Download Trauma & Falls in the Elderly Patient

Trauma & Falls in the Elderly
Patient
Anthony J. DiPasquale, D.O.
FACOEP
UMDNJ-SOM
Trauma & Falls in the Elderly Patient
This Care of the Aging Medical Patient in
the Emergency Room (CAMPER)
presentation is offered by the Department of
Emergency Medicine in coordination with the
New Jersey Institute for Successful Aging.
This lecture series is supported by an educational grant from the
Donald W. Reynolds Foundation Aging and Quality of Life
program.
Case #1
• Mr. W, 78 yo m, had a slip
and fall while walking with
his wife and landed on his
low back.
• He presents to the ER with
moderate to severe low
back pain.
• X-Rays were taken.
Photo: Microsoft Office Images #MP900401829
(http://office.microsoft.com/en-us/images/)
Mr. W’s X-Rays
Image Source: Kennedy Health Systems
Mr. W.’s Dispo Plan
X-rays show an L3 compression fracture with
greater than 50% loss of height. After
implementing appropriate pain management, the
next step is:
A.
B.
C.
D.
E.
Bone scan of spine
Nasal Calcitonin
Walker
CT of lumbar spine
Physical Therapy Consult
Case: Mrs. M, a 79 yo woman…
• A 79-year-old woman presented to the
emergency department after a ground-level fall
on her left side. On emergency department
presentation, she complained of left knee and
hip pain, but could ambulate with moderate to
significant assistance. Her left leg was neither
shortened, nor externally rotated.
• Plain films were obtained:
Image Source: Kennedy Health Systems
Case:
X-Rays negative, per Radiology. A walker was
obtained for the patient and she was discharged to
home with instructions to follow-up with her
primary care practitioner if the pain did not
improve over the next 5 to 7 days. She presented
to her primary care physician 3 days later with
worsening pain, now with the inability to weightbear. She was sent back to the Emergency
Department. Repeat plain radiographs were
unchanged, per Radiology.
Case: What is required at this point?
A. Refer to Physical Therapy
B. Increased pain medications
C. MRI scan of the hip
D. Orthopedics consult
E. X-ray of the knee joint
Image Source: Kennedy Health Systems
Case:
Mrs. L. is an 78 year old woman who was standing
on a step ladder to change a light bulb. She
suddenly lost her balance and fell forward, landing
directly on her face. On physical exam, she
reports facial pain, headache, neck pain and is
found is have a quadriparesis with significantly
greater upper extremity weakness and sensory loss
than lower extremities.
After immediate immobilization of the
patient’s cervical spine, the next step is:
A. CT of head
B. CT of facial bones
C. Transfer to trauma center
D. MRI of C-Spine
E. CT of C-Spine
Summary of Topics to be Discussed
•
•
•
•
•
•
•
Introduction / Scope
Physiology of the Geriatric Trauma Patient
Major Sources of Geriatric Trauma
Triage Protocols for Geriatric Trauma
Management of Geriatric Trauma
Review
Conclusions
Introduction
• Rapid Increase in the Elderly Population
- Will continue to not only expand, but multiply
• Geriatric patients are OVER represented in Trauma
care.
– Trauma is the 6th leading cause of death in the elderly
– Elderly trauma patients have significantly worse outcomes
• Not only numbers are increasing, the health and activity
of elders continue to expand
Health and Activity in the Elderly
• Meet Milos Kostic
– Retired scientist and engineer
– Ironman World Champion
• 3 time winner of 65-69 age
class
• 2011 winner of the 70-74 age
class
– Completed a 2.4 mile swim, a
112 mile bike ride and a 26
mile marathon at the age of
68 years young
Image Source: Wikimedia
Photo by James Heilman, MD
2011 Time in
Ironman Canada:
11:14:24
Physiology of the
Geriatric Trauma Patient
• Physiology of the geriatric trauma patient shows
minimal tolerance to physiologic instability
• Frequently will have decreased physiologic
reserves, due to:
– Normal aging
– Disease process
– Poly-pharmacy
Physiology of the
Geriatric Trauma Patient
• Cardiovascular System
–
–
–
–
Decreased reserve
Hypotension poorly tolerated
Hypovolemia is common
Medication effect  Beta-blocker, Ca-Channel
blockers, digoxin, diuretics, etc
– Underlying coronary artery disease
Physiology of the
Geriatric Trauma Patient
• Universal Definition of Myocardial Infarction
• Presented in Circulation in 2007
– TYPE 1: MI due to a spontaneous coronary atherosclerotic
event.
– TYPE 2: MI secondary to ischemia, but not related to
coronary atherosclerosis.
– TYPE 3: Sudden death with symptoms or signs of ischemia
(not requiring elevated biomarker confirmation).
– TYPE 4: MI associated with percutaneous coronary
intervention (Subtype 4a), or stent thrombosis (Subtype 4b).
– TYPE 5: MI associated with coronary bypass surgery.
Physiology of the
Geriatric Trauma Patient
• Pulmonary System
– High prevalence underlying lung disease
– Multiple physiologic changes
• Alveolar surfaces, decreased diffusion capacity, loss of
lung elasticity, increased chest wall compliance, lower
muscle mass, and decreased mucociliary clearance
– Decreased protective laryngeal reflexes
– Increased risk of rib fractures and pulmonary
contusions
Physiology of the
Geriatric Trauma Patient
• Skeletal System
– Osteoporosis
 Pelvic fractures from minor trauma
 Hip Fractures
– Increased mortality/likely requiring long term care
– Occasionally invisible to X-ray
 Decreased joint mobility
– Spinal Column
» increasing ankylosis of the spine, osteoarthritis, and
decreased bone density
» relatively minor trauma, and can produce devastating injury
» Example: Cervical Fractures
Major Sources of Geriatric Trauma
Remember Case 1 of Mr. W, who fell while walking
• Compression Fractures
- Thoracolumbar Fracture

Wedge vs Burst
Image Source: Kennedy Health Systems
Occult Fractures
• 3-9% of hip fractures are invisible to X-Ray
• 75% of occult hip fractures occur in those who are over the age
of 65 years of age
• MRI is the study of choice for confirming the diagnosis
• Missed fractures place patients at risk for displacement of their
fractures, placing them at higher risk requiring more extensive
surgery, increased morbidity through unnecessary pain, avascular
necrosis of the femoral head, nonunion, thromboembolic
complications, and increased mortality.
