Revisiting Geriatric Trauma

     Simply stated, old people break more easily than younger ones. Yet geriatric trauma is often triaged using the same criteria used for younger patients. This, it occurred to leaders of the Ohio emergency care community, might not be the optimal approach. So when the state EMS board's Trauma Committee last met for their regular review of their trauma triage criteria, they decided to take a closer look. They began scouring the data to see if they might develop better ways to help the injured elderly.

     What they came up with is a statewide set of guidelines to determine EMS transport destinations for geriatric trauma victims.

     "What we found from the data was that, not surprisingly, the mortality of geriatric patients was higher in non-trauma centers," says Tim Erskine, chief of trauma systems and research for the Ohio Department of Public Safety's Division of EMS. "Of adult trauma patients in the state, fewer than 2% die after being admitted to non-trauma centers. But in the geriatric population, that's around 16%."

     Believing some of those patients would benefit from trauma center care, an ad hoc geriatric-trauma task force got to work developing broader criteria for taking them there. What they ended up with includes:

• A Glasgow Coma Scale score of less than 15 with suspected traumatic brain injury;
• A systolic blood pressure of less than 100 mmHg;
• A fall, even from a standing position, with evidence of TBI;
• Pedestrians struck by motor vehicles;
• A known or suspected proximal long-bone fracture sustained in a motor-vehicle crash;
• Multiple injured body regions.

     In addition, geriatric patients will be given special consideration for trauma center evaluation if they have diabetes, cardiac disease, pulmonary disease (COPD), clotting disorder (including anticoagulants), immunosuppressive disorder, or require dialysis.

     But to whom exactly should the new criteria be applied? The task force's first job, before beginning work on the guidelines, was to define geriatric. Existing literature didn't feature consistent definitions, or even appeared to define it arbitrarily. So members turned to mortality data from the Ohio Trauma Registry, looking at age of patient death and adjusting for injury severity. What they found was, essentially, a sharp increase in trauma mortality at age 72. For their final recommendations, though, they reduced the cutoff to 70, to make it easier for providers to remember.

     The literature pointed members to several potential starting criteria, including falls, injury to more than one body region, and injury to a single region with one or more disease comorbidities. In addition, it suggested qualifiers like prolonged extrications, significant damage to a crashed vehicle, ejection from a vehicle or a pedestrian struck by a vehicle. Members also evaluated traditional triage measures such as GCS and BP.

     "Basically we just threw a bunch of stuff out there to see what would stick," says Erskine. "It was a bunch of people thinking, This might be an indicator, this might be an indicator, this might be an indicator. Then we evaluated all the wild guesses by running the numbers to see if there was an increase in mortality."

     On the GCS front, data showed that geriatric TBI patients with Glasgow scores under 15 have mortality risks comparable to those of adults with scores of 10 or less. With blood pressures, geriatrics with systolics of 100 mmHg or less have mortality equivalent to younger adults with systolics of 90 or below. Elderly fall victims with TBIs also die at greater rates (11.8% vs. 7% at falls from the same height), as do older pedestrians struck by vehicles (16.6% vs. 7.5%). Finally, when multiple body regions are injured, geriatrics are also more likely to die than younger adults (8.4% vs. 6.3%). The long-bone fracture criterion was suggested by authorities in Florida and supported by Ohio's data, which showed elderly patients almost 2½ times more likely to die after suffering them.

     The new guidelines were still awaiting official approval from the state Trauma Committee and EMS board in May, but were expected to be okayed and ready for rollout by early fall. Some jurisdictions, including Cincinnati, are already using them (Cincinnati Fire Department medical director Don Locasto discussed them at Eagles). There has also been some interest by the Centers for Disease Control and Prevention.

     As the guidelines come into use, officials will of course be monitoring the data to see how they're working.

     "We want to know these patients are being given the best possible opportunity for survival," Erskine says, "and make sure we're not just shifting their mortality from non-trauma centers to trauma centers. We're very fortunate to have outcome-based data from the hospitals so we can do that. We have the data with which we can make evidence-based changes to practice, and we hope to use that to deliver better care."

     The task force's report is available at www.ems.ohio.gov; follow the 'Data Center' link.