Russ Calhoun, B.S., REMT-P Associate Professor EMS/Municipal Fire Protection O.S.U. Oklahoma City 405/ /7/10

Size: px

Start display at page:

Download "Russ Calhoun, B.S., REMT-P Associate Professor EMS/Municipal Fire Protection O.S.U. Oklahoma City 405/ /7/10"

Annice Leonard
6 years ago
Views:

1 Russ Calhoun, B.S., REMT-P Associate Professor EMS/Municipal Fire Protection O.S.U. Oklahoma City 405/ /7/10

2 Summarize related demographic data and aging & illness changes common to seniors. Compare and contrast current field trauma triage guidelines for older adults. Discuss steps to improve outcomes for Oklahoma s injured elderly patients.

Robert Bob Salinas, M.D. Geriatric Specialist The University of Oklahoma Health Sciences Center Department of Family and Preventive Medicine robert-salinas@ouhsc.

3 Robert Bob Salinas, M.D. Geriatric Specialist The University of Oklahoma Health Sciences Center Department of Family and Preventive Medicine Former EMT in college Co-founder of POEMSS (Project for Optimal EMS for Seniors at Co-developer of the EMSMedFile Advocate for Improved Emergency Medical Services for Seniors and for EMS Providers

4 By the year 2030, the US population segment for those who are 65 and over will grow by ~70%, reaching about 20-22% (currently ~13%) y/olds will decline by ~ 7% by 2030; y/olds will also decrease by ~9%. Between 2000 and 2050, the U.S. 65+ population segment will grow by 147%, compared to the general segment s growth of 49% (263 million in 1995 to 394 m in 2050). 90% of the U.S. increase through 2050 will be from the minority segments. Worldwide, the 65+ population segment will double in size by 2030 (483 million currently to 974 m)

5 Old Young Males Females Males Females Age pyramid for humans prior to 1900 Age pyramid of the future SJ Olansky 2001

6 Fastest growing segment is 85 and over (the oldest old), projected for a cumulative growth of 400% from 1995 to 2050! Problem: These seniors tend to be in poorer health and require more services than the younger old elderly segment!

7 Life expectancy will increase from 76.0 years in 1993 to 82.6 years in Babies born in 2000 should live ~ 30 years longer (to 76.9 years) than those born in 1900.

8 13% of the U.S. population (~12.7 vs. Oklahoma s 13.7%) account for: 33% of all hospitalizations, 40-50% of inpatient days, 45-50% of all hospital expenditures, 36% of Rx s..., and 36-41% of all EMS responses (Albany, NY and Dallas, TX utilization studies)

[2006 CDC&P] Age Group 60-85 (all races, both sexes): 1. Heart Disease 2. Cancer/Malignant Neoplasms 3. CVA/Stroke 4.

9 [2006 CDC&P] Age Group (all races, both sexes): 1. Heart Disease 2. Cancer/Malignant Neoplasms 3. CVA/Stroke 4. COPD 5. Alzheimer s Disease 6. Diabetes 7. Influenza and Pneumonia 8. UNINTENTIONAL INJURY 9. Nephritis 10. Septicemia

2007 65+: E.D. Non-Fatal Fatal 1. Falls Falls 2. Struck by/against MV Traffic 3.

Cut/Pierce Suffocation 6. Other Bite/Sting Adverse Effects 7.

10 : E.D. Non-Fatal Fatal 1. Falls Falls 2. Struck by/against MV Traffic 3. Overexertion Unspecified 4. MV Occupant Suicide Firearm* 5. Cut/Pierce Suffocation 6. Other Bite/Sting Adverse Effects 7. Poisoning Fire/Burn 8. Transport Poisoning 9. Unknown/Unspec. Suicide/Poison.* 10. Other Specified Natural/Environment

13 1. Geriatric population increasing Plus 2. Healthier, more active and more independent Equals 3. INCREASED DEMAND ON OUR EMS & TRAUMA SYSTEMS!

