Trauma resuscitation in the Elderlyfrom a physiological perspective

Transcription

1 6 November 2017 Trauma resuscitation in the Elderlyfrom a physiological perspective Joseph Mathew Consultant, Emergency/

2 6 November

3 6 November

4 The Alfred Trauma Centre, Australia Age and injury mortality burden 15/12/ >75 years years years <26 years 0 FY2002 FY2004 FY2006 FY2008 FY2010 FY2012 FY2014 & NTRI Audit

5 Health and Activity in the Elderly Meet Milos Kostic Retired scientist and engineer Ironman 2011 Time in Ironman Canada: 11:14:24 3 time winner of age class 2011 winner of the age class Completed a 2.4 mile swim, a 112 mile bike ride and a 26 mile marathon at the age of 68 years

6

7 Associated age-related Injury Burden 6 November < 65 years Comorbidity impact on Complexity >65 years Comorbidity Impact on Complexity

8 Physiology of Elderly Trauma Patient Physiology of the geriatric trauma patient shows minimal tolerance to physiologic instability Frequently will have decreased physiologic reserves, due to: - Normal aging - Disease process - Poly-pharmacy

9 Physiology of the Geriatric Trauma Patient Cardiovascular System: Decreased reserve Hypotension poorly tolerated Hypovolemia is common Medication effect Beta-blocker, Ca-Channel blockers, digoxin, diuretics, etc Underlying coronary artery disease Stiff calcified aorta higher incidence of injury with minimal injury insult

10 Physiology of the Elderly Trauma Patient Pulmonary System High prevalence underlying lung disease Multiple physiologic changes - Alveolar surfaces, decreased diffusion capacity, loss of lung elasticity, increased chest wall compliance, lower muscle mass, and decreased mucociliary clearance Decreased protective laryngeal reflexes Increased risk of rib fractures and pulmonary contusions

11 Physiology of the Elderly Trauma Patient Skeletal System Osteoporosis -Pelvic fractures from minor trauma -Hip Fractures Increased mortality/likely requiring long term care Occasionally invisible to X-ray - Decreased joint mobility Spinal Column increasing ankylosis of the spine, osteoarthritis, and decreased bone density relatively minor trauma can produce devastating injury Example: Cervical spine fractures

12 Physiology of Trauma in Elderly Cord Injury Cord syndromes are a major concern Central cord syndrome most common High incidents of spinal canal stenosis Disc Osteophytes

13 Physiology of the Elderly Trauma Patient Central nervous system Particular risk because of: Atrophy Puts bridging veins on stretch Brain more mobile Anticoagulated Slowed protective reflexes Asymptomatic expansion Very liberal use of CT scanning Non-Contrast vs Contrast enhanced CT

14 Major Sources of Mechanisms for Elderly Trauma Trauma has increased from these 3 major sources: Falls MVA Pedestrians

15 Falls Falls account for 50% of trauma injuries Of the falls resulting in injuries, 70% occur in the elderly Low force mechanisms can still produce substantial injury High risk for repeated falling

16 6 November Trauma Team Activation Criteria Mechanism Falls Geriatric Versus Non-geriatric Injury Causes by outcome (mortality) Trauma Registry Fall Same height Fall >1M Age >65 years 20% 16% Age <66 years 16% 5%

17 6 November Case 1 80 yr old male post-fall 2m from roof. Headstrike GCS 14 (V4), HR 82, BP 127/59, SaO2 96% RA Past Medical History HTN (On Beta Blockers) High cholesterol - statin Heavy ETOH use - unclear quantity Smoker Depression

18 6 November GCS drops down to 9 BP 85/60 HR 80 RR 20

19 6 November Diagnoses : 1. Traumatic SAH/EDH/IPH 2. L occipital bone # including PTB, extending to jugular foreman, carotid canals 3. L) sided rib #s 4. L) PThx/HThx - extrapleural intrathoracic haematoma 5. L) TP #s of L L3 crush # 7. Nuchal ligament tear c spine (on MRI)

20 6 November Pitfalls Delayed presentation of decreased conscious state - Due to atrophy of brain Masking of normal physiological response blood loss - Normal heart rate Early cardiovascular collapse due to minimal blood loss - Even with 10% blood loss - Will require haemostatic resuscitation

21 6 November > 65 year Mortality by arrival systolic blood pressure (mmhg) ND % Mortality 13% 38% 21% 12% Pts % 35% 30% 25% 20% 15% 10% 5% 0%

22 6 November Case 2 81 year old male, fall from standing height Past medical history: Hypertension IHD AF Medications: Anti HT Aspirin Warfarin Initial Vital Signs: GCS 15 HR 78 BP 140/70

23 6 November Case 2 Exam findings: Left Chest pain No neurology No spine tenderness

24 6 November

25 6 November Pitfalls in the context of physiology Spinal injuries No pain or tenderness over spinal column Avoid plain x-ray s, especially for C-spine and T-spine Increased risk of aspiration with C-spine injuries Difficulty swallowing delayed nutrition Higher incidence of ligamentous injuries Chest Injuries: Delayed onset of inflammation Delayed pain response Early HDU referral Early pain services input

26 6 November Pitfalls Anticoagulation: Anticipate delayed bleeds Warfarin vs NOAC s Venous Thromboembolism: Higher incidence of early DVT and PE

27 Trauma care for the elderly Over-triage the elderly American College of Surgeons recommends that trauma patients older than 55 years be taken to trauma centers More likely to suffer significant injuries after even relatively minor events Low threshold to send geriatric patients to trauma center Twice the rate of under-triage in the elderly

28 6 November Specific Trauma Team Criteria for Age >65 years MECHANISM Low fall + GCS (any) where NOAC or Warfarin is used INJURY Low threshold for injuries that rapidly evolve such as TBI & Chest injuries SIGNS Any cardiac dysrhythmia tachy or Brady TREATMENT Pelvic binder Spine precautions Sedating analgesia OTHER Severe kyphosis Comorbidities effecting swallow Morbid obesity Inter-hospital transfer

29 Management of Elderly Trauma Traditional ABCs Increased Aggressive Management Airway: Intubate Early (no endstage disease and severe brain and truncal trauma) Anticipate problems Breathing Circulation Hypoperfusion require aggressive resuscitation in monitored setting At risk for both hypo- and hyperperfusion

30 Management of Elderly Trauma Vital Signs Multiple medications may complicate our use of vital signs Look for Secondary Signs of cellular perfusion and oxygenation - Lactate level and/or base deficits rather than vital signs Hypotension Requires rapid correction Blood transfusion may also be liberalized Decreased response to catecholamines and vasopressor medications, because of underlying conduction defects, e.g., bundle branch block and their baseline medications

31 Ethical and Social Implications Challenge in this population Communication about advance directives, quality of life and impact of trauma in life style are mandatory Withdrawal of support in over 13% and reflects humane medical care Early aggressive management adequate until clear picture evident

32 CONCLUSIONS Incidence will increase Important to know effects of aging Mortality is higher with age, comorbid diseases and ISS Triage to trauma centers those with high index suspicion High index of suspicion even if stable

33 CONCLUSIONS Early aggressive resuscitation, diagnosis and treatment warranted Wait until clear clinical picture Humane and dignified approach if futility In elderly trauma, the fight is two-fold, against both the traumatic pathology, but also the patients underlying physiology Still needed - Functional outcome studies, - more effective resuscitation strategies - management protocols

34 6 November Thank you