Geriatric Patients Fare Worse After Trauma

Cervical spine injuries are also more common in older vs. younger trauma patients, and patterns of injury differ (Ann. Emerg. Med. 2002;40:287-93), again likely reflecting differences in the mechanism, according to Dr. Levy.

"The geriatric patients were at much greater risk for C1 fractures and any fracture at C2 – most specifically, an odontoid fracture," he noted.

And importantly, "you always have to consider central cord syndrome in your elderly patients due to that [hyperextension] type of mechanism. You might have osteophytes that squeeze off the cord."

CT is indicated as the primary imaging modality in cervical spine injuries among adults older than 65 years (J. Emerg. Med. 2009;36:64-71).

"The most likely [cervical spine] area for an elderly individual to have an injury is at C2 and, coincidentally, the most likely area to be missed on plain films is C2," Dr. Levy explained. "Additionally, the elderly are at a tremendous risk of false-positive findings [on plain films]. They have a lot of arthritis."

As for chest injuries, half of all older adults who sustain rib fractures do so during simple falls from a standing position (J. Trauma 2003;54:478-85), likely from hitting something on the way down. Hence, the index of suspicion should be high even after seemingly minor spills.

"As the number of rib fractures increases, mortality increases in both elderly and nonelderly, but it increases disproportionately in the elderly," he observed.

The take-home message is early airway management: "When you see a patient with three or four rib fractures, they are not taking good deep breaths in, their saturations are hovering around 90% or 92% – that’s a patient you are probably going to want to consider intubating very early on."

Geriatric patients can get an injury unique to this age group: the sacral insufficiency fracture. "Suspect it if somebody has persistent hip pain, persistent back pain, [and] they can’t get up and walk," he advised. "The elderly person who fell, there is nothing on x-ray, you don’t see much on the CT scan, you may need to go ahead if the index of suspicion is high and make this diagnosis." In addition, relative to their younger counterparts, older adults are less likely to get open-book pelvic fractures and more likely to get acetabular and pubic rami fractures, according to Dr. Levy.

Management

Fluid resuscitation is often challenging in geriatric trauma patients because of underlying cardiac dysfunction and concerns about precipitating heart failure, Dr. Levy observed.

"You can facilitate this by using central venous pressure [CVP] guidance," he said. "If you can see what their CVP is, you can titrate their fluids to their CVP, recognizing that that might not be the best marker of preload in an elderly individual and it might not be the best marker of fluid response, but it may help."

Early consideration of blood products is important in geriatric trauma patients with hemodynamic instability, and their use has the advantages of administration of a smaller fluid volume (compared with saline) and a colloid effect.

"Rapid reversal of anticoagulation is not something a lot of us do routinely, but you should consider it in every elderly patient who comes in, especially those with traumatic head injuries. [Use] vitamin K and fresh frozen plasma," he recommended.

In a study of geriatric patients with head trauma taking warfarin, mortality was 48% in historical controls who developed intracranial hemorrhage but just 10% with use of a rapid imaging and, when indicated, reversal protocol including vitamin K and fresh frozen plasma (J. Trauma 2005;59:1131-7).

Proactive management for patients with chest trauma should include both pain control and early ventilatory support, Dr. Levy said.

"Pain control is huge," he commented. "If they are more comfortable, they are more apt to take big deep breaths in and less likely to suffer from the adverse consequences of their chest trauma."

Although strategies for ventilatory support may include intubation, "in some of these older folks with COPD [or] heart failure, when you intubate them, you may never extubate them. That’s always a concern," so a trial of bilevel pulmonary airway pressure is probably warranted if started early, he said.

Additional Considerations

Dr. Levy cautioned physicians not to forget to remove cervical collars once geriatric trauma patients have been medically cleared. "The longer they stay in that collar, the longer they stay on their back, the greater the risk they have of decubiti," he explained.

Prompt orthopedic consultation for patients with hip fracture is also key, as the time to intervention influences outcomes after this injury.