EM · Geriatric trauma
Geriatric trauma
The geriatric trauma: the physiological changes of aging, the comorbidity and the polypharmacy (the anticoagulants, the beta-blockers that mask the tachycardia), the low-energy fall that produces the significant injury, the increased TBI risk, the frailty assessment, and the higher mortality for the same injury.
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- The elderly patient on a beta-blocker may not mount the tachycardic response to the shock — the heart rate is an unreliable sign
- The atrophic brain has more space for the subdural to accumulate — the head CT is obtained liberally after the fall
- The anticoagulated patient with the head injury has the elevated ICH risk — the early reversal and the CT
- A ground-level fall in the elderly can produce the significant injury — the mechanism alone does not determine the severity
- The frailty, not the chronological age, predicts the outcome — the Clinical Frailty Scale guides the decision
- A 'normal' blood pressure in the elderly trauma patient may be the shock — the hypertensive's baseline rises with the age, so the SBP of 110 is the relative hypotension
- The elderly rib-fracture patient has the 22 per cent mortality (versus 10 per cent in the young) — the rib fracture in the elderly is the significant injury, not the minor one
- The serial GCS and the repeat CT — the delayed subdural expansion in the anticoagulated elderly presents at 24 to 48 h after the seemingly minor fall
- The lactate and the base deficit, not the vital signs, reveal the occult hypoperfusion of the elderly trauma patient
- The trauma team activation for the age over 65, even with the seemingly minor mechanism — the over-triage is the deliberate strategy in the geriatric trauma
The geriatric trauma is the injury of the patient over 65, and it is one of the fastest-growing presentations in the emergency department, as the population ages and the activity is maintained. The elderly patient is injured by the lower-energy mechanism (the ground-level fall) but suffers the higher-severity injury and the higher mortality than the younger patient with the same mechanism, because the physiological changes of aging and the comorbidity reduce the reserve. The Fellowship candidate must know the physiological changes, polypharmacy effects, atypical presentation, frailty concept, and the principles that govern the management and the disposition of the injured elderly.[1]
The physiological changes of aging
The aging alters every system in ways that affect the trauma management. The brain atrophies (the cortical volume shrinks, the subdural space enlarges), so the bridging veins are stretched and the minor head injury produces the subdural haematoma with more room to expand before the signs appear. The cardiovascular system stiffens (the less-compliant aorta, the fixed cardiac output), so the tachycardic response to the hypovolaemia is limited (and the beta-blocker or the pacemaker abolishes it entirely). The respiratory reserve falls (the reduced vital capacity, the reduced cough, the chest-wall stiffening), so the rib fracture that is minor in the young produces the pneumonia in the elderly. The renal function declines (the reduced GFR, the reduced concentrating ability), so the nephrotoxic contrast and the medications accumulate. The bone density falls (the osteoporosis), so the ground-level fall fractures the hip, the pelvis and the ribs.[1]
| System | The change of aging | The trauma consequence |
|---|---|---|
| Brain | The cortical atrophy, the stretched bridging veins, the enlarged subdural space | The subdural haematoma from the minor head injury, the delayed presentation |
| Cardiovascular | The stiffened aorta, the fixed cardiac output, the conduction disease | The absent tachycardia, the relative hypotension at the 'normal' SBP, the shock at the lower heart rate |
| Respiratory | The reduced vital capacity, the weakened cough, the stiffened chest wall | The pneumonia, the atelectasis, the respiratory failure after the rib fracture |
| Renal | The reduced GFR, the reduced concentrating ability | The accumulation of the contrast and the nephrotoxic drugs, the acute kidney injury |
| Musculoskeletal | The osteoporosis, the sarcopenia, the slow gait | The hip, the pelvic and the rib fractures from the ground-level fall |
| Integument | The thin skin, the fragile subcutaneous vessels | The extensive bruising, the torn bridging veins, the large scalp haematoma |
| Immune | The blunted febrile response, the reduced T-cell function | The atypical presentation of the sepsis (the confusion, the fall), the delayed diagnosis |
References7ShowHide
- [1]Jacobs DG, Plaisier BR, Barie PS, et al. Practice management guidelines for geriatric trauma: the EAST Practice Management Guidelines Work Group J Trauma, 2003.PMID 12579072
- [2]Rossaint R, Bouillon B, Cerny V, et al. The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition Crit Care, 2023.PMID 36859355
- [3]Pollack CV Jr, Reilly PA, Eikelboom J, et al. Idarucizumab for Dabigatran Reversal N Engl J Med, 2015.PMID 26095746
- [4]Connolly SJ, Milling TJ Jr, Eikelboom JW, et al. Andexanet Alfa for Acute Major Bleeding Associated with Factor Xa Inhibitors N Engl J Med, 2016.PMID 27573206
- [5]Bulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib fractures in the elderly J Trauma, 2000.PMID 10866248
- [6]Rockwood K, Song X, MacKnight C, et al. A global clinical measure of fitness and frailty in elderly people CMAJ, 2005.PMID 16129869
- [7]Nishijima DK, Gaona S, Waechter T, et al. Do EMS Providers Accurately Ascertain Anticoagulant and Antiplatelet Use in Older Adults with Head Trauma? Prehosp Emerg Care, 2017.PMID 27636529