- Learn about the pathophysiology of aging.
- Understand how pre-existing medical conditions affect the geriatric population.
- Relate the changes of aging to modifications in care for the elderly trauma patient.
- Summarize the effect of aging on the ability of the geriatric patient to compensate for shock.
Anticoagulant: A substance or drug that prevents or delays coagulation.
Antidopaminergic: A medication that blocks the release of dopamine
Kyphosis: An abnormal condition of the vertebral column, characterized by increased convexity in the curvature of the thoracic spine as viewed from the side.
Osteoporosis: A loss of normal bone density with thinning of bone tissue and the growth of small holes in the bone.
The geriatric trauma patient presents unique challenges to the EMS provider. There are many ways to classify older adults, but for the purpose of this article, the term geriatric will be defined as individuals who are â‰¥ 65 years old. People are living longer and are relatively healthier than their counterparts a generation ago, resulting in a rapid increase in both the number and percentage of people 65 and over. Estimates predict that by 2030, one in five people in the United States will have reached age 65.1
Geriatric trauma patients differ than younger patients due to associated physiological changes that occur with normal aging, multiple comorbidities and prescription drug regimens that present prior to their traumatic event.2,3 Because of these age-related differences, geriatric trauma patient injuries from relatively minor accidents can have devastating consequences–their response to bleeding, injury and shock differs greatly from their 18-year-old counterparts.
PATHOPHYSIOLOGY OF AGING
Aging is a progressive process and many factors impact how quickly a person ages. Even if a focused effort is placed on staying in shape, physiologic reserve continues to decrease with age and eventually effects outcomes.2,4,5 Age-related changes such as weakness, unsteady gait, slowed reaction times and cognitive impairments, and changes in eyesight predispose older individuals to trauma. Additionally, factors such as medication or devices such as pacemakers can impact the response to trauma and clinical assessment.
Normal changes of aging affect every pathophysiologic system. (See Figure 1, p. below.) However, individual response to trauma varies greatly and can be affected by previous injury in younger years, inhaled smoke and other pollutants, the presence of chronic disease, and genetics.6
The cardiovascular system loses the ability to respond to compensatory mechanisms efficiently with aging due to loss of vasculature elasticity and arthrosclerosis. Response to sympathetic catecholamines is reduced and baroreceptor activity decreases, diminishing tachycardic response to changes in blood pressure. This results in shock developing earlier in the elderly than the younger trauma patient.7 Shock may go unrecognized due to the lack of tachycardia.
Aging respiratory systems result in loss of alveolar elastic recoil, stiffening of the chest wall and an increase in flow resistance. This results in reduced oxygen exchange and decreased ventilation/perfusion ratio.8
Geriatric patients are more likely to have osteoarthritis, scoliosis and kyphosis, which impact normal physiology, mobility and function. Osteoporosis tends to affect women more than men and has an earlier onset in females. It usually occurs near the time of menopause and leads to increased potential to traumatic fracture. These fractures occur most commonly in the hip, distal radius, humerus and vertebral bodies.9 Collectively, blunt trauma in the presence of the boney changes due to age can be devastating. One common example is the occurrence of as few as 2—3 nondisplaced rib fractures becoming a major source of pneumonia in the geriatric trauma patient.10
The changes in the central nervous system are both in structure, with decreasing numbers of neurons, and function, with subtle changes in vision, reaction time and cognitive function.11 Decreasing numbers of neurons cause the brain mass to shrink. This increase in the relative intracranial space, combined with decreased elasticity of the bridging veins lining the meninges, results in increased risk of rupture on impact with subdural and/or epidural hematoma formation.2 Shrinking brain mass also increases susceptibility to shearing forces and axonal injuries.2
Additionally, the incidence of varying degrees of dementia is more common than previously thought with as many as 35% of geriatric patients exhibiting some degree of dementia in the ED.12 It’s important to note that cognitive changes can be evidence of normal aging, a cause of trauma, a subtle sign of injury, or suggestive of a medical cause of the injury, such as a stroke or myocardial infarction.
