Geriatric Trauma Resuscitation: Lessons from a Geriatric Trauma Surgeon

Transcription

1 Geriatric Trauma Resuscitation: Lessons from a Geriatric Trauma Surgeon Aurelio Rodriguez, M.D., FACS Conemaugh Memorial Medical Center Trauma Center Johnstown, PA

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3 Demographics The fastest growing age group Baby boomers ( ) Age Chronological Age 65? Consensus Physiological Age 45+ pre-existing conditions USA 2000 > 65 y 12.4% USA 2020 > 65 y 16% Europe 2050 > 65 y 22-50%

4 Source: Trauma, Sixth Edition; McGraw-Hill

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6 Allegheny General Hospital Geriatric Admissions by Year Age < Age > (21%) (21%) (26%) (24%) (24%) 17.6% of all trauma admissions are age > 65 from the NTDB Version 5.0

7 % Total Trauma Patients > 65 years of age 50% 50% 45% 40% 43% 35% 38% 30% 25% 20% 15% 10% 5% 0%

8 Demographics Over age 65 40% Hospital Resources 24% of Office Visits 25% of prescription drug costs 25% of Medicare Expenditures in last year of life Half of this: last 60 days.

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10 Source: Trauma, Sixth Edition; McGraw-Hill

11 Source: Trauma, Sixth Edition; McGraw-Hill

12 Co-morbidity in the Elderly Significant differences in the reporting. Definition of co-morbidity Bias in the reporting Miltzman: 40 years - 17% comorbidities 60 years - 40% comorbidities 75 years - 69% comorbidities Bergeron (Triss by age categories) Prevalence of co-morbidities <55 4.6% > % % > % The ability to respond to stress: severely compromised.

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14 MECHANISM OF INJURY PENETRATING TRAUMA Very limited No difference in survival in matched ISS Longer hospital stay and more medical complications

15 Mechanisms of Injury 1. Falls 2. MVC 3. Pedestrian vs. car 4. Assault and domestic abuse 5. Penetrating trauma 6. Suicide 7. Burns

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17 Management of the Geriatric Trauma Patient TRIAGE: Despite ACS recommendations: under triage occurs >55 y Trauma Center The Trauma score (TS) varies 0-16 Blood pressure Respiratory rate Respiratory effort GCS Capillary refilling Useful as a pre-hospital tool

18 Is there any correlation between trauma scores and outcomes? The Ohio Geriatric Trauma rules The Washington State The Pennsylvania Trauma Foundation: in infancy The outcome is better when elder is sent to Trauma Center.

19 Activation Criteria Inaccurate Triage: Shock at arrival Inaccurate activation criteria Demetriades: Heightened level of alertness: better outcome. Change in Protocol: > 70 y Trauma Activation Ohio recommendations - AGH protocol

20 End points of resuscitation: Geriatric Trauma Scalea, T et al - J. Trauma 30 (4): , 1990 Cardiac Index > 4 l/min HCT > 30% Inotropes if necessary Oxygen consumption index > 170 ml/min/m2 Patients were admitted to ICU Survival - 7% when not optimized Survival - 53% when optimized

21 Allegheny General Hospital ISS and % Admissions to ICU ISS Age < Age > ICU % Age < Age >

22 End Points of Resuscitation: Geriatric Trauma Velmahos, G et al, Ann Surg 232 (3): , 2000 Systolic blood pressure > 100 mmhg HCT > 30% Urine > ml/kg/hour Base deficit < -3 Cardiac Index > 4.5L/min/M2 PaO2/Fio2 >200 No patient over the age of 50 achieved optimal values.

23 End Points of Resuscitation: Geriatric Trauma McKinley et al, Arch Surg 135: 688, 2000 Oxygen deliver index 500 ml/min/m2 GOAL: DO2I - >600 - the first 24 hours in ICU PA catheter Crystalloids solutions Packed red blood cells transfusions Moderate inotropic support

24 Mckinley Patient Selection >65 AT HIGH RISK POST INJURY MOF: Major organ or vascular injury Initial base deficit of 6 meq/ L or greater Need for more than 6 units in first 12 hours Age 65 y or older or any two previous criteria

25 Mckinley - 19 Month Study Period Protocol 12 Old patients ( > 65) 9 (75%) DO 2L > (92% ) Survival >7 days 5 (42%) Survival >30 days 45 Young patients ( >65) 45 (83%) DO2I > (92%) Survival >7 days 48 (80%) Survival >30 days Ultimate outcome is poorer than Younger cohort: resuscitation is not futile. Limitations: No control group in the elder out of protocol

26 Only Randomized Trial: Resuscitation in Geriatric Trauma 70 hip fractures Shultz F., et al, J. Trauma 25:309, 1985 Central venous line vs. P.A. catheter control group Significant increase in mortality 290% vs 2.9% in The monitor group Flaws: No multiple injured patients. No description of optimization protocol

27 320 Geriatric Fracture Procedure Volume From FY 2008 to FY Procedures FY 2008 FY 2009 FY 2010 FY 2011 FY 2012

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29 The Selection Criteria elderly patients need aggressive resuscitation and monitoring. Have yet to be determined.

30 Trauma Score < 15 Base Deficit > 6 SBP < 90 Worst outcomes May help to identify patients: aggressive resuscitation monitoring in the ICU.

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33 Source: Trauma, Sixth Edition; McGraw-Hill

34 The Geriatric Patient with T.B.I. Increased mortality from 30% to 75% New admission 6CS <8 poor outcome Worst functional outcome: Patients on Coumadin: INR? Vitamin K Fresh frozen plasma. How much? Factor VII Prothrombin concentrates Patients on Plavix: same or worse?

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40 Geriatric Trauma Institute (GTI) Central Pennsylvania

41 Pre-Hospital Neurosurgery Guidelines Orthopedic Guidelines Trauma Surgeon Guidelines Pharmacy Rehabilitation Social Service Nurse s Guidelines Emergency Medicine GTI Central PA

42 GTI Mission Statement Provide Geriatric Trauma Patient with State of the Art Trauma, Neurosurgical, Orthopedic and Medical Care Expedite Operative Procedures to Accelerate Recovery Process Provide Aggressive and early Rehabilitation Pursue future Research Opportunities Trauma Prevention