Considerations in the Management of Geriatric Trauma
Good news! We re all living longer. As health care has improved over centuries, the average life expectancy, particularly in developed countries, has steadily increased. In ancient times, a person was considered elderly and wise at 40, whereas now we refer to people in their 60s as relatively young. Likewise, with the advancements in medical technology, people have a better chance of maintaining an independent active lifestyle and a high quality of life for many more years than ever before. The not-so-good, sort-of-complicated news is that as the geriatric population increases during the upcoming decades, we in EMS will have in our care more elderly patients who have maintained or increased their activity after the typical age of retirement.
In the world of trauma care, we have the familiar phrases the golden hour and a child is not a small adult. As we look at the geriatric patient, we don t need to sift through volumes of research literature to establish a similar truth -- an older patient is not as resilient. Common sense will tells us that the healthy elderly patient in the face of trauma is not as resilient at the healthy 22-year-old involved in equivalent traumatic events.
The development of age-related brain atrophy and osteoporosis, reductions in cardiac reserve and lung capacity and compliance, and decreased mobility and rates of healing are all a part of the natural process of aging. The presence of co-morbid disease states can also increase the rates of mortality after a relatively minor traumatic event. To handle our geriatric trauma patients, we must be aware of each of these processes. Additionally, we should be considering whether specialty care centers would benefit our geriatric trauma patients.
The natural response of the cardiovascular system to hypovolemia is to increase the cardiac output, which increases the myocardial workload. The patient with underlying cardiac disease will certainly not tolerate a significant loss in blood volume. An increased cardiac workload to compensate for blood loss in the presence of coronary artery disease or pre-existing myocardial injury or dysfunction can cause myocardial ischemia. Routine medications can exacerbate effects of hypovolemia. Diuretics, which are frequently used as the first-line treatment for hypertension, cause a state of relative hypovolemia as well as hypokalemia. Calcium-channel blockers, such as verapamil (Calan, Covera, Isoptin, Verelan) or diltiazem (Cardizem, Dilacor, Tiazac), and beta-blockers, such as propranolol (Inderal) and metoprolol (Lopressor, Toprol) reduce myocardial workload and may decrease the cardiac output.
A growing number of patients are on anticoagulants for a variety of medical conditions, including atrial fibrillation, coronary artery disease, pulmonary emboli, cerebrovascular disease and other conditions for which embolic prophylaxis is warranted. Two decades ago, a trauma surgeon would cringe upon hearing that their patient was taking warfarin (Coumadin) because of its anticoagulant effects. As outpatient treatment has become the trend, patients with deep-vein thrombosis and other conditions that place the patient at risk for pulmonary emboli are treated at home with subcutaneous non-fractionated heparin or enoxaparin sodium (Lovenox). The newest generation of medications for embolic prophylaxis, such as clopidogrel bisulfate (Plavix), act by inhibiting the normal function of platelets and create a heightened risk for hemorrhage in the traumatized patient. These classes of medications can create an insurmountable hurdle for the trauma surgeon because the effects of these medications have lengthy half-lives and can t be quickly reversed.
Neurological & Musculoskeletal Concerns
Age-related cerebral atrophy makes the brain prone to intracranial movement during trauma with potential impact against the skull. Subdural hematomas occur frequently in the elderly due to this phenomenon, and the incidence is increased in those taking anticoagulant medications. Due to the fragility of the walls of the vasculature, less force of impact is required to cause an aortic tear, pulmonary contusions or intracranial hemorrhages. In addition, delayed disruption of vascular integrity may result in internal or intracranial bleeding that wasn t present during the initial physical examination or radiographic studies.
Osteoporosis makes the skeleton prone to fractures with minimal trauma, and the elderly have decreased joint mobility. The fractured osteoporotic spine places the patient at grave risk of spinal cord injuries. Also, a stiff arthritic cervical spine can make airway management more difficult for the EMS provider. The majority of cervical spine fractures in the elderly occur in the first three cervical vertebrae where an associated spinal cord injury will cause respiratory compromise in addition to paralysis. In particular, fractures of the pelvis and femur typically cause clinically significant hypovolemia from retroperitoneal and compartmental bleeding, respectively.
Geriatric Trauma Centers
The Ohio Department of Public Safety Division of EMS has a trauma data registry that serves as a repository of clinical data for prehospital treatment and transport of trauma patients. Approximately a year ago, I asked our data center for a simple graph comparing the mortality rates of trauma victim who wore seatbelts with those who were unbelted. The mortality rates for the unrestrained patients involved in motor vehicle crashes far exceeded the mortality rates of those wearing seatbelts -- until the age of approximately 72.
I was surprised to note that for patients 72 years of age or older, the mortality rates were nearly equal regardless of seatbelt use. More research needs to be done to define the factors that cause this trend, but it certainly highlights the fact that trauma has a more severe impact on the elderly. The trend also raises the question of whether we have a need for geriatric trauma centers that have specialized resources to address the triage, trauma care and rehabilitation of the elderly patient, analogous to what we have in place for our pediatric trauma victims.
As we examine the research that has been completed, we already know that the leading cause of trauma in the elderly is secondary to falls with a peri-injury mortality rate of more than 10% and a mortality rate within one year of the injury of 50%. The second leading mechanism of traumatic injury in the elderly is MVCs, and a third of these patients die within the peri-injury period. The presence of a pelvic fracture alone is associated with a mortality rate of at least 10% and decreased ambulatory status up to 50% of the survivors after one year.
The determination of need and development of geriatric trauma centers is in its infancy. However, enough evidence supports a heightened awareness of the higher acuity during triage and prehospital care of elderly trauma victims by EMS and emergency care providers. The threshold for the initiation of expeditious transport of elderly patients to trauma centers should be lower than the criteria utilized during the triage of younger adults.
The geriatric segment of our population is growing faster than ever before, and the number of elderly trauma victims is expected to quadruple in the next four decades. None of us are getting younger, but more of us will remain active and independent as we age, and our EMS systems and trauma care will need to adapt to accommodate our future needs. When I m 80 years old and zipping around town in my red six-speed on my way to the Chippy Club, I hope my room is ready.