This guideline (best viewed on a handheld or Mac) represents the practices at the University of Kentucky.
1. Purpose
Elderly patients can suffer
significant injury despite relatively trivial mechanism. The physiologic response of older trauma
victims might differ from that seen in younger patients. Alterations in mentation are more often attributed
to dementia or delirium so recognition of shock or traumatic brain injury may
be delayed. Under-triage (allocation of
elderly trauma victims to lower level trauma centers or non-trauma centers) is
associated with a two-fold increase in the risk of death. It is important to recognize the potential
severity of even minimal rib fractures in the elderly and to have a low
threshold for hospitalization, ICU admission, and aggressive pain management
strategy.
2. General Guidelines for
Managing Elderly Trauma Patients (from EAST)
·
Advanced patient age is not an absolute predictor of poor
outcomes following trauma and should not be used as the sole criterion for
denying or limiting care in this patient population. (Level 3 recommendation,
EAST)
·
An initial aggressive approach should be pursued for
management of the elderly patient unless in the judgment of an experienced
trauma surgeon it seems that the injury burden is severe and the patient
appears moribund. (Level 3 recommendation)
·
In patients aged 65 years or older with a GCS less than 8,
if substantial improvement in the GCS is not realized within 72 hours of
injury, consideration should be given to limiting further aggressive
therapeutic interventions. (Level 3 recommendation)
·
At UK, all patients ≥ 65 with significant chest, abdomen, pelvic or extremity injuries warrant
Trauma Alert activation. EAST recommends a lower threshold for trauma
activation for injured patients aged 65 years or older than for patients
younger than 65 (Level 2 recommendation, EAST).
·
The primary survey is the same for any injured patient.
The
secondary survey should emphasize the following:
3. Determine medications that
affect initial evaluation and care:
Ø Coumadin
Ø Clopidrogrel
Ø Other
anticoagulants
Ø ASA
Ø Beta
blockers
Ø ACE
inhibitors
4. Consider common, acute, non-traumatic
events that could complicate the patient’s presentation, including:
Ø Acute
coronary syndrome (EKG)
Ø Hypovolemia/dehydration
Ø Urinary
tract infection
Ø Pneumonia
Ø Acute
renal failure
Ø Cerebrovascular
event
Ø Syncope
5. Lab assessment:
Hypoperfusion is often
underappreciated in the elderly. Base
deficit (BD) should be assessed quickly to identify those patients in shock who
need resuscitation, abbreviated evaluation, and admission to an ICU. Assess BD via VBG in Trauma Alerts, ABG in
TA-Reds or by specific order in non-activated (non-alerted) patients. Base
deficit may provide useful information in determining the status of initial
resuscitation and risk of mortality for geriatric patients. ICU admission should be considered for
patients aged 65 years or older with an initial base deficit of 6mEq/L or more
(at or below -6, Level 3 recommendation).
The following should be considered for all elderly patients with injury:
Ø
Liberal use of lactic acid level (Initial lactate
measurements may increase the accuracy of recognizing occult hypoperfusion and
shock and provide better insight into the perfusion status of geriatric
patients.)
Ø
The following lab tests are included in the TA and TAR
panels. Use liberally in geriatric trauma victims, even when non-activated, Level
3 recommendation):
o
PT/PTT/INR)
o
Renal function (BUN, Cr, estimated GFR)
o
Blood alcohol
o
Urine toxicology
o
Serum electrolytes
In addition to the above,
in all patients > or = 65, add lactic acid.
6. Imaging:
Initial imaging should include liberal use of CT scanning
for blunt injury. Occult injuries are
common in the elderly and radiation exposure is of minimal risk.
Ø NEXUS
criteria may be equally sensitive in geriatric patients as in non-geriatric
patients. That being said, NEXUS has received recent criticism. UK Trauma
Imaging Guidelines recommend liberal use of spine CT in elderly patients, even
in same height falls. Ligament injury is a separate problem. Vanguri et al from
VCU advocate liberal CT scanning (as a single cervical spine diagnostic tool,
and limited concern for ligamentous injury in those with negative CT’s).
