Professional Documents
Culture Documents
31 Biese Geriatric Trauma Edit 6-7-11 FINAL
31 Biese Geriatric Trauma Edit 6-7-11 FINAL
WHAT DO WE KNOW?
Kevin Biese, MD, MAT
Ellen Roberts PhD, MPH
Jan Busby-Whitehead, MD
AGS
Division of Geriatric Medicine
Center for Aging and Health
Department of Emergency Medicine
Slide 2
GERIATRIC TRAUMA: OUTLINE
• The basics
• Rib fractures
• Pelvic fractures
• Head trauma
• Warfarin
• C-spine fractures
• Triage
Slide 3
GERIATRIC TRAUMA: DISCLAIMERS
• Most studies are retrospective reviews
Slide 4
GERIATRIC TRAUMA: EPIDEMIOLOGY
• Elderly are growing in numbers
Slide 5
GERIATRIC TRAUMA: MECHANISMS
• Falls — most common
Balance, strength, vision
Slide 6
GERIATRIC TRAUMA:
COMPLICATING FACTORS
• Past medical history
Cardiac and pulmonary disease limit physiological response
to stressors
Vital signs are difficult to interpret
• Medications
Anticoagulants
Beta blockers
Slide 7
CASE 1: INTRODUCTION
• 71-year-old woman restrained driver in MVC
• “T-boned” on passenger side
• Unknown rate of speed
• No airbag deployment
• Prolonged extrication
• Not ambulatory at scene
• EMS: systolic blood pressure (SBP) 100, HR 80,
oxygen saturation 100% on non-re-breather mask
Slide 8
CASE 1:
ADDITIONAL INFORMATION
• Patient is complaining of shortness of breath, left
chest wall pain, and left clavicle pain
• She hit her head with reported loss of consciousness
• Patient denies neck or back pain
• No nausea or abdominal pain
• Yellow trauma alert — no trauma team activation
Slide 9
CASE 1:
PRIMARY SURVEY
Slide 10
CASE 1:
SECONDARY SURVEY
• Vital signs: 103/51, 80, 18, 36.3 F, 100% NRB
• General: Dyspneic, awake and alert
• HEENT: 3-cm laceration on left side of scalp, PERRLA
• Chest: Bruising left clavicle/left chest wall with tenderness
• CV: RRR with HR 80
• Abdomen: No bruising, soft, non-tender, non-distended
• Pelvis stable
• Neurologically intact
Slide 11
CASE 1:
PAST MEDICAL HISTORY
• Hypertension
• Osteoporosis
• “Non-cardiac chest pain”
• Medications:
Hydrochlorothiazide
Alendronate (Fosamax)
• Allergies:
Penicillin
Slide 12
CASE 1: CHEST X-RAY
Slide 13
CASE 1: PELVIS X-RAY
Slide 14
CASE 1: CHEST CT
Slide 15
CASE 1: LAB RESULTS
• Hematocrit — 36
• Potassium — 2.9
• Creatinine — 1.0
• INR — 1.0
Slide 16
CASE 1: HOSPITAL COURSE
Slide 20
PELVIC FRACTURES
IN THE ELDERLY (2 of 2)
• 92 consecutive blunt trauma pelvic fracture patients received
angiographic embolization (AE) for “liberal indications”:
Hemodynamically labile, concerning fracture pattern (open
book, vertical shear, butterfly), or pelvic hematoma on CT
• Patients >60 years (n=17) were compared with younger patients
No difference in injury severity score, pelvic fracture pattern,
SBP, or blood requirement
>60 years: 94% chance of active bleed vs. 52% in younger
patients
• Consider AE before hemodynamic collapse in elderly patients
with significant pelvic fractures
Slide 22
HEAD TRAUMA IN ELDERLY
Slide 24
AGGRESSIVE
COUMADIN PROTOCOL (1 of 2)
• Emergency department initiated new protocol for
patients with suspected head trauma on warfarin
Immediate evaluation
Immediate head CT
Type & cross match
Thaw 2 units AB FFP
• If positive head CT
Transfuse FFP, Vitamin K IV, neurosurgery evaluation
• If negative head CT
Admit for observation
Slide 27
GERIATRIC C-SPINE FRACTURES
Slide 31
CRITERIA FOR TRAUMA
TEAM ACTIVATION (TTA) (1 of 3)
• Review of Trauma • 25% met TTA criteria:
Registry at UCLA and LA SBP <90 or Pulse >120
County from 19932000 RR <10 or >29
Unresponsive to pain
• Included admitted trauma Gunshot wound to trunk
patients age >70, except
interhospital transfers,
ground-level falls,
subacute subdurals
• 883 patients included
0%
ISS <15 ISS 16-29 ISS 30+
• Include age 70 years
as TTA criterion?
ISS = Injury Severity Score
Slide 35
CASE 1
• EMS brings in a 71-year-old woman who was “T-
boned” on the passenger side while driving at an
unknown rate of speed.
Slide 36
CASE 1, QUESTION 1
Which of the following is not true regarding the epidemiology
of geriatric trauma? Select the one best answer.
A. Although people 65 years account for only 10% of all trauma
evaluations, they account for more than 25% of all trauma mortality.
Slide 37
CASE 1, QUESTION 2
True or False?
Slide 38
CASE 1, QUESTION 3
Which of the following statements regarding triaging
elderly trauma patients is not true?
Slide 40
CASE 2, QUESTION 1
True or False?
Slide 41
CASE 2, QUESTION 2
Which of the following statements regarding patients on
warfarin is not true? Select the one best answer.
D. Nine percent (9%) of all elderly patients with traumatic brain injury
are on warfarin.
Slide 42
CASE 2, QUESTION 3
Which of the following types of cervical spine
fractures is most increased in frequency in elderly
patients?
a) Clay-shoveler’s fracture
b) Hangman’s fracture
c) Jones fracture
d) Odontoid fractures
Slide 43
ANSWER KEY
• Case 1
Question 1: D
Question 2: False
Question 3: B
• Case 2
Question 1: True
Question 2: C
Question 3: D
Slide 44
BIBLIOGRAPHY (1 of 2)
• Bergeron et al. Elderly trauma patients with rib fractures are at
greater risk of death and pneumonia. J Trauma. 2003;54:478-485.
Slide 45
BIBLIOGRAPHY (2 of 2)
• Ivascu et al. Rapid warfarin reversal in anticoagulated patients
with traumatic intracranial hemorrhage reduces hemorrhage
progression and mortality. J Trauma. 2005;59:1131-1139.
Slide 46
SPECIAL THANK YOU
Slide 47
THANK YOU FOR YOUR TIME!
Visit us at:
www.americangeriatrics.org
Facebook.com/AmericanGeriatricsSociety
Twitter.com/AmerGeriatrics
linkedin.com/company/american-geriatrics-
society
Slide 48