Trauma in the Elderly Nathanael Wood, MD Albany Medical Center March 21, 2007.

Trauma in the Elderly Trauma in the Elderly

Nathanael Wood, MDNathanael Wood, MDAlbany Medical CenterAlbany Medical Center

March 21, 2007March 21, 2007

Case Study 1Case Study 1

83 year-old female83 year-old female Driver, belted, no airbag deploymentDriver, belted, no airbag deployment Parking lot speed, minimal auto damageParking lot speed, minimal auto damage No complaintsNo complaints Highest HR en route: 90Highest HR en route: 90 Lowest SBP en route: 110Lowest SBP en route: 110 Boarded and collaredBoarded and collared

PMH: HTN, osteopeniaPMH: HTN, osteopenia PSH: CholecystectomyPSH: Cholecystectomy Meds: Lopressor, calciumMeds: Lopressor, calcium Social: Non smoker, non-drinkerSocial: Non smoker, non-drinker

Vitals on Arrival to EDVitals on Arrival to ED

HR 95, BP 115/85, RR 18, T 98, HR 95, BP 115/85, RR 18, T 98, O2 97% RA O2 97% RA

Primary SurveyPrimary Survey

A: PatentA: Patent B: Breathing comfortably, equal B: Breathing comfortably, equal

breath sounds b/lbreath sounds b/l C: Radial and femoral pulses equal, C: Radial and femoral pulses equal,

strongstrong D: No deficitsD: No deficits

Secondary SurveySecondary Survey

General: Awake, alertGeneral: Awake, alert HEENT: NC/ATHEENT: NC/AT Neck: hard collar, NTNeck: hard collar, NT CV: RRR, pulses equal/strong throughoutCV: RRR, pulses equal/strong throughout Lungs: CTA BLLungs: CTA BL Abd: soft, NT, ND, bowel sounds presentAbd: soft, NT, ND, bowel sounds present Extremities: no deformities, no Extremities: no deformities, no

tenderness, FROMtenderness, FROM Neuro: Non focal examination, A&O X3Neuro: Non focal examination, A&O X3

ED CourseED Course

Neck cleared using NEXUS criteria, Neck cleared using NEXUS criteria, hard collar removedhard collar removed

No imaging indicatedNo imaging indicated Pt refused analgesiaPt refused analgesia Signed out to next resident: Needs Signed out to next resident: Needs

to ambulate, likely d/c soonto ambulate, likely d/c soon

ED Course, continuedED Course, continued

Patient unable to ambulatePatient unable to ambulate CT Abdomen, pelvis…CT Abdomen, pelvis…

Grade 3 liver lacerationGrade 3 liver laceration Admitted to hospital for observationAdmitted to hospital for observation D/C after two daysD/C after two days

ED Course, continuedED Course, continued

Then, one day after d/c…Then, one day after d/c… Neck discomfort.Neck discomfort. Back to ED.Back to ED. CT neck…CT neck…

C5 fractureC5 fracture

D’OH!D’OH!

How did we miss all that?How did we miss all that?

Unlucky?Unlucky? Different physiology?Different physiology? Medications?Medications?

The “Elderly”The “Elderly”

What is “Elderly” or “Geriatric”?What is “Elderly” or “Geriatric”? 55?55? 65?65? 70?70?

DependsDepends


12% of the population is over age 55 12% of the population is over age 55 36% of all ambulance transports 36% of all ambulance transports 25% of hospitalizations25% of hospitalizations

>85, fasted growing age group>85, fasted growing age group


In 2000, 35 million aged 65+In 2000, 35 million aged 65+ By 2030, 70 million aged 65+By 2030, 70 million aged 65+

20% of US population20% of US population 70% of ambulance transports70% of ambulance transports

““Geriatric”Geriatric”

> 70> 70 Exhibits significant anatomical or Exhibits significant anatomical or

physiological characteristics associated physiological characteristics associated with advanced aging. with advanced aging.

Trauma in the ElderlyTrauma in the Elderly

Fifth leading cause of death, > 65 years

Significant cause of morbidity. Minor trauma may result in functional

decline. Older patients have worse outcomes

despite lesser injury severity.

