Goals. Geriatric Trauma. What s the impact Erlanger Trauma Symposium

Transcription

1 Geriatric Trauma William S. Havron III MD Assistant Professor of Surgery University of Oklahoma Goals Realize the impact of injuries in the ageing population Identify the pitfalls associated with geriatric trauma and understand the role of altered physiology in the elderly Review specific injury patterns and the morbidity / mortality associated with them Discuss ways to optimize treatment and understand the need for prevention programs What s the impact Trauma: 9 th leading cause of death in those >65 yrs Trauma mortality rates 56 deaths per 100,00 traumas in all ages 113 per 100,000 in those older than : 12% of population was >65 >1/3 of ambulance transports 25% of all hospital costs 33% of all trauma costs

2 Geriatric Trauma Most commonly accepted age range from the literature is 65 yrs old and older The Old: The Really Old: >80 Not just chronological age Physiologic age Presence of pre-existing co-morbidities Physiologic changes in the elderly CNS alterations: Autonomic system Neurotransmitters Decreased cerebral oxygen consumption Cardiovascular: Decreased response to beta adrenergic stimuli (decreased inotropic effect) Increased peripheral vascular resistance Slowed ventricular filling Physiologic changes in the elderly Respiratory: Decreased chemoreceptor response to hypox Decreased diffusion capacity Decreased cough reflex Weaker respiratory muscles Renal: Decreased response to vasopressin and Aldo Decreased drug elimination Musculoskeletal Chronologic age Is advanced chronological age an independent marker for mortality Waters are muddy at best Literature differs greatly from the definition of geriatric to the inclusion / exclusion criteria No consensus

3 Chronologic age Morris et al. 199,737 trauma pt 15 yrs and older ISS best predictor of mortality Age and pre-existing conditions were independent predictors of mortality Mortality in minor injuries (ISS<9) increases beyond age 65 Mortality in moderate injuries (ISS 9-24) sig. increases in pts over 45 Chronologic age Perdue et al. Age of 65 or greater was predictive of both early and late mortality 2.46 fold increase in early mortality 4.64 fold increase in late mortality Knudson et al. 852 pts, age was not a predictor of in hospital mortality 1.33 fold increase in risk of death in pts 75 or older P=0.06 Horst et al. No sig difference in age between elderly (>60) survivors and nonsurvivors after trauma Taylor et al. Retrospective review of trauma registry data on 26,237 pts Age >65 yrs was associated with a two to three fold increased risk of mortality in mild (ISS < 15) / moderate (ISS 15-29) / severe (ISS 30 or above) trauma (p<0.001) Chronologic age Demetriades et al Old age as a criterion for trauma team activation Retrospective review of trauma database 883 pts 70yrs or older 223 (25%) met criteria for activation 50% mortality 660 pts (75%) didn t meet criteria 24% ICU admission 16% mortality Age 70 should be a criteria for activation Physiologic Age Presence of pre-existing conditions Represents functional status Frequency increases with advanced age Difficult to separate actual impact on mortality Likely that both chronological age and preexisting conditions together impact mortality Polypharmacy

4 Physiologic Age Milzman et al; J o Trauma Pre-existing disease in trauma patients 3000 trauma pts Mortality 3x higher in pts with pre-existing medical conditions Impact of pre-existing conditions diminished with advancing age Physiologic Age Grossman et al; J o Trauma Effects of pre-existing conditions on mortality in geriatric trauma pts Review of 30,000 records from a trauma database Overall mortality was 7.6 % Increased 6.8% each year over 65 After controlling for other variables, pre-existing conditions were and independent factor of mortality Effect with specific disease states Hepatic disease odds ratio of 5.1 Renal disease odds ratio of 3.1 Malignancy odds ratio of 1.8 Mechanism of injury Falls Most common cause of geriatric injury Approx 60% of all non-fatal elderly ER visits 1/3 of people 65yrs or older fall yearly Higher in institutionalized pts Many fall repeatedly (50%) 6% of all medical cost in the geriatric population is attributed to the management of falls