14 Physiologic capacity to compensate for traumatic insults is impaired due to: a. Normal aging processes/declines b. Effects of chronic illness Cardiovascular decreased C.O. and decreased sensitivity to catecholamine response with stress Cerebral brain atrophy and tension on cerebral vessels; more subdural hematomas Renal meds metabolism and protracted recovery periods Immune System increased infection risk [c]

15 Rx Medications a. Blood thinners, anti-platelet agents (Coumadin (Warfarin), ASA and Plavix) b. Beta-blockers and Calcium-channel blockers c. Diuretics (Lasix, etc.)

16 Co-morbid illnesses a. CAD b. CHF c. Diabetes d. COPD e. O.A. f. O.P. g. Renal Failure/Dialysis

17 Guidelines for Field Triage of Injured Patients (with Continuing Education Exam inside) and including Field Triage Criteria and Decision Schemes [MMWR (Morbidity and Mortality Weekly Report) 1/23/09 Department of Health and Human Services Centers for Disease Control and Prevention]

18 1. Vitals Signs and L.O.C. (Physiological) 2. Anatomy of Injury 3. M.O.I. and/or High-Energy Impact 4. Special Patient/System Considerations

19 1. Physiologic Parameters 2. Anatomical Injury 3. Consider Co-morbid factors and/or Gestalt (EMS clinical judgment) NOTE: Non-secured Airway [or possibly a Traumatic Arrest] goes to nearest appropriate facility.

1997 Tokyo, Japan (by Sugimoto, Aruga, Hirata and Shindo) Conclusion: in geriatric-age patients, direct transfer patients have a lower mortality rate than indirect transfer patients when controlled

20 1997 Tokyo, Japan (by Sugimoto, Aruga, Hirata and Shindo) Conclusion: in geriatric-age patients, direct transfer patients have a lower mortality rate than indirect transfer patients when controlled for their ISS. Therefore, a different set of triage criteria should be developed and implemented for geriatricage victims with trauma-induced injuries and that those who meet these more stringent requirements should be transferred directly to a Trauma Center.

21 Washington State Department of Health Geriatric Trauma Care Guideline 3/07 Early aggressive trauma care has been shown to improve outcomes for geriatric patients with survivable injuries Recognition of the increased risk of poor outcome in this population should prompt consideration of early transfer to a higher level of trauma care [Except for patients already moribund on arrival] an initial aggressive approach should be pursued, as the majority will return home and up to 85% will return to independent function.

23 Ohio Prehospital Trauma Triage Rules Revised January 2009

24 Ohio Department of Public Safety, Division of EMS Ohio Trauma Registry data collected and reviewed Found significant increases in mortality at age 72 [ 70 years is the official cut-off point for geriatrics age-specific triage criteria.]

Injuries many times not serious in most adults were fatal to older patients! Fewer than 2% of adult trauma patients died after admission to a non-trauma center, vs. 16% of geriatric trauma patients!

25 Injuries many times not serious in most adults were fatal to older patients! Fewer than 2% of adult trauma patients died after admission to a non-trauma center, vs. 16% of geriatric trauma patients! The mortality of geriatric patients is higher in nontrauma centers. Paramedics will be sending injured patients 70 or older to a trauma center if they are struck by a car or if their blood pressure drops below 100 systolic.

26 Paramedics used to divide people into two groups pediatric patients and everyone else. Pediatric patients are now age birth to 16 y/o Adults are now age Geriatric patients are now age 70+ OHIO is the first state with distinct GERIATRIC trauma triage criteria.

27 When evaluating an injured person for triage to a trauma center, EMS providers must look for certain indicators of serious injury. These indicators will be either: - Anatomic the injuries suffered - Physiologic the body s response to the injury, or - Mechanistic cause of injury (geriatrics only).

