Geriatric Trauma

The elderly account for the most rapidly growing segment of the U.S. population. Twelve percent of the population is over age 55 and that number could increase to more than 20% as the Baby Boomer population ages.1,2 As of 2000, the number of individuals age 65 or greater had reached 35 million, and it is anticipated that by 2030, individuals age 65 or greater will reach 70.3 million, or 20% of the total U.S. population.3 While the elderly represent 12% of the population, they account for more than 36% of all ambulance transports and 25% of hospitalizations (see Table I).

     Considering the potential impact the elderly have on our prehospital systems and the potential impact of EMS providers on patient outcomes, it is important to understand the unique issues related to caring for elderly trauma patients to ensure they are managed appropriately.

     This article focuses on trauma to the elderly in the prehospital setting, including a review of pathological differences, the possible impact of coexisting disease processes, the effect of multisystem trauma on the elderly and an overview of prehospital treatment options.

Physiologic Differences
     The anatomy and physiology of the elderly differ from that of younger adult patients. Although some of these differences may appear to be inconsequential, they can significantly affect the treatment that is provided in the field.5 Consider, for example, the elderly patient's airway. Gum disease, tooth decay and dental prostheses can complicate basic and advanced airway management, as can dental work like caps, bridges and fillings.1,7 If the provider does not consider these types of potential differences, managing the patient's airway can become extremely challenging. Overly aggressive airway management may lead to bleeding, iatrogenic trauma or hypoxia.

     In addition to airway differences, the elderly patient's respiratory system may be inhibited by osteoporosis, decreased vertebral body structure, pain, decrease in muscle mass or a decrease in chest wall compliance. The presence of an underlying chronic respiratory condition, such as emphysema or pneumonia, will also impair the effectiveness of the elderly trauma patient's respiratory system. By age 65, vital capacity is significantly reduced.1,6 Ciliary activity in the elderly patient is also decreased, which can lead to the inability to cough and contribute to development of complications like pneumonia.1 The presence of chronic comorbid disease states, such as coronary artery disease, renal disease or diabetes, can decrease the physiologic reserve in some patients. This can be significant, as these patients might become hypoxic more quickly and be less able to tolerate the hypoxia than younger trauma victims.

     The cardiovascular system can also be influenced by age. In many patients, tachycardia is considered to be an early indicator of shock, but the elderly may be less able to produce tachycardia. Underlying heart disease or certain medications, both of which are more likely to be factors in the elderly, can affect the patient's ability to respond to stress by increasing the heart rate. Subtle clinical findings commonly present in the younger trauma patient (e.g., tachycardia, delayed capillary refill time) may not be present. Hypotension is not a reliable indicator of the severity of the patient's condition. The patient with chronic hypertension may mask the symptoms of hypovolemia through vasoconstriction. In these situations, blood pressure changes, tachycardia and delayed capillary refill time may not be reliable indicators of shock.1,7 Patients' blood pressures may appear normal when they are actually hypotensive.

     The myocardium also changes with age. The left ventricle becomes thicker, resulting in reduced systolic function. This can contribute to decreased cardiac output and reduced ability to respond to stressors, such as hypovolemia. The myocardial electrical conduction system also becomes less effective. Left ventricular and electrical conduction changes may lead to complications, including arrhythmias, congestive heart failure or pulmonary edema. Cardiac output may be impaired, resulting in poor perfusion.1,7

     The renal system and adrenal glands change with age as well. Renal mass decreases and vascularity changes, potentially compromising renal function and resulting in an accumulation of waste in the blood. Adrenal stimulation, including the body's ability to respond to stressors via the fight-or-flight syndrome, may be impaired.1,7

     The brain and nervous system are also affected by age. Brain mass decreases and there is a reduction in the number of cerebral cells. The dura mater may adhere to the skull as the remaining cerebral tissue shrinks, creating a situation where the subdural space becomes more prone to injury. Further, blood flow to the brain decreases, leading to a decrease in cerebral perfusion and oxygenation.1,7

