Trauma & Falls in the Elderly Patient

1. Trauma & Falls in the Elderly Patient Anthony J. DiPasquale, D.O. FACOEP UMDNJ-SOM

2. 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.

3. 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/)

4. Mr. W’s X-Rays Image Source: Kennedy Health Systems

5. 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: • Bone scan of spine • Nasal Calcitonin • Walker • CT of lumbar spine • Physical Therapy Consult

6. 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:

7. Image Source: Kennedy Health Systems

8. 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 weight-bear. She was sent back to the Emergency Department. Repeat plain radiographs were unchanged, per Radiology.

9. Case: What is required at this point? • Refer to Physical Therapy • Increased pain medications • MRI scan of the hip • Orthopedics consult • X-ray of the knee joint

10. Image Source: Kennedy Health Systems

11. 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.

12. After immediate immobilization of the patient’s cervical spine, the next step is: • CT of head • CT of facial bones • Transfer to trauma center • MRI of C-Spine • CT of C-Spine

13. 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

14. 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

15. 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 2.4mile 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

16. 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

17. 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

18. 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.

19. 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

20. 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

21. 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

22. 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

23. Traumatic Hip Pain Positive w/ appropriate Rx Radiographs MRI not available Negative w/ continued clinical suspicion Consider CT scan Admit to hospital at bed rest w/ bone scan in 24-36 hours MRI available MRI Rx per result

24. 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

25. Major Sources of Geriatric Trauma • Cord Injury • Once fractures are ruled out, cord syndromes are still a major concern • Central cord syndrome

26. Major Sources of Geriatric Trauma • Trauma has increased from these 3 major sources: • Falls • MVC • Pedestrian vs car

27. 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

28. 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

29. 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/

30. Additional Injuries in the Elderly • Burns • Particularly devastating in the elder patient • Very high mortality

31. 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.

32. 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: • Rib binder, narcotics, incentive spirometry and discharge home • Non-narcotic medication, with close follow up with PMD. • Hospital admission, pain control, incentive spirometry • 4 Hour observation in the Emergency Room • Lidoderm patch and outpatient physical therapy

33. 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

34. 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

35. 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

36. 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

37. 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

38. Review • Introduction / Scope • Physiology of the Geriatric Trauma Patient • Major Sources of Geriatric Trauma • Triage Protocols for Geriatric Trauma • Management of Geriatric Trauma

39. 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!

40. Thank you Questions?