Types of TraumaTypes of Trauma

FallsFalls MVAsMVAs ViolenceViolence BurnsBurns

FallsFalls

Falls and the ElderlyFalls and the Elderly

Leading cause of elder traumaLeading cause of elder trauma Occur in 1/3rd of independent eldersOccur in 1/3rd of independent elders More common in nursing home residentsMore common in nursing home residents 10% of falls result in significant injury10% of falls result in significant injury Severity/frequency increases with ageSeverity/frequency increases with age May be a symptom of general declineMay be a symptom of general decline 50% 1 year mortality if hospitalized for a fall50% 1 year mortality if hospitalized for a fall

MVAsMVAs

MVAs and the ElderlyMVAs and the Elderly

13-15% of all MVAs13-15% of all MVAs Higher incidence ofHigher incidence of

2 vehicle MVAs2 vehicle MVAs Pedestrian-MVAsPedestrian-MVAs MortalityMortality

MVAs and the Elderly: MVAs and the Elderly: PatternsPatterns

IntersectionsIntersections Good weatherGood weather Close to homeClose to home During daylightDuring daylight

Geriatric Abuse & NeglectGeriatric Abuse & Neglect


Physical, psychological injury of older Physical, psychological injury of older person by their children or care person by their children or care providersproviders

Knows no socioeconomic boundsKnows no socioeconomic bounds


Contributing factorsContributing factors Advanced age: average mid-80sAdvanced age: average mid-80s Multiple chronic diseasesMultiple chronic diseases Sleep pattern disturbances leading to Sleep pattern disturbances leading to

nocturnal wandering, shoutingnocturnal wandering, shouting Family has difficulty upholding Family has difficulty upholding

commitmentscommitments


Primary findingsPrimary findings Trauma inconsistent with historyTrauma inconsistent with history History that changes with multiple History that changes with multiple

tellingstellings

BurnsBurns

Burns and the ElderlyBurns and the Elderly

More likely to suffer injury More likely to suffer injury Unable to evacuate burning structuresUnable to evacuate burning structures Cognitive impairmentCognitive impairment Decreased coordinationDecreased coordination Older homes (wiring, smoke detectors, Older homes (wiring, smoke detectors,

etc.)etc.)

Burns and the ElderlyBurns and the Elderly

High mortality ratesHigh mortality rates 50% BSA burn 50% BSA burn

<65 years, 50% fatal<65 years, 50% fatal >65 years, approaching 100% fatal>65 years, approaching 100% fatal

Effects of AgingEffects of Aging

Cardiovascular SystemCardiovascular System

Speed, force of myocardial contraction decreasesSpeed, force of myocardial contraction decreases Cardiac conducting system deterioratesCardiac conducting system deteriorates Resistance to peripheral blood flow rises, Resistance to peripheral blood flow rises,

elevating systolic blood pressureelevating systolic blood pressure Blood vessels lose ability to constrict, dilate Blood vessels lose ability to constrict, dilate

efficientlyefficiently

What effects will these changes have on ability to compensate for shock?

For heat and cold exposure?

Respiratory SystemRespiratory System

Respiratory muscles lose strength; rib cage Respiratory muscles lose strength; rib cage calcifies, becomes more rigidcalcifies, becomes more rigid

Respiratory capacity decreasesRespiratory capacity decreases Gas exchange across alveolar membrane slowsGas exchange across alveolar membrane slows Cough, gag reflexes diminish increasing risk of Cough, gag reflexes diminish increasing risk of

aspiration, lower airway infectionaspiration, lower airway infection

What will be the consequences of these changes during chest trauma?

Musculoskeletal SystemMusculoskeletal System

Osteoporosis develops, especially in Osteoporosis develops, especially in femalesfemales

Spinal disks narrow, resulting in kyphosisSpinal disks narrow, resulting in kyphosis Joints lose flexibility, become more Joints lose flexibility, become more

susceptible to repetitive stress injurysusceptible to repetitive stress injury Skeletal muscle mass decreasesSkeletal muscle mass decreases

What effect do these changes have on incidence and severity of orthopedic trauma?

Packaging? Backboards? Intubating?

Long term outcomes?

Nervous SystemNervous System

Brain weight of decreases 6 to 7%Brain weight of decreases 6 to 7% Brain size decreasesBrain size decreases Cerebral blood flow declines 15 to 20%Cerebral blood flow declines 15 to 20% Nerve conduction slows up to 15%Nerve conduction slows up to 15%

What effect will decreased nerve conduction have on pain sensation and

reaction time?