     The elderly patient's sensory perception, including hearing, smell and vision, may be reduced. Peripheral nerve conduction slows and may be further impaired by the chronic use of analgesics. When these factors are combined, elderly patients' ability to "sense" that they have been injured may be reduced. Thermoregulatory mechanisms may also be impaired, leading to hypothermia. The ability of an elderly patient to react to an adverse environment may be limited, further compounding the problem. Depending upon severity of the injury and any delays in receiving care, these factors may negatively impact the patient's recovery and final outcome.2,6,7

     Musculoskeletal system changes include height loss secondary to osteoporosis, which may result in a change in posture. If significant changes occur, kyphosis (an "s"-like curvature of the spine) may develop. Kyphosis occurs in more than 50% of the elderly.1 Demineralization of the bone occurs and makes the elderly patient more prone to fractures. For individuals over age 85, 1% of males and 2% of females will experience a hip fracture each year.1 As many as half of them will require nursing home services for a year post-incident. In contrast to younger patients, less force is required to cause an injury in the elderly.1,8

     The elderly patient's ability to defend against infection is often reduced. The inability to resist illness is a considerable factor in trauma management and recovery. The older trauma patient who initially appears to be healthy is more likely to experience complications and/or sepsis at a later date from a combination of injuries and an impaired immune system. This may negatively impact the patient's final outcome.1,9-13

     The patient's gastrointestinal processes, including saliva production, gastric secretion and esophageal motility, may be depressed. Water volume is reduced, and there is a loss of cells. A reduction in metabolism influences the elderly patient's ability to metabolize medications, which can contribute to the development of acid-base imbalances.1

     In contrast to most younger trauma patients, the elderly are more likely to have underlying medical conditions and be taking one or more prescription medications. The presence of one or more coexisting medical conditions like arthritis or hypertension in addition to a traumatic injury has been correlated with more difficult resuscitations and increased risk of death.2 Also, depending on the medication being taken, the signs and symptoms the trauma patient would normally exhibit may be masked, as well as the patient's response to treatment. The combination of underlying medical conditions and the use of medications not only influences the patient's response to resuscitation, it may also limit the patient's ability to recover to their level of pre-injury function following resuscitation.1,5,14

Injury Patterns
     A majority of injuries sustained by the elderly are secondary to falls and motor vehicle accidents. Falls are the most common cause of injury in patients over age 65 and are reported as the underlying cause of 9,500 deaths each year in this age group.15 When falls are involved, injuries tend to include fractures of the hip, femur and wrist, and head injuries. In those over age 85, 20% of fatal falls occur in nursing homes.16 Auto-vs.-pedestrian cases are less common. Though they tend to result in fewer overall injuries, they are associated with higher fatality rates. Penetrating trauma cases are even less frequent, with a majority involving suicide attempts.1

Mechanism of Injury and Triage
     When managing a trauma case that involves an elderly patient, it is important to thoroughly assess the patient and to consider the mechanism of injury (MOI). While certain MOIs (e.g., gunshot wounds, assaults) tend to be associated with younger trauma patients and may appear to be more significant than some of the MOIs seen with older patients (e.g., falls from beds, falls down stairs), providers should always do a thorough assessment. Avoid situations where the seemingly "minor" mechanism results in undertriage, which may lead to less aggressive treatment and potentially poorer outcomes.6 Healthcare providers are encouraged to not only consider the "here and now" of the patient's condition, but to also consider the long-term care (intensive care unit, rehabilitation, etc.) in an effort to ensure that optimal triage and treatment are pursued.3,10

Assessment: Scene and Patient
     A complete assessment must include an assessment of the scene. This is critical when attempting to identify the MOI. As you arrive at a scene, take a moment to conduct an overall assessment. Are there any obvious indicators of trauma? If bystanders are available, ask what was observed during the event. If the patient was discovered "down" and there are no witnesses, the combination of scene and patient assessment and bystander reports may prove to be invaluable in determining the possibility of trauma and potential injuries.8

     In addition to assessing the scene and determining the MOI, it is also important to expose the patient so that a comprehensive evaluation can be performed. After the patient has been exposed, however, keep him or her covered as much as possible to avoid contributing to hypothermia and to help reassure the patient that his/her privacy is being considered.

