nursing home, on a feeding tube? Or are they a fully functional individual in the community?" Dr. Levy said. "Certainly, these are all factors in the equation to consider when you are making that decision."

LAS VEGAS – Geriatric patients – with their age-related changes, frequent comorbidities, and some unique patterns of injury – "are clearly at risk for poor outcomes with trauma," Dr. Phillip D. Levy said.

Injury severity scores among trauma patients are generally similar across age ranges (J. Trauma 2010;69:88-92). "However, at every injury severity score, the percent mortality for geriatric patients ... is much worse," he said.

Aging leads to a host of anatomical and physiological changes – including reduced cardiac and pulmonary function, altered brain anatomy, and decreased musculoskeletal mass – that play a role in the setting of serious injury, said Dr. Levy, associate director of clinical research in the department of emergency medicine at Wayne State University in Detroit.

"The net effect is that there is a diminished physiological response, and some of these things may also lead to a delayed onset of overt consequences," he said, which may initially mask the extent of injury.

The EAST (Eastern Association for the Surgery of Trauma) guidelines for trauma care in older adults highlight several key concepts, he noted, such as the risk of undertriage and the adverse impact of pre-existing conditions and postinjury complications on outcomes (J. Trauma 2003;54:391-416).

Pre-existing conditions are present in 40% of patients aged 65-74 years, 65% of those aged 75-84 years, and 90% of patients aged 85 years and older, and these patients are often taking medications. For example, trauma patients with heart failure have more than double the risk of death, compared with those without heart failure, and the elevation of risk is even greater for those who are also taking beta-blockers or warfarin (J. Trauma 2010;69:645-52).

Because of these factors, the initial evaluation, secondary survey, and management of geriatric trauma patients have some unique aspects, according to Dr. Levy.

Initial Evaluation

Although the standard ATLS (Advanced Trauma Life Support) protocols still apply in older adults with trauma, "there are some caveats with it," Dr. Levy said.

One caveat is that this population is highly vulnerable to respiratory compromise with chest trauma. "Even one or two rib fractures in an elderly patient has dramatic impact," he noted.

Age-related issues such as nasopharyngeal fragility, the presence of arthritis in the temporomandibular joint, and dentures affect airway management in geriatric patients.

"Probably the most important thing when considering the airway, though, is recognizing that there are pharmacokinetic responses that are different," Dr. Levy said. Because older adults have increased responsiveness to sedatives, the dose should be reduced by 20%-40% to avoid complications.

Hypoperfusion is often occult in the elderly. "You facilitate the search by looking at serum markers of [tissue] oxygen deficit: base deficit and lactic acid," he said. These measures predict mortality in older normotensive adults who have sustained blunt trauma (J. Trauma 2009;66:1040-4). In particular, a base deficit of –6 or less or a venous lactic acid level greater than 4.0 mmol/L is associated with a mortality rate of nearly 40%, independent of injury severity.

He cautioned that specificity is much greater than sensitivity with these markers; hence, "if it’s positive, it’s positive. If it’s negative, well, it may not really be negative; you may be just early in the phase."

Use of pulmonary artery catheters (PACs) may seem an extreme approach for hemodynamic monitoring in geriatric trauma patients, Dr. Levy acknowledged. But "it enables direct measurement of cardiac function and it does improve outcomes if you use a targeted therapeutic approach, either targeting improving cardiac index or improving oxygen consumption."

For instance, therapy using PACs has been associated with a nearly 70% reduction in the risk of death for patients aged 61-90 years with severe injuries (Crit. Care Med. 2006;34:1597-601). "You optimize the patient’s hemodynamic status and their perfusion status, and you may not have even known that it was not optimized before," he said.

Secondary Survey

In blunt head trauma, patients older than 65 years are more likely to sustain traumatic brain injury than are their younger peers, according to one study (Acad. Emerg. Med. 2006;13:302-7).

"What was really interesting was that they found that 26%, about a quarter, of all elderly patients who had an injury had an occult presentation, no symptoms," he noted.

Outward clues, such as decreased alertness, prolonged loss of consciousness, and an abnormal Glasgow Coma Scale score were all less common in the older group, meaning that physical exam findings can’t be relied on to predict whether an older patient has a head injury, he said.

On CT imaging, likely because of different mechanisms of injury, geriatric patients are less likely to have linear skull fractures and epidural hemorrhages, but more likely to have subdural hematomas and subarachnoid hemorrhages.

Cervical spine injuries are also more common in older vs. younger trauma patients, and patterns of injury differ (Ann. Emerg. Med. 2002;40:287-93), again likely reflecting differences in the mechanism, according to Dr. Levy.

"The geriatric patients were at much greater risk for C1 fractures and any fracture at C2 – most specifically, an odontoid fracture," he noted.

And importantly, "you always have to consider central cord syndrome in your elderly patients due to that [hyperextension] type of mechanism. You might have osteophytes that squeeze off the cord."