Ø Imaging
should include all CT scans needed to rule out injury in appropriate areas at
risk (see Trauma
Imaging Guideline )
Ø Level
3 recommendation (EAST): All elderly with suspected head injury who were taking
medication for systemic anticoagulation before their injury should be evaluated
with head CT as soon as possible after admission (see Anticoagulated
Trauma Patient Guideline
7. Anticoagulation assessment
and reversal:
The frequent use of
warfarin, antiplatelet agents, direct thrombin inhibitors, and direct factor Xa
inhibitors in the elderly puts them at higher risk for significant bleeding
events, even in the context of minor injury.
See Anticoagulated
Trauma Patient Guideline and/or Novel
Oral Anticoagulants in Trauma and Surgery Guideline.
Reversal should be
initiated immediately (within 2 hours of arrival is an EAST Level 3
recommendation).
8. Resuscitation and Inpatient
monitoring:
Ø In patients 55 years of age and older, an admission base deficit > 6
is associated with a 66% mortality. Patients in this category may benefit from
in-patient triage to a high-acuity nursing unit (EAST Level 3 Recommendation).
Ø Age
should not be used as a criterion to deny geriatric trauma patients
non-operative management of splenic injuries
Ø Any
geriatric patient with physiologic compromise (relative hypotension,
tachycardia, tachypnea/dyspnea, elevated BD/lactate), significant injury, and
high-risk mechanism of injury (rollover, ejection, high speed), uncertain
cardiovascular status, or chronic cardiovascular or renal disease should
undergo close monitoring, in ICU. (Level 2 recommendation) For hemodynamic
compromise, consider using a pulmonary artery catheter, ScvO2 monitoring or
other invasive monitor.
StO2 has also been described as a valuable (and noninvasive)
tool to assess perfusion in geriatric trauma victims but is not locally
available.
Ø Elderly
patients have a two-fold increase in the incidence of nosocomial infection
compared to younger patients. Reduction
of invasive monitoring as soon as possible is recommended.
Ø Parameters
for shock in the elderly should be considered:
SBP ≤110 may represent hypotension mm Hg and /or pulse ≥ 120 beats/min. Elevated lactate: ≥ 2.5 mMol/L. Base deficit >6.
Ø Consider
a higher threshold for ‘hypotension’ in elderly.
Ø Repeat
lactate liberally early after injury, pre-op and 24hr post-op.
Ø Maintain
a lower threshold for angioembolization in pelvic fracture (Henry
et al, J Trauma 2002).
9. Specialized Inpatient
Geriatric Care-the Comprehensive Geriatric Assessment
In 22 randomized trials involving over 10,000 inpatients,
comprehensive geriatric assessment (CGA) followed by appropriate treatment and
follow-up increases the likelihood of a patient being alive in their home after
1 year by 25%. In trauma, proactive geriatric consultation reduces the number
of episodes of delirium, decreases in-hospital falls, reduces the risk of
discharge to a LTC facility and shortens LOS.
If the response to 2 or more of the questions below is
‘yes’, a comprehensive geriatric assessment should be obtained:
1.
Before you were injured, did you need someone to help you on
a regular basis?
2.
Since the injury, have you needed help more than usual to
help take care of yourself?
3.
Have you been hospitalized for one or more nights in the
past 6 months?
4.
In general, do you have problems seeing well?
5.
In general, do you have serious problems with your memory?
6.
Do you take more than 3 different medications every day?
In ALL geriatric patients,
obtain a thorough past medical history by involving family and/or PCP and
obtain an accurate medication list including OTC medications.
Use
the following geriatric medication prescribing guidelines:
1.
Follow Beers Criteria and use them in decision-making. http://www.americangeriatrics.org/files/documents/beers/BeersCriteriaPublicTranslation.pdf
2.
Discontinue non-essential meds.
3.
When possible, continue meds with withdrawal potential,
including SSRI’s, TCA’s, antidepressants, BDZ’s, anti-psychotics, MAOI’s, beta
blockers, clonidine, statins and steroids.
4.
Continue beta blocker or start if indicated.
5.
Continue statins when appropriate.
6.
Adjust dosages for renal function based upon GFR.
1.
Use elderly-appropriate drugs and dosages.