Changes of aging also have an effect on pain perception, lessening the intensity and quality of pain.6 The caregiver can be lulled into missing internal injury, particularly of the abdomen and specifically when the spleen is involved.
During the aging process, the skin loses the structural support of elastin fibers and atrophy of all skin layers. Oil and sweat glands become prominent. The skin becomes more fragile, causing delayed wound healing, increased risk for full-thickness injury and difficulty maintaining body temperature.2,6,8
EFFECTS OF PRE-EXISTING DISEASES
Pre-existing diseases are prevalent in the older adult. Just over 50% of older adults have underlying hypertension and > 30% have heart disease.13 Other conditions such as diabetes, previous cerebrovascular accident (CVA), chronic obstructive pulmonary disease (COPD), dementia and endocrine disorders are also more prevalent among the elderly and complicate the response to, and recovery from, trauma. If a geriatric patient with a history of congestive heart failure is on a beta-blocker or an anticoagulant and suffers a traumatic event, the mortality rate is 5—10 times greater.14
Vital signs and physical examination can be deceptive in these patients, and there are key physiologic considerations to take into account. Whether or not medications are on board, vital signs can be falsely reassuring. Heart rates above 90 and systolic blood pressures (SBPs) < 110 mmHg are associated with increased mortality.15 An SBP < 120 may be hypotensive if the normal SBP is 170 and heart rates above 80 may be concerning in an elderly patient on beta-blockers.2
In general, medication use, particularly antihypertensives, and pacemakers can confuse vital signs, physical assessment and responses to trauma, leading to the underestimation of the severity of injury and the misinterpretation of physical findings.
Polypharmacy remains a confounding factor in all aspects of trauma care. Obtaining a full recording of all medications, herbal preparations and recreational drug use, including alcohol, is warranted.
When the patient is on anticoagulants or antiplatelets, relatively minor wounds can bleed more rapidly. In the presence of blunt trauma to the head, particularly closed head injuries occurring during a fall, the prevalence of intracerebral bleeding increases. Significant subdural and epidural bleeds can exist with relatively few or minor neurologic signs. Many of the newer antiplatelet and anticoagulant medications don’t have specific reversal agents. It’s important for caregivers to determine as soon as possible what anticoagulant/antiplatelet medication the patient may be on and to notify the receiving hospital as soon as possible.
Finally, although not a true pre-existing medical condition, the suspicion of elder abuse can’t be ignored. A history of trauma that doesn’t correlate with clinical history or findings, the presence of bruising in odd places such as the middle of the back, top of the head, inner thighs, etc., are all suspicious for abuse. When suspected, conditions and assessment should be documented and reported.
MECHANISMS OF GERIATRIC TRAUMA
The geriatric trauma patient is five times more likely to die from trauma than a younger patient who sustains a similar mechanism of injury.1 Blunt trauma is more common with falls, accounting for nearly three quarters of all geriatric trauma. Motor vehicle crashes (MVCs) account for almost 25% of traumatic injuries in the elderly with penetrating and other mechanisms accounting for about 4%.16
One out of five falls causes a serious injury such as broken bones or a head injury.17 Falls associated with blunt cerebral injury and long bone fractures have the greatest morbidity and mortality. According the CDC, more than 95% of hip fractures in the elderly are caused by falling–usually by falling sideways–and17 one in five geriatric patients who suffer a hip fracture die within one year.1 Females are more likely than men to be injured when they fall.18
When immobilizing the geriatric patient, the goals are to restrict spinal and pelcvic movement, prevent pressure points, allow access to the patient and provide warmth.
