Kevin Biese MD, MAT

Kristen Barrio MD

Geriatric Trauma – Quick Fact Sheet

Epidemiology

  • Patients ≥ 65 years are 10% of all traumas, but 28% of deaths
  • Trauma is the 7th leading cause of death in elderly
  • Falls are the most common trauma mechanism
  • Motor vehicle collision (MVC) is the most fatal trauma mechanism

General Principles

  • Cardiac and pulmonary disease and medications may limit physiological response to stressors, (i.e. beta blockers, etc)
  • Trauma patients are under-triaged in violation of paramedic protocols
  • Changing trauma team activation thresholds for elderly patients has been shown to decrease mortality

Head Trauma

  • Patients aged >65 y/o have 30-85% mortality with intracranial hemorrhage (ICH)
  • ICH can occur from seemingly minor trauma, such as a fall from standing
  • Age ≥ 65 considered high risk in both Canadian and New Orleans Head CT protocols
  • Subdural hematomas account for majority of findings on Head CT
  • Beware of delayed acute subdural hematoma (DASH) – consider admission for observation even if negative head CT

Warfarin

  • Risk of spontaneous ICH on warfarin is 0.3-5.4%
  • Blunt head trauma on warfarin with minimal or no symptoms: 7-14% have ICH
  • Remember patients frequently have supra-therapeutic INR: 11% with INR >5
  • For patients with head injury on warfarin, reduced mortality if protocol implemented requiring immediate head CT and FFP be ordered

Cervical Spine Trauma

  • In blunt trauma victims age>65, C-spine fractures are 2x more likely than in younger patients
  • Odontoid fractures: 20% of elderly c-spine fractures compared to 5% in younger patients
  • Patients >65 included in NEXUS criteria and identified as high risk in Canadian C-Spine Rule

Chest Trauma

  • In elderly patients with isolated thoracic injuries, mortality of patients >65 was 15%
  • If patient has 3 or more rib fractures mortality was > 30%
  • Most mortality subsequent to pneumonia

Pelvic Trauma

  • In pelvic fractures, elderly patients have high rates of hemorrhage, transfusion, and ICU admission even with a benign fracture pattern (lateral compression)
  • There is some evidence that early angiographic embolization is helpful in elderly patients with pelvic trauma
  • Hip fractures have 15-20% mortality rate within the first year. Between 25-50% of patients will not regain the ability to ambulate

Burn Injuries

  • Elderly patients represent 1/5 of all burn unit admissions
  • Traditional mortality estimate is age + %burn

References

  • Bergeron et al. Elderly trauma patients with rib fractures are at greater risk of death and pneumonia. J of Trauma 2003; 54: 478-85.
  • Callaway, Wolfe. Geriatric Trauma. Emerg Med Clin 2007; 25: 837-860.
  • Demetriades et al. Effect on outcome of early intensive management of geriatric trauma patients. Brit J Surg 2002; 89: 1319-1322.
  • Demetriades et al. Old age as a criterion for trauma team activation. J Trauma 2001; 51: 754-7.
  • Hylek et al. Major hemorrhage and tolerability of warfarin in the first year of therapy among elderly patients with atrial fibrillation. Circulation AHA 2007; 115: 2689-2696
  • Ivascu et al. Rapid warfarin reversal in anticoagulated patients with traumatic intracranial hemorrhage reduces hemorrhage progression and mortality. J Trauma 2005; 59: 1131-1139.
  • Kimbrell et al Angiographic embolization for pelvic fractures in older patients. Arch Surg 2004; 139: 728-733.
  • Ma et al. Compliance with prehospital triage protocols for major trauma patients. J Trauma. 1999 Jan; 46(1) 168-75.
  • Meldon S, Ma O., Woolard R. Geriatric Emergency Medicine. McGraw Hill, 2004.
  • Touger et al. Validity of a decision rule to reduce cervical spine radiography in elderly patients with blunt trauma. Ann Emerg Med. 2002 Sep; 40(3): 287-93.