2.
Avoid benzo’s, unless already dependent.
3.
Monitor opiates and consider PCA.
4.
Consider early use of non-narcotics (see Pain
Control Guideline for Hospitalized Patients).
5.
Epidural is preferable in those with 4 or more rib fractures
at age 65, or lesser numbers of ribs in older patients (see guideline, http://uktraumaprotocol.blogspot.com/2013/11/blunt-thoracic-trauma-analgesia.html).
Establish
a past history of elderly-specific comorbidities, including:
1.
Pulmonary disease
2.
Chronic renal failure
3.
Chronic anemia
4.
Depression
5.
Baseline cognitive impairment
6.
Baseline functional impairment
7.
Baseline frailty score
8.
Baseline nutritional status
9.
Alcohol, tobacco or drug abuse/dependence
10. Thyroid
dysfunction
11. Glucose
intolerance
12. Decubitis
ulcer
Cognition
and Stress/mental health can be assessed in the following ways:
For
Cognition, two options:
1.
Most use the
Montreal cognitive assessment (MoCA)
2.
Mini-COG (also
quick and good).
For
depression, 2 options:
1.
PHQ-2
(followed by PHQ-9) is simple, quick, (in EPIC already), and very sensitive but
less specific than the GDS (see below)
2.
(Brief) Geriatric
Depression Scale (GDS) - validated, easy to use, and score. More specific than
PHQ-2 in elderly but more challenging to administer.
Use
these criteria as part of a formal geriatric assessment conducted by a multi-disciplinary
trauma team.
10.Patient Decision-Making
Capacity and Care Preferences
1.
Discuss with family, surrogates and healthcare team and
document the following:
a.
Patient’s priorities and preferences regarding treatment
options.
b.
Post-injury risks of complications, mortality and
temporary/permanent functional decline.
c.
Advance directives or living will and how these affect
initial care and life-sustaining preferences, including mechanical ventilation,
CPR, dialysis, blood transfusion, permanent enteral feeding and transition to
comfort care should complications occur.
d.
Identify surrogate decision-maker
e.
Make liberal use of palliative care options
f.
In appropriate setting, present hospice as a positive active
treatment
g.
Hold family meeting within 72 hours of admission and discuss
goals of treatment
2.
Regularly evaluate and address delirium risk factors
(cognitive impairment and dementia, depression, alcohol use, polypharmacy,
psychotropic meds, poor nutrition, hearing and vision impairment) (refer to Delirium
Prevention and Treatment Guideline)
3.
Regularly monitor for reversible causes of delirium (wake-sleep
cycle disruption, sleep deprivation, immobilization, hypoxia, infection,
uncontrolled pain, renal insufficiency, dehydration, electrolyte abnormalities,
urinary retention, presence of a Foley, fecal impaction/constipation, use of restraints)
4.
Monitor the patient’s fluid status (daily input/output,
daily weight, consider noninvasive CO in the ICU in order to achieve euvolemia).
5.
Post-injury complications in the elderly
trauma patient negatively impact survival and contribute to longer lengths of
stay in survivors and nonsurvivors compared to younger trauma patients.
Specific therapies designed to prevent and/or reduce the occurrence of
complications (particularly iatrogenic complications) should lead to optimal
outcomes in this patient population (EAST, Level 3 Recommendation). Protect
patients from iatrogenic complications:
a.
Mobilize early, ambulate within 48 hours
b.
Assess and address fall risk
c.
Avoid aspiration (HOB up, upright during and 2 hours after
eating, evaluate dysphagia)
d.
Perform spirometry or chest PT
e.
Use a bowel regimen if opiates in use
f.
Screen for pressure ulcers and document skin integrity
11.Discharge
1.
Begin discharge planning immediately post-injury (including
assessment of home environment, social support, medical equipment needs and
patient acceptance of options)
2.
Provide a discharge document to the patient including:
a.
Diagnoses
b.
Meds with dosing and possible reactions
c.
Reconciliation of inpt/outpt meds
d.
Directions for wound care
e.
Diet and mobility instructions
f.
Therapy needs
g.
Contact information for the clinic
h.
Appointments with specialty surgeons
i.