How will brain degeneration change the effect of head trauma?

Gastrointestinal SystemGastrointestinal System

Senses of taste, smell declineSenses of taste, smell decline Gums, teeth deteriorateGums, teeth deteriorate Saliva flow decreasesSaliva flow decreases Cardiac sphincter loses tone, esophageal reflux Cardiac sphincter loses tone, esophageal reflux

becomes more commonbecomes more common Peristalsis slowsPeristalsis slows Absorption from GI tract slowsAbsorption from GI tract slows

What effects can these changes have on the nutrition of older persons? How does this change the response to traumatic injury?

Renal SystemRenal System

Renal blood flow decreases 50%Renal blood flow decreases 50% Functioning nephrons decrease 30 to 40%Functioning nephrons decrease 30 to 40%

What effect will these changes have on ability to eliminate drugs from the

body?

Integumentary SystemIntegumentary System

Dermis thins by 20%Dermis thins by 20% Sweat glands decrease; sweating decreasesSweat glands decrease; sweating decreases

What effect will this have on:

Severity of burn injuries?

Wound healing?

Cold and heat tolerance?

Geriatric AssessmentGeriatric Assessment

Factors Complicating Factors Complicating AssessmentAssessment

VariabilityVariability Older people differ from one another Older people differ from one another

more than younger people domore than younger people do Physiological age is more important than Physiological age is more important than

chronological agechronological age


Response to illnessResponse to illness Seek help for only small part of Seek help for only small part of

symptomssymptoms Perceive symptoms as “just getting old”Perceive symptoms as “just getting old” Delay seeking treatmentDelay seeking treatment Trivialize chief complaintsTrivialize chief complaints


Presence of multiple pathologiesPresence of multiple pathologies 85% have one chronic disease; 30% 85% have one chronic disease; 30%

have three or morehave three or more One system’s acute illness stresses One system’s acute illness stresses

other’s reserve capacityother’s reserve capacity One disease’s symptoms may mask One disease’s symptoms may mask

another’sanother’s One disease’s treatment may mask One disease’s treatment may mask

another’s symptomsanother’s symptoms


Altered presentationsAltered presentations Diminished, absent painDiminished, absent pain Depressed temperature regulationDepressed temperature regulation Depressed thirst mechanismsDepressed thirst mechanisms Confusion, restlessness, hallucinationsConfusion, restlessness, hallucinations Generalized deteriorationGeneralized deterioration Vague, poorly-defined complaintsVague, poorly-defined complaints


The Organs of the Aged Do The Organs of the Aged Do Not Cry!Not Cry!


Communication problemsCommunication problems Diminished sightDiminished sight Diminished hearingDiminished hearing Diminished mental facultiesDiminished mental faculties DepressionDepression Poor cooperation, limited mobilityPoor cooperation, limited mobility


PolypharmacyPolypharmacy Too many drugs!Too many drugs! 30% of geriatric hospitalizations drug 30% of geriatric hospitalizations drug

inducedinduced Anti-hypertension drugs (beta-blockers) Anti-hypertension drugs (beta-blockers)

may mask early signs of shockmay mask early signs of shock Diuretics (Lasix, HCTZ) may make pt Diuretics (Lasix, HCTZ) may make pt

relatively dehydrated relatively dehydrated

History TakingHistory Taking

Probe for significant complaintsProbe for significant complaints Chief complaint may be trivial, non-Chief complaint may be trivial, non-

specificspecific Patient may not volunteer informationPatient may not volunteer information


Dealing with communication Dealing with communication difficultiesdifficulties Talk to patient firstTalk to patient first If possible, talk to patient aloneIf possible, talk to patient alone Formal, respectful approachFormal, respectful approach Position self near middle of visual fieldPosition self near middle of visual field Do not assume deafness or shoutDo not assume deafness or shout Speak slowly, enunciate clearlySpeak slowly, enunciate clearly


Do Do NOTNOT assume confused or assume confused or disoriented patient is “just disoriented patient is “just

senile!”senile!”