     Assess the patient's neurologic status as soon as possible. This can be accomplished using the AVPU system (see Table II) to rapidly determine if the patient is alert, responsive to verbal stimuli, responsive to painful stimuli or unresponsive. Following the initial AVPU assessment, conduct a comprehensive neurologic exam, if possible. This should include assessment of the patient's mental status, capillary reaction, extremity movements and ability to follow commands. Assessment tools (e.g., Glasgow Coma Scale, mini-mental status exam) can be used to facilitate this. If spinal or extremity immobilization is indicated, check the patient's neurologic status prior to and following any manipulation. If possible, and depending on factors like the acuity of the patient and transport time, reassess the patient's neurologic status every five to 10 minutes.8,17

     You should recall that, due to the potential decrease in sensory perception, patients might not feel the degree of pain you expect, even though they are injured. Because of this, when conducting an assessment, it is important to be as thorough as possible. Watch the patient for painful responses, feel and palpate for abnormal findings, listen for abnormal noises (e.g., crepitus) and look for deformity, bruising or bleeding.8,17

     Monitor the patient's vital signs and overall condition throughout the call. EKG monitoring, pulse oximetry and capnometry may also be used. Document any trends and changes in vital signs and communicate them to the hospital staff.8

     Using the DCAP-BTLS mnemonic will help to ensure that injuries are not overlooked. DCAP-BTLS consists of: Deformity, Contusions, Abrasions, Puncture, Burn, Tenderness, Laceration and Swelling. When applied to each section of the body, this mnemonic assists in identifying any potential injuries.8,17

     As in all patients, airway, breathing and circulation are priorities in the geriatric trauma patient. The MOI and resultant injury may complicate airway management. Complicating factors can include dentures and facial trauma. If the patient has dentures, they may need to be removed to obtain an adequate mask-face seal. The presence of facial injuries may also impede the mask-face seal. In such cases, consider using a different approach (e.g., altering hand placement) to ensure a good seal. Depending on the medications the patient is taking, such as blood thinners, there is more chance of bleeding. This may also apply in cases where the patient is taking certain over-the-counter (OTC) medications. Exercise caution to avoid causing injury or hemorrhage from aggressive airway management techniques, including insertion of a laryngoscope blade or aggressive insertion of endotracheal tubes when performing oral or nasal airway procedures.8,17

     If manual ventilation is indicated, intervene with confidence while exercising caution. Due to the physiologic changes that occur with the aging process, in addition to underlying medical conditions, the elderly patient may develop complications such as gastric distention if overly aggressive ventilation is provided. When a chest injury is suspected, use caution to avoid contributing to the exacerbation of any injuries. Overly aggressive ventilation in a patient with a pneumothorax may lead to development of a tension pneumothorax. By carefully monitoring the resuscitative efforts, such complications can be minimized.

     In addition to managing airway and breathing, it is also important to assess and support the patient's circulation. Remember, the elderly patient's ability to compensate for injury through tachycardia and increased cardiac output may be impaired. In addition, tachycardia may not be present due to medications (e.g., beta-blockers) and underlying medical conditions.8,17

     Initiate intravenous access and fluid replacement as soon as possible. The amount of fluid and rate of administration will be influenced by numerous factors, including the patient's overall condition, suspected volume loss and the patient's medical history. Due to the potential for coexisting diseases, the rate and amount of fluid administration should be monitored closely. The elderly, particularly those with a history of congestive heart failure, may not be able to tolerate fluid boluses that we are accustomed to giving younger trauma patients. Following each fluid bolus, reassess the patient and monitor breath sounds. Development of rales is a possible sign of fluid overload.8,17

Trauma Triage Tools
     Several tools are available to assist with assessment and triage of the trauma patient, such as the Injury Severity Score (ISS), Revised Trauma Score (RTS), Prehospital Index (PHI) and Glasgow Coma Scale (GCS). These tools utilize a variety of clinical findings, as well as MOI parameters, to assist with your assessment and, in some cases, management of the trauma patient.1,3,14

     While the exact effectiveness of these tools has been debated in the literature, they are an option that you may want to incorporate into your trauma practices.6,10 Whether these tools can be used to evaluate geriatric trauma patients in the same way they are used in younger trauma patients has not been well studied. It has been recognized, however, that for any given ISS, geriatric patients will suffer greater morbidity and mortality than their younger adult counterparts.