$fracture (this does not include isolated hip fractures) Injury sustained in two or more$

28 Penetrating injury to the head, neck or torso Significant penetrating injury to the extremities, proximal to the knee or elbow, with neurovascular compromise Visible crush of head, neck or torso Abdominal tenderness, distention or seat belt sign Flail chest Pelvic fracture (this does not include isolated hip fractures) Injury sustained in two or more body regions*

29 Injuries to the extremities with Visible crush or Evidence of neurovascular compromise Amputations proximal to the wrist or ankle Fracture of 2 or more proximal long bones (humerus or femur) [Check the upcoming mechanism indicators.] Signs and symptoms of spinal cord injury Serious burns 2 nd or 3 rd degree burns over more than 10% of total body surface area or Involving face, airway, hands, feet, genitalia

Glasgow Coma Score of 13 or less [<14 CDC] Glasgow Coma Score less than 15 with a known or suspected traumatic brain injury* Loss of consciousness for greater than 5 minutes Failure to localize pain

30 Glasgow Coma Score of 13 or less [<14 CDC] Glasgow Coma Score less than 15 with a known or suspected traumatic brain injury* Loss of consciousness for greater than 5 minutes Failure to localize pain (GCS motor score 4 or less) Respiratory rate less than 10 or greater than 29 Requires endotracheal intubation Requires relief of tension pneumothorax Pulse rate greater than 120 with evidence of hemorrhagic shock Systolic blood pressure less than 100 mm Hg*

31 Fracture of 1 or more proximal long bones (humerus or femur) sustained in a motor vehicle crash* Pedestrian struck* Falls from any height including standing with evidence of a traumatic brain injury*

The patient dies or suffers complications or disabilities

32 Undertriage Transporting a severely injured patient to a hospital that is not a trauma center. Worst case scenario? The patient dies or suffers complications or disabilities that are avoidable. Trauma systems should aim for 0% undertriage!

33 Overtriage Transporting a minimally injured patient to a trauma center. Worst case scenario? Trauma center overload; unnecessary, expensive transfers of the patient; inconvenience for the patient and their family. Trauma systems accept a certain amount of overtriage in order to keep life-threatening undertriage low.

34 Allegheny General Hospital in Pittsburgh, PA has established a Geriatric Trauma Institute

35 Wake County EMS, N.C. Wake County Debuts Advanced-Practice Paramedics by Heightman (JEMS.com 1/9/09) 1. Joint response with first units to high-acuity calls 2. Prevention and public health visits 3. Alternative destinations (mental health/substance abuse patients)

36 GEMS (Geriatric Education for Emergency Medical Services) by Jones & Bartlett Geriatric Prehospital Care by Brady Grandma is Speeding to the Chippendale Club Again: Considerations in the Management of Geriatric Trauma by Carol Cunningham, M.D. (JEMS.com 8/21/07) More Than A Number: Age Does Matter in Your Assessment by Heightman (JEMS 4/1/09)

37 Geriatric Trauma: What to Think About Before Assessing, Treating and Packaging the Elderly by Barishansky & O Connor (JEMS 4/1/09) Revisiting Geriatric Trauma: How Transport Decisions Impact Patient Outcome by Ohio DPS/EMS Division (EMSResponder.com) Geriatric Trauma: The Elderly Trauma Patient Can Pose Unique Challenges for EMS Providers by Colwell, Murphy and Bryan (EMSResponder.com) Geriatric Trauma Triage by Locasto (JEMS.com 1/26/09)

38 Thanks! Russ Calhoun, B.S., REMT-P Associate Professor of Fire/EMS Oklahoma State University-OKC 900 N. Portland Ave. Oklahoma City, OK /

County of Santa Clara Emergency Medical Services System

County of Santa Clara Emergency Medical Services System EMS System Policy Change Coversheet EMS SYSTEM POLICY CHANGE COVERSHEET Policy Number and Name: 605: Prehospital Trauma Triage Date: May 27, 2014