5 Mechanism of injury Motor vehicle collisions 28% of all injuries in geriatric patients Most common fatal traumatic event in the elderly Higher rate of MVC per mile driven Increased risk for death and hospitalization Why? Decreased peripheral vision, limited cervical mobility, slower reaction times, potential cognitive deficits, polypharmacy, etc Mechanism of injury Pedestrian Struck Geriatric population represents 10% of pedestrian population yet compose 21% of the fatality rate Assault / Elder abuse Penetrating Trauma 8-14% of the injuries in the elderly Suicide represents the majority 1:4 completion rate vs 1:25 in general public 85+ the suicide rates are 5x the general public

6 Specific Injuries Rib Fractures Bergeron et al; J of Trauma Reviewed 405 patients with rib fractures, adjusting for severity and comorbidities found that pts 65 and older had 5x the risk of dying Brasel et al; Crit Care Med 17,308 trauma patients In pts with rib fxs, controlling for other factors, found both age and ISS were the only important predictors of mortality Traumatic Brain Injury Structural changes Cortical atrophy Decreased epidural space Increased subdural space SDH 3x as common Venous structures are under tension Anticoagulant use TBI + pre-injury anticoagulation = Ohm et al; J of Trauma Review of elderly trauma pts on ASA, Clopidogrel, or both presenting with ICH vs not on anti-platelet tx Mortality 23% vs 8.9% p=0.016 Lavoie et al; J of Trauma Pre-injury warfarin in elderly patients with CHI More severe head injuries p=0.02 Higher rate of mortality p=0.01 Franko et al; J of Trauma Warfarin use has a 6 fold increase in TBI mortality Pts on warfarin and that are older than 70 have an even higher mortality

7 Pelvic Fractures Pelvic Fractures Chong et al; Impact of pelvic fractures on mortality 343 pts with pelvic fractures Elderly had 4 fold increase in mortality despite less severe ISS and pelvic fxs Henry et al; pelvic fx in geriatric pts Older pts 2.8x more likely to require transfusion More likely to require angiography Higher in hospital mortality LC fx 4.6x more common in elderly Less severe than younger counterparts but 4x as likely to require transfusion How do we impact mortality? Decreased time in ER and to invasive monitoring 5.5 hrs vs 2.2 hrs Used A lines / CVL / Swan Ganz in high risk pts Optimized cardiac output and SVR Survival increased from 7% to 53% (p<0.001) Highly sig difference between optimized cardiac output and SVR in survivors and non-survivors (p<0.0001) How do we impact mortality? Demetriades et al; BJS Effect on outcome of early invasive management of geriatric trauma patients Two groups Group 1: Pts admitted prior to implementation of aggressive invasive monitoring and age >70 as a criteria for trauma activation Group 2: Pts admitted with the new protocols in place Mortality: (1) 53.8% (2) 34.2% p<0.003 Utilization of the trauma team and aggressive monitoring, evaluation, and resuscitation in geriatric trauma improves survival

8 Complications Complications Adams, Holcomb et al ; presented at Western Trauma 2010 Unique pattern of complications in elderly trauma pts Database review of >15k pts,13% elderly (65) Incidence of 10 complications (per age group) divided into 3 categories End organ failure Infections Thrombo-embolic events Western Trauma 2010 (cont.) Increased age correlated with: Mortality (regardless of ISS) End organ failure Thrombo-embolic events Significant breakpoint at 45 (all with p<0.05) Increased mortality Decubiti Renal failure Outcomes Outcomes DeMaria et al; J of Trauma Geriatric trauma survivors at D/C 33% independent 37% dependant but living at home 30% required NH Older, higher ISS, & required more surgery 63% of the NH pts returned home with 57% becoming independent Richmond et al; Amer geriatrics soc. Characteristics and outcomes of serious traumatic injury in older adults 38,707 pts mean age % of survivors D/C d home 25.4% to SNF Increased age, total number of injuries, injury to extremities or abdominal contents, falls, and a lower functional level predicted D/C to SNF (p<0.01)

