Geriatric Trauma

Background and Importance

There is no standard definition of the term geriatric trauma in the literature; studies vary in their age criteria. In this chapter, unless noted, we are referring to patients 65 years and older. In 2016, older adults accounted for almost 13% of all injury-related ED visits in the United States, and this percentage is expected to increase with the aging of the population. Currently, unintentional injury is the sixth leading cause of death among older adults, and falls are the most common cause. Given the same mechanism of injury, older adults sustain more severe injuries than younger adults. Even low-energy mechanisms can cause morbidity and mortality. Managing these patients appropriately requires a holistic, multidisciplinary approach as recommended by the American College of Surgeons’ Geriatric Trauma Management Guidelines, the Eastern Association for the Surgery of Trauma Practice Management Guidelines for Geriatric Trauma, and the Geriatric ED Guidelines. These guidelines incorporate geriatric principles into the care of the injured older adult from the trauma alert through the initial Advanced Trauma Life Support (ATLS) assessment, imaging decisions, and injury management.

Age as a Trauma Triage Criterion

Trauma activation and/or transfer to a trauma center improves outcomes for older adults. Treatment at a trauma center reduces mortality in the first 7 days after injury (hazard ratio 0.62). However, injured older adults are less likely to be transported to a trauma center either by emergency medical services (EMS) or by a referring hospital. Traditional trauma triage criteria are less sensitive to the presenting signs and symptoms of older adults. For example, confusion could represent a baseline mental status or be a sign of acute traumatic brain injury (TBI). Medication effects such as anticoagulation must also be considered. Trauma triage criteria specific for older adults have been developed with age limits for triage criteria ranging from 55 years to 77 years. The most researched age-specific trauma criteria at this time is the Ohio Prehospital Geriatric Trauma Triage Criteria, which incorporates an age limit of 70 years old or older with additional mechanisms of fall and pedestrian struck by motor vehicle. Pedestrians older than 50 years old who are struck by a motor vehicle have a mean Injury Severity Score 9 points higher than younger adults, which is why this mechanism is part of geriatric trauma triage criteria. These criteria increase sensitivity from 61% to 93%, reducing the under-triage of older adults.

Mechanisms of Injury

Falls are the leading mechanism of injury and the leading cause of injury-related death in older adults. Most falls are from standing and occur at the place of residence; 12% of community-dwelling older adults fall each year. Traditional trauma criteria include a fall from a significant height or down a full flight of stairs, but for older adults a fall from standing or even out of a chair has an associated risk for injury. Mortality from a ground-level fall is only 0.1% for younger adults, but 4% to 5% for older adults. The next most common injury mechanism is motor vehicle collisions. A detailed crash history is important, and single-vehicle crashes should raise the suspicion that a medical problem caused the crash (e.g., syncope, myocardial infarction, stroke). An evaluation for coincident events leading to trauma should be undertaken during the ATLS trauma evaluation.

Thermal injuries, elder abuse/neglect, and self-injury are less common but are also important injury mechanisms. Burns can require significant wound care and recovery time which may be difficult for older adults to manage. In one multicenter study of older adults with a burned body surface area of 10% or greater, inpatient mortality was 25% and of the survivors, 15% required inpatient rehabilitation and 18% to 50% needed skilled nursing facility placement at discharge. Burns, head and neck injuries, and delayed injury presentation are also all suspicious for elder abuse. Elder abuse is a complex problem (see Chapter 181 ). The secondary exam should include a full skin and genital exam and thorough documentation of any injuries. The Geri-IDT (Geriatric Injury Documentation Tool) can be helpful in guiding this assessment.

A final concerning mechanism in geriatric trauma is self-injury. Older adults have a higher likelihood of completing suicide attempts than any other age group. Risk factors include recent bereavement, decreasing functional status, and increasing burden of disease. They are less likely to present with a chief complaint of depression/suicidality and less likely to receive mental health care in the ED.

Pathophysiology of Aging Affects Both the Injuries Sustained and the Recovery

Although older adults in a good state of health have sufficient reserves to accomplish activities of daily living, when they are stressed by acute trauma and the subsequent response to injury, the decrease in physiologic reserve can lead to rapid progression of tissue hypoperfusion and organ failure. In a trauma registry study out of Germany, 30% of older trauma patients experienced sepsis, 20% had multiple organ failure, and 45% had cardiovascular failure. Renal function also decreases with age and can be misrepresented by assessing creatinine clearance. Serum creatinine is a muscle breakdown product; in an older adult creatinine clearance can appear artificially normal due to decreased overall muscle mass.

Skin changes predispose to skin tears, poor wound healing, and pressure ulcers ( Fig. 179.1 ). Backboards and cervical collars placed during a trauma activation can lead to skin injury. In one study, trauma patients had a median time in a cervical collar of 117 minutes, 78% developed pressure damage to the skin, and 28% developed severe indentations. A final area of concern in older adults is age-related changes in the inflammatory and pain responses. Older adults have higher pain thresholds and reduced sensitivity to some types of painful stimuli. Decreases in the functionality of their white blood cells result in muted inflammatory responses and a lack of peritoneal abdominal signs on exam. In the older trauma patient, any abdominal tenderness is concerning for significant intra-abdominal injury.