Chapter 158. Trauma in the Elderly

Emergency physicians need to stay abreast with many of the unique injury mechanisms and clinical features associated with geriatric trauma patients, and apply special management principles when caring for them.

Falls are the most common cause of injury in patients over 65 years of age. Syncope, which has been implicated in many cases, may be secondary to dysrhythmias, venous pooling, autonomic derangement, hypoxia, anemia, or hypoglycemia. Motor vehicle crashes rank as the most common mechanism for fatal incidents in elderly persons through 80 years of age. Also, elderly pedestrians struck by a motor vehicle are much more likely to die compared to younger pedestrians. Emergency physicians should have a heightened suspicion for elder or parental abuse.

The geriatric trauma patient should be viewed as both a medical and a trauma patient. Since elderly patients may have a significant past medical history that impacts their trauma care, obtaining a precise history is vital. Often, the time frame for obtaining information about the traumatic event, past medical history, medications, and allergies is quite short. Family members, medical records, and the patient's primary physician may be helpful in gathering information regarding the traumatic event and the patient's previous level of function. Medications, such as cardiac agents, diuretics, psychotropic agents, and anticoagulants, must be carefully listed.

On physical examination, frequent monitoring of vital signs is essential. Emergency physicians should be wary of a “normal” heart rate in the geriatric trauma victim. A normal tachycardic response to pain, hypovolemia, or anxiety may be absent or blunted in the elderly trauma patient. Medications such as β-blockers may mask tachycardia and delay appropriate resuscitation.

Special attention should be paid to anatomical variation that may make airway management more difficult. These include the presence of dentures, cervical arthritis, or temporomandibular joint arthritis. A thorough secondary survey is essential to uncover less serious injuries. These “minor” injuries may not be severe enough to cause problems during the initial resuscitation, but cumulatively may cause significant morbidity and mortality. Seemingly stable geriatric trauma patients can deteriorate rapidly and without warning.

Head Injury

It would be a grave error to assume that alterations in mental status are due solely to any underlying dementia or senility when evaluating the elderly patient's mental status. Elderly persons suffer a much lower incidence of epidural hematomas than the general population; however, there is a higher incidence of subdural hematomas. The rate of intracranial hemorrhage approaches 7% to 14% in anticoagulated patients with blunt head injury who are experiencing no or minimal symptoms. More liberal indications for computed tomography (CT) scanning are justified.

Cervical Spine Injuries

The pattern of cervical spine injuries in the elderly is different than in younger patients, as there is an increased incidence of C1 and C2 fractures with the elderly. Emergency physicians need to place special emphasis on maintaining cervical immobilization until the cervical spine is properly assessed. Because underlying cervical arthritis may obscure fracture lines, the elderly patient with persistent neck pain and negative plain radiographs should undergo CT of the neck.

Chest Trauma

In blunt trauma, there is an increased incidence of rib fractures due to osteoporotic changes. The pain associated with rib fractures, along with any decreased physiologic reserve, may predispose patients to respiratory complications. More severe thoracic injuries, such as hemopneumothorax, pulmonary contusion, flail chest, and cardiac contusion, can quickly lead to decompensation in elderly individuals whose baseline oxygenation status may already be diminished. Arterial blood gas analysis may provide early insight into elderly patients' respiratory function and reserve.

Abdominal Trauma

The abdominal examination in elderly patients is notoriously unreliable compared to younger patients. The adhesions associated with previous abdominal surgical procedures may increase the risk of performing diagnostic peritoneal lavage. The focused assessment with sonography for trauma (FAST) examination may assist in evaluating for hemoperitoneum and the need for exploratory laparotomy in hemodynamically unstable patients. CT with contrast is a valuable diagnostic test for patients who are stable. It is important to ensure adequate hydration and baseline assessment of renal function prior to the contrast load for the CT scan. Some patients may be volume depleted due to medications, such as diuretics. This hypovolemia coupled with contrast administration may exacerbate any underlying renal pathology.

Orthopedic Injuries

Hip fractures occur primarily in 4 areas: intertrochanteric, transcervical, subcapital, and subtrochanteric. Intertrochanteric fractures are the most common, followed by transcervical fractures. Emergency physicians must be aware that pelvic and long bone fractures are not infrequently the sole etiology for hypovolemia in elderly patients. Timely orthopedic consultation, evaluation, and treatment with open reduction and internal fixation should be coordinated with the diagnosis and management of other injuries.

Long bone fractures of the femur, tibia, and humerus may produce a loss of mobility with a resulting decrease in the independent lifestyle of elderly patients. Early orthopedic consultation for intramedullary rodding of these fractures may result in increased early mobilization.

The incidence of Colles fractures and humeral head and surgical neck fractures in elderly patients are increased by falls on the outstretched hand or elbow. Localized tenderness, swelling, and ecchymosis to the proximal humerus are characteristic of these injuries. Early orthopedic consultation and treatment with a shoulder immobilizer or surgical fixation should be arranged.

As in all trauma patients, the primary survey should be assessed expeditiously.

1. The main therapeutic goal is maintaining adequate oxygen delivery. Consider prompt tracheal intubation and use of mechanical ventilation in patients with more severe injuries, respiratory rates greater than 40 breaths/min, or when the PaO2 is <60 mm Hg or PaCO2 >50 mm Hg. While nonventilatory therapy helps to prevent respiratory infections and is always desirable, early mechanical ventilation may avert the disastrous results associated with hypoxia.

2. Geriatric trauma patients can decompensate with over-resuscitation just as quickly as they can with inadequate resuscitation. Elderly patients with underlying coronary artery disease and cerebrovascular disease are at a much greater risk of suffering the consequences of ischemia to vital organs when they become hypotensive after sustaining trauma. During the initial resuscitative phase, administer crystalloid judiciously since elderly patients with diminished cardiac compliance are more susceptible to volume overload. Strong consideration should be made for early and more liberal use of packed red blood cell transfusion. This practice early in the resuscitation enhances oxygen delivery and helps minimize tissue ischemia.

3. Early invasive monitoring has been advocated to help physicians assess the elderly's hemodynamic status. One study found that urgent invasive monitoring provides important hemodynamic information early, aids in identifying occult shock, limits hypoperfusion, helps prevent multiple organ failure, and improves survival. Survival was improved because of enhanced oxygen delivery through the use of adequate volume loading and inotropic support.

4. If the insertion of invasive monitoring lines is impractical in the ED, every effort should be made by emergency physicians to expedite care of elderly trauma patients and prevent unnecessary delays. While it is vital to be thorough in the diagnosis of occult orthopedic injuries, expending a great deal of time in the radiology suite may compromise patient care. Only a few radiologic studies, such as emergent head and abdominal CT scans, should take precedence over obtaining vital information from invasive monitoring. Elderly trauma patients will benefit most from an expeditious transfer to the intensive care unit for invasive monitoring; in that setting, patients can be assessed for subtle hemodynamic changes that may compromise those with limited physiologic reserve.

5. Emergency physicians, in consultation with the trauma surgeon, should have a low threshold for having the geriatric trauma patient admitted for further evaluation and observation.