9 Outcomes Geriatric trauma patients seen by geriatrician Identified and participated in treatment numerous conditions ETOH abuse, newly diagnosed medical conditions, delirium, advanced care planning, disposition, and medication changes Reduced hospital acquired complications What next? Summary Prevention programs Safety while maintaining independence Fall prevention Especially targeting the institutionalized population Elderly driver safety High index of suspicion for elder abuse Early interventions with depression and suicide prevention Discussing limitations of care Patients of advanced age should be seen at a trauma center Liberal activation of the trauma team with geriatric patients Older patients are at considerable risk for under triage The presence of comorbidities is associated with worse outcomes in the geriatric population Potential pitfall with polypharmacy

10 Summary Future Post injury complications are associated with worse outcomes Early and aggressive resuscitation, treatment, and invasive monitoring are often warranted 85% will return to independent function High index of suspicion old people are tricky Physiologic changes Decreased functional reserve Need more geriatric studies Resuscitation Modes and endpoints Current outcomes Multi-discipline approach to older patients Appropriate triage parameters Questions References Fallon et al; Geriatric outcomes are improved by a geriatric trauma consultation service: JOT Nov 2006;61, Taylor et al; Trauma in the elderly: Intensive care unit resource use and outcome: JOT Sept 2002;53, Sterling et al; Geriatric falls: Injury sevarity is high and disproportionate to mechanism: JOT Jan 2001;50, Demetriades et al; Old age as a criterion for trauma team activation: JOT Oct 2001;51, Brasel et al; Rib fractures: Relationship with pneumonia and mortality: CCM; 34, Bakhos et al; Vital capacity as a predictor of outcome in elderly patients with rib fractures: JOT July 2006;61,131-4 Bergeron et al; Elderly trauma patients with rib fractures are a great risk of death and pneumonia: JOT March 2003;54, Cohen et al; Traumatic brain injury in anticoagulated patients: JOT March 2006;60,553-7 Ivascu et al; Treatment of trauma patients with intracranial hemorrhage on preinjury warfarin: JOT Aug 2006;61,318-21

11 References References Ohm et al; Effects of antiplatelet agents on outcomes for elderly patients with traumatic intracranial hemorrhage: JOT March 2005;58, Jones et al; The effects of preinjury clopidogrel use on older trauma patients with head injuries: Amer J of Surg 2006;192, Lavoie et al; Preinjury warfarin use among elderly patients with closed head injuries in a trauma center: April 2004;56,802-7 Franko et al; Advanced age and preinjury warfarin anticoagulation increases the risk of mortality after head trauma: JOT 2006;61, DeMaria et al; Survival after trauma in geriatric patients: Amer J of Surg;206, DeMaria et al; Aggressive trauma care benefits the elderly: Amer J of Surg;27, Richmond et al; Characteristics and outcomes of serious traumatic injury in older adults: Amer Ger Soc 2002;50, Scalea et al; Geriatric blunt multiple trauma: Improved survival with early invasive monitoring: JOT 1990;30, Demetriades et al; Effect on outcome of early intensive management of geriatric trauma patients: Brit J of Surg 2002;89, Trunkey et al; Management of the geriatric trauma patient at risk of death: Arch of Surg 2008;135,34-38 McGwin Jr et al; Long term survival in the elderly after trauma: JOT 2000;49, Adams et al: The unique pattern of complications in the elderly trauma patients at a Level 1 trauma center: presented at Western trauma March 3 rd 2010 ACS Geriatric trauma: R M Albrecht EAST Practice guidelines: Geriatric Trauma Morris et al; Mortality in trauma patients: The interaction between host factors and survival: JOT;30,1476 Morris et al; The effect of pre-existing conditions and mortality in trauma patients: JAMA;263,1942 Perdue et al; Differences in mortality between elderly and younger adult trauma patients: Geriatric status increases risk of death: JOT;54,805 Feliciano et al; Trauma: 6 th ed. 2008