• Missed fracture is the leading cause of lawsuits against the
emergency physicians
Traumatic Hip Pain
Radiographs
Positive w/ appropriate Rx
Negative w/ continued
clinical suspicion
MRI available
MRI
Rx per result
MRI not available
Admit to hospital
at bed rest w/ bone
scan in 24-36 hours
Consider
CT scan
Physiology of the Geriatric Trauma
Patient
• Central nervous system
– Particular risk because of:
 Atrophy
–
–
–
–
–
Puts bridging veins on stretch
Brain more mobile
Anticoagulated
Slowed protective reflexes
Asymptomatic expansion
– Very liberal use of CT scanning
 Non-Contrast vs Contrast enhanced CT
Major Sources of Geriatric Trauma
• Cord Injury
– Once fractures are ruled
out, cord syndromes are
still a major concern
– Central cord syndrome
Major Sources of Geriatric Trauma
• Trauma has increased from these 3 major
sources:
– Falls
– MVC
– Pedestrian vs car
Major Sources of Geriatric Trauma
• Falls
– Falls account for ≈50% of trauma injuries
– Of the falls resulting in injuries, 70% occur in the
elderly
– Low force mechanisms can still produce substantial
injury
– High risk for repeated falling
 Consider enrolling in fall prevention programs
Major Sources of Geriatric Trauma
• Motor Vehicle Collisions
– 65+ years old having the 2nd highest crash rate per mile
driven and those 85+ years old having the highest crash
rate per mile driven
– Second-leading cause of hospitalization for multisystem
trauma among elderly
– Overall fatality rate as high as 21% in the elder MVC
victim (7 times that of younger patients)
– Elderly MVC’s are more often single vehicle, occur in
the daytime, in good weather, and near patient’s home
– Increased risk is multi-factorial
Major Sources of Geriatric Trauma
• Pedestrian vs auto
– Tragic injuries
– Aged >65 years old are at the
greatest risk of being hit by a car,
even greater than children
– Pedestrian vs auto accounts for 9%
to 25% of trauma in elders
– Extraordinary high fatality rate of
30% to 55%.
– Crosswalks 4ft/sec
Image used by permission of Stanley Rabinowitz
http://www.mathpropress.com/stan/crossings/
Additional Injuries in the Elderly
• Burns
– Particularly devastating in the elder patient
– Very high mortality
Case
Mr. T. is a 80 year old male who tripped in his
bathroom and fell hitting the right side of his chest
against the bathtub and comes to the ER holding
the R side of his chest.
Case: X-rays reveal 3 nondisplaced fractured ribs on
the right, without any pneumothorax, pleural
effusion or pulmonary contusion. Your plan for
this patient should be:
A. Rib binder, narcotics, incentive spirometry and
discharge home
B. Non-narcotic medication, with close follow up with
PMD.
C. Hospital admission, pain control, incentive spirometry
D. 4 Hour observation in the Emergency Room
E. Lidoderm patch and outpatient physical therapy
Additional Injuries in the Elderly
• Rib Fractures
– Isolated rib fx  36% of patients had pulmonary
complications, which were fatal in ≈10%.
– Multiple rib fractures  Admit
– Six or more rib Fractures  ICU level care
– High risk for pneumonia, pulmonary contusions,
and atelectasis
Additional Injuries in the Elderly
• Over-triage the elderly
– American College of Surgeons recommends that
trauma patients older than 55 years be taken to
trauma centers
– More likely to suffer significant injuries after even
relatively minor events
– Low threshold to send geriatric patients to trauma
center
– Twice the rate of under-triage in the elderly
Additional Injuries in the Elderly
• Investigation into the cause of the trauma
– Increased incidence of underlying disease
– Serious medical problems could be the source of the
trauma and may require simultaneous diagnosis and
treatment in the setting of trauma and, at times, may
take priority over the trauma assessment
Management of Geriatric Trauma
• Traditional ABCs
• Increased Aggressive Management
– Airway:
 Intubate Early
 Anticipate problems
– Breathing
– Circulation
 Hypoperfusion require aggressive resuscitation in
monitored setting
 At risk for both hypo- and hyperperfusion
Management of Geriatric Trauma
• Vital Signs
– Multiple medications may complicate our use of vital
signs
– Look for Secondary Signs of cellular perfusion and
oxygenation
 Lactate level and/or base deficits rather than vital signs
– Hypotension
 Requires rapid correction
 Blood transfusion may also be liberalized
 Decreased response to catecholamines and vasopressor medications,
because of underlying conduction defects, e.g., bundle branch block
and their baseline medications
Review
•
•
•
•
•
Introduction / Scope
Physiology of the Geriatric Trauma Patient
Major Sources of Geriatric Trauma
Triage Protocols for Geriatric Trauma
Management of Geriatric Trauma
Conclusions
• The stereotypical trauma patient is a young
healthy male, and the physician’s fight is against
the traumatic pathology alone.
• In geriatric trauma, the fight is two-fold, against
both the traumatic pathology, but also the
patients underlying physiology
– Minimal margin of error
– Aggressive Resuscitation
– What we do matters!
Questions?
Thank you