CT is indicated as the primary imaging modality in cervical spine injuries among adults older than 65 years (J. Emerg. Med. 2009;36:64-71).

"The most likely [cervical spine] area for an elderly individual to have an injury is at C2 and, coincidentally, the most likely area to be missed on plain films is C2," Dr. Levy explained. "Additionally, the elderly are at a tremendous risk of false-positive findings [on plain films]. They have a lot of arthritis."

As for chest injuries, half of all older adults who sustain rib fractures do so during simple falls from a standing position (J. Trauma 2003;54:478-85), likely from hitting something on the way down. Hence, the index of suspicion should be high even after seemingly minor spills.

"As the number of rib fractures increases, mortality increases in both elderly and nonelderly, but it increases disproportionately in the elderly," he observed.

The take-home message is early airway management: "When you see a patient with three or four rib fractures, they are not taking good deep breaths in, their saturations are hovering around 90% or 92% – that’s a patient you are probably going to want to consider intubating very early on."

Geriatric patients can get an injury unique to this age group: the sacral insufficiency fracture. "Suspect it if somebody has persistent hip pain, persistent back pain, [and] they can’t get up and walk," he advised. "The elderly person who fell, there is nothing on x-ray, you don’t see much on the CT scan, you may need to go ahead if the index of suspicion is high and make this diagnosis." In addition, relative to their younger counterparts, older adults are less likely to get open-book pelvic fractures and more likely to get acetabular and pubic rami fractures, according to Dr. Levy.

Management

Fluid resuscitation is often challenging in geriatric trauma patients because of underlying cardiac dysfunction and concerns about precipitating heart failure, Dr. Levy observed.

"You can facilitate this by using central venous pressure [CVP] guidance," he said. "If you can see what their CVP is, you can titrate their fluids to their CVP, recognizing that that might not be the best marker of preload in an elderly individual and it might not be the best marker of fluid response, but it may help."

Early consideration of blood products is important in geriatric trauma patients with hemodynamic instability, and their use has the advantages of administration of a smaller fluid volume (compared with saline) and a colloid effect.

"Rapid reversal of anticoagulation is not something a lot of us do routinely, but you should consider it in every elderly patient who comes in, especially those with traumatic head injuries. [Use] vitamin K and fresh frozen plasma," he recommended.

In a study of geriatric patients with head trauma taking warfarin, mortality was 48% in historical controls who developed intracranial hemorrhage but just 10% with use of a rapid imaging and, when indicated, reversal protocol including vitamin K and fresh frozen plasma (J. Trauma 2005;59:1131-7).

Proactive management for patients with chest trauma should include both pain control and early ventilatory support, Dr. Levy said.

"Pain control is huge," he commented. "If they are more comfortable, they are more apt to take big deep breaths in and less likely to suffer from the adverse consequences of their chest trauma."

Although strategies for ventilatory support may include intubation, "in some of these older folks with COPD [or] heart failure, when you intubate them, you may never extubate them. That’s always a concern," so a trial of bilevel pulmonary airway pressure is probably warranted if started early, he said.

Additional Considerations

Dr. Levy cautioned physicians not to forget to remove cervical collars once geriatric trauma patients have been medically cleared. "The longer they stay in that collar, the longer they stay on their back, the greater the risk they have of decubiti," he explained.

Prompt orthopedic consultation for patients with hip fracture is also key, as the time to intervention influences outcomes after this injury.

Be alert for rhabdomyolysis, especially in patients who have been immobile for a prolonged period, he said. In this setting, creatine kinase is more sensitive than urine myoglobin.

If "somebody comes in and they have multiple long bone fractures, multiple upper extremity fractures, a lot of bruising," consider the possibility of elder abuse or neglect, Dr. Levy further advised.

"And always, always, always look for medical causes in trauma," he stressed, as a patient’s accident may have been precipitated by a stroke or myocardial infarction that can be overlooked in the rush to treat their injuries.

Geriatric trauma patients are potential candidates for being discharged home if they had minor closed head trauma and are not on anticoagulation, they had a simple fall and do not have ambulatory difficulties, or they have isolated extremity fractures, provided they have adequate mobility and home support. "I would say pretty much consider admissions for most if not all others," he said.

A final consideration to be aware of is end-of-life issues in patients with little potential for recovery, Dr. Levy noted. Risk stratification tools can help physicians and families make treatment decisions in this context, he said. For example, the combination of age, base deficit, and head injury severity assessed on arrival in the emergency department can help predict if care is likely to ultimately be futile in geriatric trauma patients (J. Trauma 2004;57:37-41).

"We can consider that within the context of everything else: Are they demented, living in a nursing home, on a feeding tube? Or are they a fully functional individual in the community?" Dr. Levy said. "Certainly, these are all factors in the equation to consider when you are making that decision."