1. Discuss the impact of chronic medical conditions and medications on resuscitation of elderly trauma patients.

2. Use appropriate imaging techniques to assess elderly patients with cervical spine injuries.

3. Identify patients who may benefit from reversal of anticoagulation therapy after head trauma.

4. Diagnose and treat elderly patients with isolated and multiple rib fractures.

5. Implement guidelines for clearing the cervical spine of the comatose trauma patient.

Geriatric Trauma
Douglas McGee, DO, Chief Academic Officer and Director, Emergency Medicine Residency Program, Albert Einstein Medical Center, New York, NY

Background: population aging; older adults consume disproportionate percentage of health care dollars; older trauma patients have much higher rates of mortality than younger patients with similar injuries; reasons for increased mortality include physiologic effects of aging, presence of comorbidities, and patterns of injury; most studies define geriatric patients as \>65 yr of age, but some have lower cutoff

Falls: most common reason for injury in older adults; falls from standing or sitting may cause substantial injury; reasons for falling include impaired vision, cognition, and mobility; studies show that assistive devices (eg, canes, walkers) do not reduce rate of falling and may contribute to falls; medical conditions (eg, cardiac dysrhythmias, hypovolemia) contribute to ≈25% of falls; morbidity and mortality—≈10% mortality during acute injury phase; 50% mortality at 1 yr; common reason for institutionalization

Motor vehicle accidents (MVAs): second most common cause of death among elderly; mortality rate ≈20% (7 times that of younger patients); slow reaction time contributes to many accidents; MVAs often occur in daytime, in good weather, and near patient’s home; most common scenario involves turning left in front of oncoming traffic; MVAs less likely to involve alcohol, speeding, or reckless driving, compared to younger drivers; patterns of injury generally similar, but older adults suffer more sternal fractures; medical conditions may precipitate MVA (single-vehicle accident increases index of suspicion); vehicle-pedestrian accidents—associated with severe injury and high rate of mortality (elderly patient 21 times more likely to die than younger patient); contributing factors include impaired vision, hearing, mobility, and judgment

Impact of aging on injuries and recovery: cardiovascular (CV)—aging myocardium and conducting system; brittle vascular system (eg, large vessels often calcified and prone to disruption); preexisting heart disease reduces ability to tolerate initial insult and resuscitation; medications (eg, β-blockers, antihypertensive agents, diuretics) complicate resuscitation; pulmonary—decreased residual volume and vital capacity; osteoporosis increases risk for rib fracture; fragility and decreased compliance render chest wall intolerant to mechanical insult; other complicating factors include congestive heart failure and chronic obstructive pulmonary disease; skeletal—osteoporosis increases risk for fracture; decreased mobility and range of motion increase risk for accidents; spinal stenosis increases risk for spinal cord injury; central nervous system (CNS)—increased risk for cord syndromes; increased risk for epidural hematoma (dura tightly adhered to skull); presence of brain atrophy increases risk for subdural hematoma, even with relatively small translational force

Medications: increase risk for accidents and complicate resuscitation; examples—sleeping aids, phenothiazines, antidepressants, and other agents have CNS effects; antihypertensive agents and β-blockers have CV effects; diuretics may result in dehydration (patients often volume-depleted at presentation); anticoagulant therapy complicates head injuries; prevalence (study data)—50% of elderly trauma patients take diuretics; 60% take medications with CV effects; 38% take medications with psychotropic effects; 20% take anticoagulants

Trauma triage protocols: increased morbidity and mortality associated with advanced age lowers threshold for decision to send to trauma center; factors that increase morbidity and mortality include preexisting medical conditions, significant base-deficit, low revised trauma score, and low respiratory rate; insufficient triage common among patients ≥55 yr of age; establishment of triage protocols specific for elderly patients recommended

Resuscitation: elderly patients less able to recover from O2 debt and more likely to have late presentation of and low tolerance for shock; compensatory tachycardia may not occur, due to devices (eg, pacemaker) or medications (eg, β-blockers); overresuscitating patient with ventricular dysfunction often fatal; hyper- and hypoperfusion poorly tolerated; goals—treat for shock; diagnose and admit patient as quickly as possible; reducing time to admission to advanced care setting significantly improves survival