Follow-up at 6 weeks after surgery
j.
Pending labs/radiography/diagnostics
3.
Communicate with PCP including findings. Verbal contact is
very helpful.
4.
Provide a discharge summary to the receiving facility if
applicable. Verbal contact can be very helpful.
5.
Arrange for follow-up visit OR phone call within 3 days of
discharge to assess:
a.
Pain control
b.
Tolerance of food
c.
Ability to ambulate
d.
Mental status
e.
Understanding of post-discharge medications/instructions
12.Predicting Outcomes:
TQIP guidelines suggest
against making prognostic decisions based upon age. However, after careful
assessment by the trauma team, dialogue with patient and family is essential
and goals of care should be discussed, at least preliminary, within 24-48 hours
of admission. The following tools can be used to predict discharge disposition
and mortality. They are only predictors and are not absolute indicators.
Predicting
Discharge Disposition
Frailty Scoring-The Trauma
Specific Frailty Index TSFI) described by Joseph et al at University of Arizona
at Tucson helps predict unfavorable discharge disposition (subacute nursing
facility). Total the score for all categories and divide by the total possible-15.
A score > .27 predicts SNF at discharge. Early, aggressive resource
allocation and patient/family counseling is warranted in this group.
Trauma-Specific Frailty
Index
Comorbidities
1.
Cancer history
Yes 1
No 0
2.
Coronary heart disease
Myocardial infarction 1
Coronary artery bypass
grafting 0.75
Percutaneous coronary
intervention 0.5
Medication 0.25
No medication 0
3.
Dementia
Severe 1
Moderate 0.5
Mild 0.25
None 0
Daily activities
4.
Help with grooming
Yes 1
No 0
5.
Help managing money
Yes 1
No 0
6.
Help doing household work
Yes 1
No 0
7.
Help toileting
Yes 1
No 0
8.
Help walking
Wheelchair 1
Walker 0.75
Cane 0.25
None 0
Health attitude
9.
Feel less useful
Most time 1
Sometimes 0.5
Never 0
10. Feel
sad
Most time 1
Sometimes 0.5
Never 0
11. Feel
effort to do everything
Most time 1
Sometimes 0.5
Never 0
12. Falls
Most time 1
Sometimes 0.5
Never 0
13. Feel
lonely
Most time 1
Sometimes 0.5
Never 0
14. Function,
sexually active
Yes 1
No 0
15. Nutrition
Abumin <3 1
>3 0
Mortality
Prediction
This mortality predictor (the
Geriatric Trauma Outcome Score) uses age, ISS and requirement for transfusion
(yes/no) to assess mortality risk. To calculate ISS, use the manual in the ICU
or contact the program office.
(Zhao et al. J Palliative
Med 2015-UT Southwestern Trauma)
References:
2. EAST Practice Management Guidelines for Geriatric Trauma, Evaluation and Management. (2012). Retrieved from www.east.org
3. Geriatric Trauma Clinical Guideline. (2010) Washington State Department of Health. Retrieved from www.doh.wa.gov/Publichealthandhealthcareprovider/EmergencyMedicalServicesEMSSystems
4. Jacobs, D. (2003). Special considerations in geriatric injury. Current opinion Critical Care Lippincott, Williams, & Wilkins, 9, 535-539.
5. Henry, Sharon M. MD; Pollak, Andrew N. MD; Jones, Alan L. MD; Boswell, Sharon RN; Scalea, Thomas M. MD. Pelvic Fracture in Geriatric Patients: A Distinct Clinical Entity. Journal of Trauma-Injury Infection& Critical Care: 2002; 53:15-20.
6. Joseph B, Pandit V, Zangbar B, et al. Validating trauma-specific frailty index for geriatric trauma patients: a prospective analysis. J Am Coll Surg 2014;219:10-7.
7. Zhao FZ, Wolf SE, Nakonezny PA, Minhajuddin A, Rhodes RL, Paulk ME, Phelan HA. Estimating Geriatric Mortality after Injury Using Age, Injury Severity, and Performance of a Transfusion: The Geriatric Trauma Outcome Score. J Palliat Med. 2015 Aug;18(8):677-81.