MVCs have almost double mortality for the geriatric patient than younger adults. About 25% of geriatric patients in MVCs suffer rib fractures and flail segments, which have more serious outcomes such as pneumonia and respiratory failure.19
Another concerning mechanism of trauma is a medical event that precipitates a traumatic event. For example, syncope, myocardial infarction, sepsis, acute abdominal pathology, elder abuse, postural instability, failing vision, failing hearing and over medication are all common causes of falls. Determination of what caused the trauma and obtaining pre-event status is valuable and can alter treatment decisions. The presence of a precipitating medical event in the older trauma patient may complicate assessment, response to treatment, and outcome.
Mental status: Mental status may be difficult to determine due to the presence of deafness and poor eyesight. Confusion in the elderly can be a result of the emotion of the incident and pre-existing degrees of dementia, but just as importantly, can also be due to hypoxia and hypotension. Antipsychotics and antidopaminergic preparations for Parkinson’s disease may also alter neurologic examinations.
Pupillary response may be altered, delayed, or absent, due to medication for glaucoma, previous stroke, previous eye surgery or current central nervous system injury. Evaluate pupil reaction in light of the entire mental status assessment.
Airway: Maintaining an intact airway is the primary objective. Intraoral evaluation and evaluating speech characteristics, such as garbled sounds, may indicate a foreign body airway obstruction. The presence of dental appliances, such as partial plates, can become foreign bodies if dislodged. Intact dentures are critical to maintaining a good seal if assisted ventilation is necessary.
Osteoporosis or kyphosis may alter normal alignment of the head and neck. Any resistance to alignment should be carefully respected. Intubation for unstable patients may require use of video laryngoscopy.
If rapid sequence intubation is necessary and part of your agency’s protocols, medications should be tailored to the age of the patient with drug doses reduced (e.g., etomidate, half strength 0.15 mg/kg; midazolam 0.1 mg/kg or 0.05 mg/kg in frail elders). Risk factors for succinylcholine-induced hyperkalemia such as stroke and neuromuscular diseases are more frequently found in the elderly. In the absence of a clear history, rocuronium at 1 mg/kg may be a safer choice. Consult your medical director and follow local protocols.
Breathing: Because older adults have less pulmonary reserve, application of oxygen will help avoid hypoxia. Muscle fatigue will occur more quickly so close attention to respiratory rate is necessary.
Use of end-tidal carbon dioxide (EtCO2) may be helpful but is only as accurate as the degree of pulmonary perfusion. Use of EtCO2 by itself can be misleading. However, once the values are understood in light of the physiology of pulmonary perfusion, values may be helpful in determining adequacy of perfusion and ventilation.
Circulation: The elderly are particularly vulnerable to occult shock. The presence of arteriosclerosis, pre-existing hypertension and age-related delay in compensatory response, can leave the caregiver with a false sense of security. Traditional methods to assess the presence of shock such as low blood pressure, tachycardia and delayed capillary refill are each, by themselves, unreliable in the elderly. However, trending of vital signs is valuable and is the most important indicator of shock. Due to the prevalence of beta-blockers and calcium channel blockers, tachycardia may be present when the heart rate is above 80. Due to the prevalence of pre-existing hypertension, hypoperfusion may exist when the systolic pressure is < 110—120.
Altered mental status due to poor perfusion is an early sign of shock and may manifest itself as confusion, agitation or lethargy. These are the same alterations found in traumatic brain injury. While it can be challenging to establish a patient’s baseline, altered mental status should be suspected when patient responses don’t make sense or consist of continued repetition of information. Early signs of shock are subtle and warrant a high index of suspicion and close observation.
Administering fluid to treat shock is a standard approach but there’s no agreed upon endpoint in fluid resuscitation. It’s more helpful if fluid is used in a similar manner as a medication with specific dose requirements. The traditional fluid replacement dose is 20 mL/kg administered in 500 mL boluses. However, large volumes of fluid given too fast aren’t tolerated well in the elderly and may increase the risk of pulmonary edema.20 It may be more prudent to use smaller amounts of fluid such as 200—300 mL with close observation for clinical change between boluses. This will give the heart time to adjust to the amount of fluid being administered and avoid the consequence of volume overload.
