Head injuries in the elderly cause almost 142,000 United States ED visits resulting in discharge, 82,000 survivable hospitalizations, and 14,000 deaths annually.22 Age is an independent predictor for morbidity and mortality in patients with moderate or severe head trauma. When evaluating the patient's mental status, it would be a grave error to assume that alterations in mental status are due solely to dementia or senility.
Elders are less prone to develop epidural hematomas than the general population because of the denser fibrous bond between the dura mater and the inner Table of the skull. There is, however, a higher incidence of subdural and intraparenchymal hematomas in the elderly than in younger patients. As the brain mass decreases with age, there is greater stretching and tension of the bridging veins that pass from the brain to the dural sinuses. Bridging veins are more susceptible to traumatic tears. Diagnosis of intracranial bleeding may be delayed because brain atrophy increases intracranial free space, allowing blood to accumulate without initial signs or symptoms.
One study of blunt head trauma patients taking warfarin who were experiencing no or minimal symptoms found a rate of injury on head CT that changed disposition in 7%.23 Therefore, immediate noncontrast head CT is recommended for patients who take warfarin and have a mechanism of injury concerning for even a minor head injury. Check the INR, because the degree of anticoagulation correlates with the risk of adverse outcomes.24 The risk conferred by other anticoagulant medications is less known. Some studies have shown the antiplatelet medication clopidogrel to confer an increased risk of intracranial bleeding after head injury.25 There is insufficient evidence to delineate the risk conferred by aspirin, low-molecular-weight heparins, or the newer oral anticoagulants.26,27
The incidence of cervical spine injury is about twice as great in elders as in a younger cohort of blunt trauma patients. Odontoid fractures are particularly common in geriatric patients, accounting for 20% of geriatric cervical spine fractures, as compared with 5% of nongeriatric fractures.28 Preexisting cervical spine pathology, such as osteoarthritis, bulging discs, and osteoporosis, may predispose elderly patients to spinal cord injuries. With hyperextension injuries, elderly patients may develop a central cord syndrome, which causes motor deficits in the upper extremities more often than the lower extremities, variable sensory loss, and bladder dysfunction. The Canadian Cervical-Spine Rule, but not the National Emergency X-Radiography Utilization Study criteria, excludes patients age ≥65 years from being considered low risk for cervical spine injury.29,30 Thus, liberal imaging of the cervical spine in geriatric trauma patients is warranted. Because of the higher pretest probability of injury, as well as the difficulties in interpreting plain radiographs in a patient with age-related degeneration, CT scan is the preferred initial modality for assessing the geriatric cervical spine. Many fractures in one section of the spine are accompanied by fractures in another section, so identification of one fracture should prompt imaging of the entire spinal column.31
THORACOLUMBAR SPINAL INJURIES
Thoracic and lumbar spine fractures account for almost half of all osteoporotic fractures.32 They are most common at the thoracolumbar junction (T12-L1) and midthoracic areas (T7-T8).33 Anterior wedge compression fractures are the most common. Because of the low sensitivity of plain films for identifying thoracolumbar fractures in trauma patients, CT scan is the first-line imaging modality for adult patients.34 This is even more significant in elders, in whom osteoporosis and degenerative changes make plain radiographs more difficult to interpret. See chapter 258, Spine Trauma, for more information on specific fracture types and management.
The elderly are more susceptible to chest injuries from blunt trauma and have a decreased ability to compensate for these injuries. In blunt trauma, rib fractures are the most common injury found. Rib fractures in the elderly often lead to morbidity, pneumonia, and death. The adjusted odds of death in the elderly with rib fractures is about five times that of a younger cohort.35 Rates of pneumonia and mortality in patients ≥65 years old are twice that of younger patients, with the rates increasing with each additional fractured rib.36 In young adults, a chest radiograph to exclude complications such as pneumothoraces may be sufficient evaluation for suspected rib fractures, as isolated fractures may be treated conservatively at home. Because of the significant mortality associated with rib fractures in elders, a CT may be necessary to assess the extent of injuries that might not be seen on plain radiographs.
The abdominal examination in elderly patients is unreliable. The FAST examination is an ideal imaging study to detect free intraperitoneal fluid. Even with an initially benign physical examination, maintain a high suspicion for intra-abdominal injuries in those with associated pelvic and lower rib cage fractures. As in younger patients, many solid organ injuries can be managed nonoperatively. Rates of successful nonoperative management of splenic injuries in elderly patients range from 62% to 85%.37 Therefore, CT with contrast is a valuable diagnostic test for evaluating the extent of injury and ongoing hemorrhage; however, the risk of contrast-induced nephropathy increases with age, hypovolemia, diuretic and nephrotoxic medications, diabetes, and preexisting renal disease. The risk can be reduced by volume expansion with isotonic crystalloids. Oral N-acetylcysteine does not appear to prevent contrast-induced nephropathy in patients undergoing coronary angiography.38 Other strategies, including sodium bicarbonate, ascorbic acid, and use of iso-osmolar versus low osmolar contrast, have had mixed results in studies.39,40,41,42,43
While pelvic fractures in the young are generally caused by high-energy mechanisms, the elderly, especially women, frequently suffer pelvic fractures from low-energy falls to the ground from standing or from a seated position. Pubic ramus fractures are the most common injuries, and lateral compression is the most common mechanism.44
CT of the pelvis should be ordered in sTable patients with pelvic tenderness after an injury if plain radiographs are negative.45,46 Plain radiography is especially insensitive for posterior fractures involving the sacrum and iliac wings, so tenderness of the posterior pelvis strongly suggests the need for cross-sectional imaging.47 Plain radiography may be omitted in sTable patients who will be going promptly to CT.48 Even CT may be only 77% sensitive for pelvic fractures in the elderly, particularly with nondisplaced posterior fractures in osteoporotic bone. Therefore, consider MRI for patients with pelvic pain or pain on weight bearing with negative CT imaging.49
Studies have been contradictory on whether age is an important predictor of the need for angiographic assessment for bleeding in pelvic fractures.50 One study found that 94% of patients 60 years of age and older taken to angiography required embolization, which is significantly higher than the 52% in younger patients.51 Therefore, these authors advocate liberal use of angiography in elderly patients with significant pelvic fractures, even in the absence of hemodynamic instability or need for transfusion. Other studies have not demonstrated an association between age and the need for angioembolization.