Obtain thorough medication historyObtain thorough medication history More than one doctorMore than one doctor More than one pharmacyMore than one pharmacy Multiple medicationsMultiple medications Old vs. current medicationsOld vs. current medications Shared medicationsShared medications Over-the-counter medicationsOver-the-counter medications

Physical ExamPhysical Exam

Examine in warm areaExamine in warm area May fatigue easilyMay fatigue easily May have difficulty with positioningMay have difficulty with positioning Consider modestyConsider modesty Decreased pain sensation requires Decreased pain sensation requires

thorough examthorough exam


If they say it hurts, it probably If they say it hurts, it probably REALLYREALLY hurts! hurts!

EXAMINE CAREFULLYEXAMINE CAREFULLY


Misleading findingsMisleading findings Inelastic skin mimics decreased turgorInelastic skin mimics decreased turgor Mouth breathing gives impression of Mouth breathing gives impression of

dehydrationdehydration Inactivity, dependent position of feet may Inactivity, dependent position of feet may

cause pedal edemacause pedal edema Rales in lung bases may be non-Rales in lung bases may be non-

pathologicpathologic Peripheral pulses may be difficult to feelPeripheral pulses may be difficult to feel

TraumaTrauma

Head InjuryHead Injury

More likely, even with minor traumaMore likely, even with minor trauma Signs of increased ICP develop slowlySigns of increased ICP develop slowly Patient may have forgotten injury, delayed Patient may have forgotten injury, delayed

presentation may be mistaken for CVApresentation may be mistaken for CVA Decreased brain mass increases risk of ICHDecreased brain mass increases risk of ICH

What change in the elderly accounts for increased ICP’s slower onset?

Cervical InjuryCervical Injury

Osteoporosis, narrow spinal canal Osteoporosis, narrow spinal canal increase injury risk from trivial forcesincrease injury risk from trivial forces

Sudden neck movements may cause Sudden neck movements may cause cord injury without fracturecord injury without fracture

Decreased pain sensation may mask Decreased pain sensation may mask pain of fracturepain of fracture

Hypovolemia & ShockHypovolemia & Shock

Decreased ability to compensateDecreased ability to compensate Progress to irreversible shock rapidlyProgress to irreversible shock rapidly Tolerate hypoperfusion poorly, even Tolerate hypoperfusion poorly, even

for short periodsfor short periods

Hypovolemia & ShockHypovolemia & Shock

Hypoperfusion may occur at “normal” Hypoperfusion may occur at “normal” pressurespressures

Medications (beta blockers) may mask Medications (beta blockers) may mask signs of shocksigns of shock

Cardiac and renal disease make fluid Cardiac and renal disease make fluid resuscitation more risky.resuscitation more risky.

Why can older persons be hypoperfusing at a “normal” blood pressure?

Positioning & PackagingPositioning & Packaging

May have to be modified to May have to be modified to accommodate physical accommodate physical

deformitiesdeformities

Environmental Environmental ConsiderationsConsiderations


Tolerate temperature extremes Tolerate temperature extremes poorlypoorly

Contributing factorsContributing factors Skin changesSkin changes Cardiovascular diseaseCardiovascular disease Endocrine diseaseEndocrine disease Poor nutritionPoor nutrition Drug effectsDrug effects


HIGH INDEX OF SUSPICIONHIGH INDEX OF SUSPICIONAnyAny patient with altered LOC or patient with altered LOC or

vague presentation in hot or cool vague presentation in hot or cool environmentenvironment

Which came first?Which came first?

Which came first? Which came first? Trauma or…Trauma or…

MI?MI? PE?PE? CVA?CVA? TIA?TIA? Dementia?Dementia? Intoxication?Intoxication? Spontaneous fracture?Spontaneous fracture?

SummarySummary

The elderly are coming.The elderly are coming. Minor mechanisms can create major injuries.Minor mechanisms can create major injuries. No complaint does not mean no injury.No complaint does not mean no injury. Minor injuries can cause major morbidity.Minor injuries can cause major morbidity. What came first: injury or the trauma?What came first: injury or the trauma? CV disease and medications can mask early CV disease and medications can mask early

signs of shock.signs of shock. Lower threshold for transport to trauma Lower threshold for transport to trauma

center.center.

Questions?Questions?

Thank you.Thank you.

Trauma in the Elderly Nathanael Wood, MD Albany Medical Center March 21, 2007.

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