Soft tissue injuries: Due to thinning of the skin and loss of support structures, skin tears and subcutaneous bruising are both extremely common in the elderly. Subcutaneous bruising can be extensive, and in the presence of anticoagulant/antiplatelet medication, this third spacing of blood can be significant enough to effect perfusion. Immobilization of the extremity, application of pressure dressings to control bleeding and taping dressing-to-dressing–to avoid tape-to-skin–will help minimize bleeding and avoid further trauma to fragile skin.
RESTRICTING SPINAL MOTION/POSITIONING
Fractures of the spine, ribs, hips and extremities are among the injuries more likely to occur in older patients. Elderly patients are more likely to sustain injuries that are usually considered rare. These include C1 or C2 C-spine fractures, which may result from minor mechanisms such as a simple fall from standing onto a hard surface. High cervical fractures (e.g., odontoid) are more common in the elderly.
Central cord syndrome is a complication of C-spine injury that occurs more often in older trauma patients and is characterized by disproportionately greater motor impairment in upper extremities compared to lower extremities, bladder dysfunction, and a variable degree of sensory loss below the level of injury.2,20
Figure 1: Physiologic changes of geriatric patients4
When immobilizing the geriatric patient, the goals are to restrict spinal movement, prevent pressure points, allow access to the patient and provide warmth.
Of concern is that the elderly patients don’t tolerate C-collars well and have a very difficult time tolerating the backboard. Spinal immobilization can cause respiratory restrictions in the elderly. In one study of 39 healthy volunteers, spinal immobilization restricted respirations by an average of 15%.21 This was more pronounced at the extremes of age. The presence of osteoporosis and kyphosis may complicate positioning to maintain an airway and stabilize the C-spine.
Unfortunately, many studies validating C-spine immobilization decision rules, such as NEXUS and Canadian C-spine rules, either excluded geriatric patients from being eligible for clinical C-spine clearance without C-spine imaging, or their study population wasn’t representative of the number of elderly patients for whom immobilization is a consideration in the prehospital setting.22-25Provider judgment may be needed to determine when strict immobilization is necessary and when a more permissive approach is acceptable. The more permissive approach may allow for elevation of the head of the bed (< 30%), a side-lying position with pillows/folded blanket between the knees, or foregoing a rigid backboard in favor of a long vacuum splint. Alternative spinal motion restriction techniques such as a blanket rolled in a horse-collar shape with a scoop board, or use of other soft, formable splinting material that extends the full length of the body, may be more appropriate.
Keeping the patient warm is critical to the post-trauma outcome of the older patient, particularly since any degree of hypothermia can be detrimental to the trauma patient.2 Methods to provide warmth include adjusting heat in the back of the ambulance, use of blankets and warmed IV fluids.
Assessment, treatment and transport of the geriatric trauma patient must be carried out with consideration of the unique physiology of the elderly and the devastating injuries they experience in response to relatively minor trauma.
Most elderly trauma patients will do well and return to function if they survive hospitalization.2-4 As trauma care improves, and recognition of subtle signs of injury become the norm, more of our elderly trauma patients will survive with good outcomes. Field providers are a major part of the early recognition of signs of injury and, as such, are a critical link in the treatment and survival of this very special population group.
1. Centers for Disease Control and Prevention. The State of Aging and Health in America 2013. Atlanta, Ga.: Centers for Disease Control and Prevention, US Dept of Health and Human Services, 2013.
2. American College of Surgeons: Advanced trauma life support for doctors: Student course manual, 8th ed. American College of Surgeons: Chicago, 2008.
3. National Association of EMTs: Prehospital trauma life support: Student course manual, 8th ed. Jones and Bartlett: Burlington, Ma., 2016.
4. Bonne S, Schuerer DJE. Trauma in the older adult: Epidemiology and evolving geriatric trauma principles. Clin Geriatr Med. 2013;29(1):137—150.