Management of Burn Injuries
     Burns are the third-leading cause of traumatic death in the elderly.1 If the patient has injuries along with burns, manage the injuries first. The rule of nines and burn depth can be used to estimate the body surface area (BSA) involved. Location, severity, BSA and local protocols will influence management of the burn patient. Oxygen administration, airway management, intravenous access, fluid administration and pain relief may be indicated. As with many traumatic injuries, burns may have a greater impact on the elderly than on their younger counterparts.1,8,9,17 Triage to a burn center, when available, should be considered in any elderly burn victim.

Management of Specific Injuries

Head Injury
     Manage external hemorrhage via direct pressure. If an internal head injury is suspected, such as a subarachnoid hemorrhage, transport the patient to the closest and most appropriate facility. The presence of facial injuries should increase your suspicion that a potentially serious MOI was involved. In an acute head-injured patient, ventilations and airway support may be required.1,8,17

Neck Injury
     If a neck injury is suspected, consider the potential for head and chest injuries as well. If the neck injury involves airway compromise, immediate intervention is indicated. The absence of cervical spine discomfort or pain, with or without palpation, should not be used as the sole determinant that the patient's cervical spine is without injury. High cervical fractures (particularly C1 and C2) are more common in the elderly and can occur with minimal mechanism. As an example, a fall from a standing position is an unlikely cause of a cervical spine fracture in the young, but is not uncommon as a mechanism for cervical fractures in the elderly. This will need to be considered when addressing the elderly patient who is "found down," and should even be considered in the patient found in cardiac arrest who fell from a standing position.1,8,17

Patient Found Down
     If an elderly patient is "found down," a thorough patient assessment will assist in determining the potential injuries and treatment. If there is a potential for cervical or spinal injury, take spinal precautions. When immobilizing elderly patients, you may need to be creative when determining how best to immobilize them if they have kyphosis or physical abnormalities that interfere with traditional cervical immobilization. Also consider the potential for the patient to develop decubitus ulcers from prolonged immobilization. Creativity may be needed when applying long spine boards or cervical collars.1,8,17

Chest Injury
     Open chest wounds may be managed using an appropriate occlusive dressing. Observe chest wall bruising and asymmetric movements. What would otherwise be considered a minor chest injury can be more significant in the elderly. Ribs are more easily broken and underlying lung tissue more easily damaged. Signs and symptoms of these injuries may be delayed, and therefore will not always be evident in the prehospital setting.1,8,17

Abdominal Trauma
     Abdominal trauma will be influenced by a variety of factors, including the MOI and the patient's overall condition. If the patient has an abdominal evisceration, cover it with an appropriate dressing. If the abdomen is hard and rigid, or there is abdominal bruising, suspect internal bleeding. It is important to re-emphasize that the elderly may not show the same signs and symptoms of serious injury we expect to see in younger patients. As stated earlier, the elderly patient may not mount a tachycardia even in the setting of significant blood loss. What we might otherwise consider to be a normal blood pressure may represent a significant drop if the patient is normally hypertensive (a common underlying medical problem in the elderly). Waiting to act for what we would normally consider to be hypotension and tachycardia in the elderly trauma patient could have catastrophic consequences.1,8,17

Medication Administration
     Administer oxygen to most elderly trauma patients, other than those with minimal or no injuries. If there is significant potential for injury, consider high-flow oxygen. If there is significant injury or MOI and the patient appears to be "resisting" oxygen administration, he may be acutely ill with hypoxia or hypovolemia. In these cases, administration of oxygen is extremely important and should be attempted.1,8,17

     Chemical or physical restraint use may be indicated in managing the elderly trauma patient, but they need to be used with caution. Restraints may be applied to restrict the patient's movements, thereby potentially reducing the likelihood of additional injury. Restraints may also be used to help facilitate treatment of the combative or agitated patient in certain situations. There are numerous types of restraints available; some are more appropriate for the elderly than others. The use of restraints has resulted in injuries; therefore, they will need to be monitored closely. You are encouraged to become familiar with approved devices prior to using them.1,8,17