Hip fracture is the single most common injury diagnosis that leads to hospitalization in the elderly. Hip fractures are a significant cause of morbidity and mortality, with about 25% of elderly patients dying within a year of injury.54 The vast majority of hip fractures are caused by falls to the ground. The age-adjusted incidence of hip fractures in women is approximately twice that of men. Hip fractures in men occur at older ages than in women. Femoral neck (intracapsular) and intertrochanteric fractures are about equally common, with subtrochanteric fractures comprising the remaining 5% to 10%.55 Bleeding from closed pelvic and long-bone fractures can cause hypovolemia in elderly patients.
Obtain anteroposterior radiographs of the pelvis, as well as dedicated anteroposterior and cross-Table lateral radiographs of the affected hip. Because plain radiographs are only 90% sensitive for hip fractures, and delay in operative repair is associated with an increase in morbidity and mortality, normal plain radiographs should be followed by more definitive imaging in patients in whom suspicion of hip fracture persists.56 MRI has higher sensitivity than CT for detecting hip fractures, with one study finding that 17% of hip fractures that were occult on plain radiographs were seen by MRI but not CT.57 The sensitivity of CT is likely lower in patients with risk factors for osteoporosis (older age, female sex, chronic steroid use, alcoholism, inactivity, poor calcium intake, endocrine disorders) and a lower energy mechanism of injury, in which fractures are less likely to be displaced. If MRI is difficult to obtain, CT may yield a diagnosis, but should be followed by MRI if nondiagnostic. Nuclear medicine scintigraphy is highly sensitive for fractures but has the disadvantages of low specificity, difficulty obtaining the study from the ED, and limited ability to delineate the full nature of the fracture. Consider admitting patients with hip fractures to a multidisciplinary team of geriatricians, orthopedists, and rehabilitation specialists.
Distal radius fractures (Colles' fractures) are the most common fractures in women up to age 75, with a lifetime risk of about 15%.58,59 Such fractures are often caused by a fall onto an outstretched hand and are associated with low bone mineral density or osteoporosis. Assess median nerve function before and after reduction, as a deficit will require immediate orthopedic consultation for possible nerve decompression. UnsTable or displaced fractures require closed reduction with a hematoma block for anesthesia. A systematic review of unsTable distal radius fractures in the elderly reported that functional outcomes were similar with nonoperative and operative management, even though nonoperative management was associated with a less satisfactory radiographic appearance.60 So while elderly patients with active lifestyles and good functional statuses may benefit from surgical treatment, many can do as well with conservative treatment.
Fractures of the proximal humerus and humeral shaft are also common after falls from standing. Carefully assess for axillary nerve injury by checking sensation at the area of deltoid muscle insertion and deltoid muscle engagement with shoulder abduction. Note that the initial 18 degrees of shoulder abduction are generated by the supraspinatus muscle, so movement in this range may still be possible with an axillary nerve injury.
Elderly trauma patients should receive more intensive laboratory evaluation than younger patients (Table 255-2). This may be helpful to identify comorbid diseases (e.g., creatinine for renal dysfunction) or acute causes of syncope (e.g., troponin for myocardial infarction) or to uncover occult physiologic insults (e.g., lactate, INR, and base deficit). As discussed earlier, vital signs are an unreliable marker of shock in the elderly. Base deficit and lactate levels are useful initial indicators of shock, and serial measurements can guide resuscitation progress. Elevated lactate levels correlate with systemic hypoperfusion, intensive care unit and hospital length of stay, and mortality.61,62 A "normal" or mild base deficit of –3 to –5 correlates with 24% mortality, a moderate base deficit of –6 to –9 correlates with 60% mortality, and a severe base deficit of ≤–10 correlates with 80% mortality.63 Check creatine kinase levels to assess for rhabdomyolysis in patients who have fallen and been unable to receive assistance for a prolonged period.
TABLE 255-2Useful Laboratory Studies to Guide Management in Geriatric Trauma Patients ||Download (.pdf) TABLE 255-2 Useful Laboratory Studies to Guide Management in Geriatric Trauma Patients
Disseminated intravascular coagulation panel