Airway: indications for intubation similar to those for younger patients, but elderly patients may require earlier intervention; factors that affect decision to intubate include severity of O2 debt and presence of thoracic trauma; intubation complicated by—limited neck mobility, small airway opening, and friable airway tissues; increased risk for hemorrhage; dentures—leave in while ventilating with bag-valve mask; remove before intubating; induction agents—all have some CV effects; consider reducing dose

Breathing: compromised compliance and brittle thoracic cage increase risk for rib fractures and subsequent complications; recommendations—consider early intubation for patients with multiple rib fractures; be vigilant about clearing pulmonary secretions

Circulation: risk for hypo- and hyperperfusion; elderly patients have poor CV reserve and cannot accommodate extra fluid; dehydration (often present at baseline) and many medications complicate calculations; recommendations—search for occult hemorrhage; identify other issues affecting circulation; focus on cellular perfusion and oxygenation (eg, check lactate level and base deficit) rather than vital signs

Disability: most patients have some disability at baseline; although many elderly patients have impaired cognition at baseline, treat altered mental status as new-onset until proven otherwise; nontrauma–related factors that contribute to altered mental status include hypoglycemia and medications

Exposure: hypothermia—common; decreased mobility, social and economic issues, and decreased basal metabolic rate contribute; to reduce coagulation problems associated with hypothermia, keep patients warm; pressure ulcers—can form quickly; remove patient from back board as quickly as possible

Cervical spine: increased risk for fracture, especially of upper cervical segments; degenerative changes complicate interpretation of plain radiographs; guidelines for radiography (study data)—among alert asymptomatic patients >65 yr of age, presence of distracting injury above clavicle increases risk for cervical spine fracture; risk not affected by mechanism of injury; distracting injuries below clavicle had no impact; concluded that lack of distracting injury above clavicle in asymptomatic patient means x-rays not necessary; National Emergency X-Radiography Utilization Study (NEXUS) decision rule—valid for patients \>65 yr of age (can safely avoid getting x-rays when patient characterized as low-risk for fracture); odontoid fractures common; upper cervical spine fractures particularly common among patients \>75 yr of age, even after minor trauma (eg, fall from sitting in chair); some protocols (eg, Canadian Cervical Spine Rule) require radiographs for all patients ≥65 yr of age; other imaging—because of degenerative changes in spine and risk for fracture and cord syndromes, include computed tomography (CT) of neck if performing head CT

Head trauma: severity of injury and presence of preexisting medical conditions affect prognosis; elderly patients at increased risk for death due to multiorgan failure; effect of anticoagulation therapy—according to most studies, associated with increased mortality, especially when international normalized ratio (INR) elevated; warfarin, aspirin, clopidogrel, and nonsteroidal anti-inflammatory drugs (NSAIDs) increase risk for intracranial complications and mortality; deterioration may occur quickly, even in absence of obvious neurologic abnormalities; 6-hr observation period or imaging recommended for elderly patients with head trauma; contrary data—findings from one study (Gittleman et al, 2005) suggested patients with normal neurologic examination and normal Glasgow Coma Scale (GCS) score do not require CT, even if taking anticoagulants; another study found warfarin therapy associated with poor outcomes after non-head trauma but not after head trauma (most other studies show association); because age independently increases risk for death after head trauma, some clinicians recommend CT for all elderly patients with even minor head injury; reversing anticoagulation—high INR warrants reversal; reversal agents for patients on warfarin therapy include vitamin K, fresh frozen plasma, prothrombin complex concentrate, and recombinant factor VII; reversal agents for patients on aspirin or clopidogrel include platelets, desmopressin, and possibly recombinant factor VII

Thoracic trauma: impaired mechanics, poor compliance, and underlying lung disease contribute to poor outcomes; multiple rib fractures—among patients ≥65 yr of age, morbidity and mortality increases with increasing number of rib fractures; admission recommended for patients with \>3 rib fractures (admit patients with \>6 rib fractures to intensive care unit [ICU]); flail chest (study data)—associated morbidity and mortality increases by 132% with each decade (beginning at second decade); for those >55 yr of age, likelihood of death increases by 32% for each point increase in injury severity score; isolated rib fractures—study found 36% of patients had pulmonary complications (fatal in ≈10%); hypoxia and presence of comorbidities increase risk; outcomes difficult to predict; pulmonary contusions—mortality twice that of younger patients; conclusions— aggressive search for rib fractures warranted in elderly, even in absence of pneumothorax or pulmonary contusion (consider radiography series or CT); patients with multiple fractures should be admitted