     The trauma patient with an altered mental status may pose a unique challenge. While it would be helpful to determine if the patient's altered mental status is due to trauma or an underlying medical condition, or a combination of factors, this is not always possible. Treatment may include immobilization, establishing an intravenous line, oxygen administration and monitoring of vital signs. Treatment may also include administration of naloxone (suspected opiate ingestion), dextrose (suspected hypoglycemia) and thiamine (vitamin to assist with glucose metabolism). If medications are administered, consult your local protocols to ensure that the appropriate dose is used (see Table III). Each trauma scenario that involves a patient with an altered mental status will be unique and will require provider judgment.1,8,17

Early Hospital Notification
     Notify the receiving facility of the elderly trauma patient as early as possible. If a trauma team is available in the receiving facility, consider activating the team. Aggressive management of the elderly trauma victim has been associated with improved outcomes. Consider the MOI, the patient's condition, transport times, local protocols and medical control when determining the receiving facility.1,3-6,9-12

Conclusion
     With a working knowledge of the physiologic and anatomical differences of the elderly, as well as an understanding of the potential MOI, you will be confident when confronted with a critically injured elderly trauma patient. Your ability to conduct a rapid, yet thorough, assessment while providing care may prove to be invaluable in reducing trauma-related morbidity and mortality.

References

1. Hubble M, Hubble J. Principles of Advanced Trauma Care. Albany: Delmar Thompson Learning, 2002.
2. McGwin G, MacLennan P, Fife J, et al. Preexisting conditions and mortality in older trauma patients. The Journal of Trauma, Injury, Infection, and Critical Care 56(6):1291-6, 2004.
3. Hannan E, Waller C, Farrell L, et al. Elderly trauma inpatients in New York State: 1994-1998. The Journal of Trauma, Injury, Infection, and Critical Care 56(6): 1297-1304, 2004.
4. Sterling D, O'Connor J, Bonadies J. Geriatric falls: Injury severity is high and disproportionate to mechanism. J Trauma 50(1):116-119, 2001.
5. Muche J, McCarty S. Geriatric Rehabilitation. Emedicine, 2005. www.emedicine.com/pmr/topic164.htm.
6. Blanda, M. Geriatric Trauma: Current Problems, Future Directions. 2005. www.saem.org/download/02blanda.pdf.
7. Porth C. Pathophysiology: Concepts of Altered Health States. Philadelphia: J.B. Lippincott Company, 1990.
8. Bledsoe B, Porter R, Shade B. Paramedic Emergency Care. Upper Saddle River: Brady Prentice Hall, 1997.
9. Rogers F, Osler T, Shackford S, et al. A population-based study of geriatric trauma in a rural state. J Trauma 50(4):604-9 2001.
10. Ingham P. Research Points to Need For Geriatric Training in Trauma Centers. 2002. www.americangeriatrics.org/news/gttrauma.shtml.
11. Lane P, Sorondo B, Kelly J. Geriatric trauma patients. Are they receiving trauma center care? Acad Emerg Med 10(3):244-50 2003.
12. Demetriades DL, Karaiskakis M, Velmahos G. Effect on outcome of early intensive management of geriatric trauma patients. BJ Surg 89(10):1319-22 2002.
13. Meldon S. Geriatric Trauma: Outcomes of Older Adults Following Trauma. 2002. www.saem.org/download/02meldon.pdf.
14. Jacobs D, Plaisier B, Barie P. Practice Management Guidelines for Geriatric Trauma. The EAST Practice Management Guidelines Work Group, 2001. www.east.org/tpg/geriatric.pdf.
15. Smith DP, Enderson BL, Maull KI. Trauma in the elderly: Determinants of outcome. J South Med. Birmingham: Southern Medical Association, 1990.
16. Tinetti ME, Speechley M. Prevention of falls among the elderly. N Engl J Med 320:1055-9, 1989.
17. Campbell J. Basic Trauma Life Support for Paramedics and Advanced EMS Providers. Englewood Cliffs: Brady, 1995.