LAS VEGAS – Geriatric patients – with their age-related changes, frequent comorbidities, and some unique patterns of injury – "are clearly at risk for poor outcomes with trauma," Dr. Phillip D. Levy said.
Injury severity scores among trauma patients are generally similar across age ranges (J. Trauma 2010;69:88-92). "However, at every injury severity score, the percent mortality for geriatric patients ... is much worse," he said.
Aging leads to a host of anatomical and physiological changes – including reduced cardiac and pulmonary function, altered brain anatomy, and decreased musculoskeletal mass – that play a role in the setting of serious injury, said Dr. Levy, associate director of clinical research in the department of emergency medicine at Wayne State University in Detroit.
"The net effect is that there is a diminished physiological response, and some of these things may also lead to a delayed onset of overt consequences," he said, which may initially mask the extent of injury.
The EAST (Eastern Association for the Surgery of Trauma) guidelines for trauma care in older adults highlight several key concepts, he noted, such as the risk of undertriage and the adverse impact of pre-existing conditions and postinjury complications on outcomes (J. Trauma 2003;54:391-416).
Pre-existing conditions are present in 40% of patients aged 65-74 years, 65% of those aged 75-84 years, and 90% of patients aged 85 years and older, and these patients are often taking medications. For example, trauma patients with heart failure have more than double the risk of death, compared with those without heart failure, and the elevation of risk is even greater for those who are also taking beta-blockers or warfarin (J. Trauma 2010;69:645-52).
Because of these factors, the initial evaluation, secondary survey, and management of geriatric trauma patients have some unique aspects, according to Dr. Levy.
Initial Evaluation
Although the standard ATLS (Advanced Trauma Life Support) protocols still apply in older adults with trauma, "there are some caveats with it," Dr. Levy said.
One caveat is that this population is highly vulnerable to respiratory compromise with chest trauma. "Even one or two rib fractures in an elderly patient has dramatic impact," he noted.
Age-related issues such as nasopharyngeal fragility, the presence of arthritis in the temporomandibular joint, and dentures affect airway management in geriatric patients.
"Probably the most important thing when considering the airway, though, is recognizing that there are pharmacokinetic responses that are different," Dr. Levy said. Because older adults have increased responsiveness to sedatives, the dose should be reduced by 20%-40% to avoid complications.
Hypoperfusion is often occult in the elderly. "You facilitate the search by looking at serum markers of [tissue] oxygen deficit: base deficit and lactic acid," he said. These measures predict mortality in older normotensive adults who have sustained blunt trauma (J. Trauma 2009;66:1040-4). In particular, a base deficit of –6 or less or a venous lactic acid level greater than 4.0 mmol/L is associated with a mortality rate of nearly 40%, independent of injury severity.
He cautioned that specificity is much greater than sensitivity with these markers; hence, "if it’s positive, it’s positive. If it’s negative, well, it may not really be negative; you may be just early in the phase."
Use of pulmonary artery catheters (PACs) may seem an extreme approach for hemodynamic monitoring in geriatric trauma patients, Dr. Levy acknowledged. But "it enables direct measurement of cardiac function and it does improve outcomes if you use a targeted therapeutic approach, either targeting improving cardiac index or improving oxygen consumption."
For instance, therapy using PACs has been associated with a nearly 70% reduction in the risk of death for patients aged 61-90 years with severe injuries (Crit. Care Med. 2006;34:1597-601). "You optimize the patient’s hemodynamic status and their perfusion status, and you may not have even known that it was not optimized before," he said.
Secondary Survey
In blunt head trauma, patients older than 65 years are more likely to sustain traumatic brain injury than are their younger peers, according to one study (Acad. Emerg. Med. 2006;13:302-7).
"What was really interesting was that they found that 26%, about a quarter, of all elderly patients who had an injury had an occult presentation, no symptoms," he noted.
Outward clues, such as decreased alertness, prolonged loss of consciousness, and an abnormal Glasgow Coma Scale score were all less common in the older group, meaning that physical exam findings can’t be relied on to predict whether an older patient has a head injury, he said.
On CT imaging, likely because of different mechanisms of injury, geriatric patients are less likely to have linear skull fractures and epidural hemorrhages, but more likely to have subdural hematomas and subarachnoid hemorrhages.