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Multiple Trauma in the Elderly: New

Management Perspectives
Multiple trauma in the elderly is increasing with
the aging population

In contrast to their younger counterparts, elderly


patients experience significantly higher mortality
rates and complications after major trauma

Summary
Diminished physiological reserve and the existence
of multiple medical comorbidities present
additional challenges to management

A different approach is required to care for the


elderly trauma patient

Summary
The elderly comprise the fastest growing segment
of the US population.
2009 : 12.9% of the population was aged 65 years
and older(The US Census Bureau reported )
2050 : the population will reach 20.1% of the
total

Introduction
Number of elderly trauma victims will also
increase
motor vehicle collisions
pedestrians struck by motor vehicles
falls from a height
crush injuries

Low-energy mechanisms, like a fall from standing


height, are not considered in this review

Introduction
The elderly have diminished physiological reserve
and often multiple medical comorbidities
Despite these factors, survival to discharge rates
of over 50% have been reported
The purpose of this review is to identify and
address the challenges of caring for the multiply
injured elderly patient and to update management
strategies

Introduction
Richmond et al (Pennsylvania Trauma Systems
Foundation)
Injuries were sustained by
fall in 61.7%
motor vehicle crash in 22.6%
other 9.4%
pedestrian in 4.6%
hit by object in 0.9%
assault in 0.8%
Mechanisms & Types of
Injury
The body region with the most severe injury
extremity/pelvic girdle 47.4%
head/neck at 22.1%,
chest/thorax at 16.0%
external/skin at 7.6%,
abdomen/pelvic contents at 4.5%,
face at 2.3%.

Mechanisms & Types of


Injury
Champion et al
Investigated cause of injury in major trauma
in the elderly through analysis of the Major
Trauma Outcome Study from 1982 to 1986
Result : (injuries occurred)
Fall in 40.6%,
Motor vehicle accident in 20.2%,
Pedestrian hit in 10%,
other in 7.0%,

Mechanisms & Types of


Injury
Highest mortality
gunshot wounds
pedestrian hit
motor vehicle accident

Mechanisms & Types of


Injury
More recent data suggest trauma-related
deaths occur more commonly from
Pedestrians hit
Motor vehicle accidents.

As the elderly are staying active, walking,


driving, and participating in recreational
activities, an increasing number of injuries
from all mechanisms are expected.

Mechanisms & Types of


Injury
Underappreciation of the severity of injury
in the elderly trauma patient has been
noted by several authors
The Florida Department of Health and
Rehabilitative Services along with the Office
of Emergency Medical Services :
Found unacceptable levels of undertriage
in patients 55 years and older with life-
threatening injuries

Triage, Initial
Evaluation, and Care
Meldon et al:
retrospective cohort study

found a disproportionate number of elderly


trauma patients being cared for at nontrauma
centers

Triage, Initial
Evaluation, and Care
Zimmer et al :
retrospective analysis of all admissions for
acute trauma in a 2.5-year period
severely injured elderly patients, especially
females, are at risk for undertriage
current triage protocols may be inadequate
for assessing the severity of injury in the
elderly trauma patient

Triage, Initial
Evaluation, and Care
Possibly the most important thing to
recognize is that normal presenting vital
signs are not reassuring in elderly
trauma patients

Triage, Initial
Evaluation, and Care
Heffernan et al :
cohort study to determine the impact of
abnormal presenting vital signs on mortality

Overall mortality was significantly higher


in the elderly (11.4%) compared with the
young (2.4%) patients

Triage, Initial
Evaluation, and Care
Early intensive management and
resuscitation efforts can improve survival of
the elderly trauma patient

Triage, Initial
Evaluation, and Care
Demetriades et al:

elderly trauma patients may not exhibit


standard physiological criteria for trauma
team activation (TTA), including hypotension,
tachycardia, and unresponsiveness to pain...

Triage, Initial
Evaluation, and Care
McKinley et al:

elderly trauma patients are at greater


risk for shock and complications, and despite
poorer outcomes, resuscitation efforts are
not futile

Triage, Initial
Evaluation, and Care
Scalea et al :

showed that routine invasive cardiac


monitoring in the emergency room will help
to identify occult shock, limit end-organ
hypoperfusion, help prevent multiple organ
failure, and ultimately improve survival

Triage, Initial
Evaluation, and Care
Intensive monitoring, early intensive care
unit admission, and goal-directed
resuscitation are recommended in the
elderly trauma patient

Triage, Initial
Evaluation, and Care
Markers for resuscitation
HR, BP, urine output
can be unreliable in the elderly due to
hypertension,
use of beta-blockers,
pre-existing organ dysfunction

Triage, Initial
Evaluation, and Care
Base deficit and serum lactate levels may
be better guides to assess tissue perfusion
and cellular oxygenation

Triage, Initial
Evaluation, and Care
Pre-existing medical conditions are
associated with worse outcomes in geriatric
trauma patients

Grossman et al :
Hepatic disease, renal disease, cancer,
and congestive heart failure were found to
have the strongest associations with
mortality
Pre-existing Medical
Conditions
Perdue et al:
had similar findings with pre-existing
cardiovascular or liver disease, renal, or
infectious complications.

Pre-existing medical conditions


increase complications and contribute
to both early and late mortality in the
elderly trauma patient.
Pre-existing Medical
Conditions
The highest rate of mortality from trauma is
seen in patients aged 65 years and older
Clement et al
- identified patients from the Trauma Audit and
Research Network to evaluate cause and time of
death
Mortality was found to correlate with both age
and ISS. Compared with younger patients, older
Px had both an overall higher risk of mortality as
well as a higher risk of late mortality

Mortality and Complications


The highest rate of mortality from trauma
is seen in patients aged 65 years and older

Mortality and Complications


Tornetta et al :
lower GCS, higher ISS, transfusion, and
fluid requirements were significant factors
for predicting mortality
Complications, including acute respiratory
distress syndrome, myocardial infarction, and
sepsis, were also found to be significant risk
factors for mortality

Mortality and Complications


Timing to operative intervention should
also be considered

Tornetta et al :
Delay in fixation in physiologically stable
patients has been shown to increase
morbidity and mortality

Mortality and Complications


Moran et al :

mortality after surgery for hip fracture


in relationship to delay and medical
complications with delay in surgery resulted
in 2.5 times the risk of death at 30 days

Mortality and Complications


Age, combined with :
injury from trauma transfusion
fluid resuscitation requirements
pre-existing medical conditions
complications
leads to decreased survival after major
trauma in the elderly.

CONCLUSIONS
Appropriate triage
recognition of hypotension & hypoperfusion,
despite normal or near normal vital signs on
presentation
early intensive monitoring and resuscitation
= improves survival

Ongoing intensive care and monitoring of


resuscitation efforts is paramount
CONCLUSIONS

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