5. Victorino GP, Chong TJ, Pal JD. Trauma in the elderly patient. Arch Surg. 2003;138(10):1093—1098.
6. Nicole NH, Heuther SE: Chapter 44: Structure, function, and disorders of the integument. In McCance K, Heuther S (Eds.): Pathophysiology: The biologic basis for disease in adults and children. 6th ed. Mosby: St. Louis, Mo., 2010.
7. Brashers VL, McCance KL: Chapter 29: Structure and function of the cardiovascular and lymphatic systems. In McCance K, Heuther S (Eds.): Pathophysiology: The biologic basis for disease in adults and children. 6th ed. Mosby: St. Louis, Mo., 2010.
8. Brashers VL: Chapter 32: Structure and function of the pulmonary system. In McCance K, Heuther S (Eds.): Pathophysiology: The biologic basis for disease in adults and children. 6th ed. Mosby: St. Louis, Mo., 2010.
9. Crowther-Radulewicz CL: Chapter 41: Structure and function of the musculoskeletal system. In McCance K, Heuther S (Eds.): Pathophysiology: The biologic basis for disease in adults and children. 6th ed. Mosby: St. Louis, Mo., 2010.
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11. Sugerman RA: Chapter 14: Structure and function of the neurologic system. In McCance K, Heuther S (Eds.): Pathophysiology: The biologic basis for disease in adults and children. 6th ed. Mosby: St. Louis, Mo., 2010.
12. Carpenter CR, DesPain B, Keeling TN, et al. The six-item screener and ADB for the detection of cognitive impairment in the geriatric emergency department patients. Ann Emerg Med. 2011;57(6):653—651.
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14. Ferraris VA, Ferraris SP, Saha SP. The relationship between mortality and preexisting cardiac disease in 5,971 trauma patients. J Trauma. 2010;69(3):645—652.
15. Hefferman DS, Thakkar RK, Monahan SF, et al. Normal presenting vital signs are unreliable in geriatric blunt trauma victims. J Trauma. 2010;69(4):813—820.
16. Labib N, Mouh T, Winocour S, et al. Severely injured geriatric population: Morbidity, mortality, and risk factors. J Trauma. 2011;71(6):1908—1914.
17. Centers for Disease Control and Prevention. (Sept. 21, 2015.) Important facts about falls. Retrieved Sept. 24, 2015, from www.cdc.gov/HomeandRecreationalSafety/Falls/adultfalls.html.
18. Stevens JA, Sogolow ED. Gender differences for non-fatal unintentional fall related injuries among older adults. Inj Prev. 2005;11(2):115—119.
19. Lee WY, Cameron PA, Bailey MJ. Road traffic injuries in the elderly. Emerg Med J. 2006;23(1):42—46.
20. Schuur JD. (Aug. 4, 2015.) Geriatric Trauma. Clinical Gate. Retrieved May 25, 2015, from www.clinicalgate.com/geriatric-trauma/.
21. Totten VY, Sugarman DB. Respiratory effects of spinal immobilization. Prehosp Emerg Care. 1999;3(4):347—352.
22. Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. N Engl J Med. 2000;343(2):94—99.
23. Hoffman JR, Wolfson AB, Todd K, et al. Selective cervical spine radiography in blunt trauma: Methodology of the national emergency x-radiography utilization study (NEXUS). Ann Emerg Med. 1998;32(4):461—469.
24. Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. 2001;286(15):1841—1848.
25. Stiell, IG, Clement CM, McKnight RD, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003;349(26):2510—2518.
26. Keller JM, Sciadini MF, Sinclair E, et al. Geriatric trauma: Demographics, injuries and mortality. J Orthop Trauma. 2012;26(9):e161—e165.
27. Bergeron E, Lavoie A, Clas D, et al. Elderly trauma patients with rib fractures are at greater risk of death and pneumonia. J Trauma. 2003;54(3):478—85.