Pelvic fractures: associated with high rates of morbidity and mortality; insufficiency fractures—related to underlying bone disease; include compression fractures; may occur with minimal trauma; associated with long lengths of stay and high rates of debilitation (50% have poor functional recovery; 25% require institutionalization; 1-yr mortality, ≈15%)

Cervical Spine Clearance
Robert Quickel, MD, Assistant Professor of Surgery, Clinical Track, University of Minnesota Medical School, and Director of Surgical Critical Care, Hennepin County Medical Center, Minneapolis, MN

Conscious patients: cervical spine injuries occur in 2% to 4% of patients with blunt trauma; asymptomatic patients—clinical examination sufficient for patients without changes in mental status, pain, or distracting injury; symptomatic patients—radiography recommended

Comatose patients: cervical spine injuries occur in 5% to 8% of patients with traumatic brain injury; patients unable to report symptoms, and examinations unreliable; history of limb movement (all 4 extremities) indicates intact spinal cord; missed cervical spine injuries—occurs in 0.3% of comatose patients; associated with medicolegal consequences for clinician and physical and financial consequences for patient; importance of clearing cervical spine— complications associated with prolonged use of cervical collar include occipital pressure ulcers, difficult airway management, catheter-related problems, delirium (associated with prolonged immobilization of conscious patients), and increased risk for hospital-acquired pneumonia

Guidelines for clearing cervical spine in comatose patients: Eastern Association for the Surgery of Trauma— most recent revisions in 2000 (update in progress); plain radiographs (anteroposterior, lateral, and open-mouth odontoid views); axial CT of upper cervical spine (3-mm intervals from occiput to second cervical vertebra [C2]); flexion-extension radiography (static images at extremes) for patients with normal findings on radiography and CT (requires presence of surgeon); note, plain radiographs may be abandoned in updated version of guidelines; American College of Radiology—guidelines updated in 2005; multislice or multidetector CT with sagittal and coronal reconstructions; plain radiograph of upper cervical vertebrae (looking for fracture in C2, especially among older patients; axial CT misses odontoid fractures); magnetic resonance imaging (MRI) recommended for patients comatose \>48 hr

Imaging techniques: flexion-extension radiography—fallen out of favor, due to risk for harm in comatose patients; acceptable option for conscious patients (patient moves head and neck and reports pain); for comatose patients, technique often dangerous, inaccurate, inadequate, resource-intensive, and incomplete (neck extension difficult in comatose patient, so some clinicians avoid); CT—cervical CT often performed at same time as head CT; studies generally adequate and accurate; disadvantages include cost, radiation exposure, poor visualization of ligamentous injury, and scanner variability; important to perform sagittal and coronal reconstructions of axial scans; MRI— good technique for identifying injuries to ligaments and soft tissues, but not fractures; no radiation exposure; disadvantages include frequency of false-positive findings, transport and monitoring issues (eg, if scanner located remotely), and cost

Studies: several studies show high prevalence of ligamentous injury requiring immobilization but not surgery; unstable ligamentous injury rare, and may be identified with CT or MRI; retrospective review found evidence of ligamentous injury on cervical CT images originally considered negative; study concluded that multislice CT has 98.9% negative predictive value for ligamentous cervical injury and 100% negative predictive value for unstable cervical spine injury; other studies support use of helical CT for clearing cervical spine (all clinically relevant injuries identified); clearing cervical spine early with CT (vs waiting until patient regains consciousness) reduces immobilization-related complications, time on ventilator, and ICU and hospital stays, and does not increase mortality; no predictive factors identify patients likely to benefit from MRI

Closing comments: technique, operator experience, and CT scanner characteristics important when clearing cervical spine of comatose patient; additional studies include lateral plain films of C2 or MRI (especially if patient has not moved extremities); speaker recommends keeping data from CT for additional reconstruction (eg, at 1-mm intervals), if necessary