Multidisciplinary Geriatric Trauma Care Background Traumatic injury in the geriatric population is increasing in prevalence and is associated with higher mortality and complication rates comparted to younger patients (TQIP) Here at AUMC we have seen an increase in geriatric trauma and expect that trend to continue. Historically there was no written guideline for the management of G-60 (age > 60) trauma distinct from the general practice guideline. This guideline was developed to address that need. Goal: The goal of this guideline is provide an adequate risk assessment, adhere to key prevention strategies, ensure active surveillance and recognize and treat complications when they occur to reduce mortality and morbidity in the elderly patient population. Geriatric Trauma is defines as any patient arriving with a trauma mechanism age > 60 (G-60 Trauma) Trauma Activation Activation criteria for G-60 trauma is designed to mitigate late recognition of significant injuries, therefore a lower threshold for trauma team activation is used. Patient age > 60 arriving from the field or in transfer from another facility with trauma mechanism must at a minimum be a level 3 activation with a trauma service consult as needed. If anticoagulant or antiplatelet use is yes upgrade the activation at EM Physician s discretion. Primary and Secondary Survey The primary survey is the same for all patients. The secondary survey for the G-60 population will emphasize the following: Special attention to home medications that could interfere with initial evaluation and care. Documentation of all home medications must be on H&P. If patient is unable to report home meds obtain information from family once they arrive. Some key home medication to assess for would be: Coumadin Clopidogrel Other anticoagulants ASA Beta blockers ACE inhibitors
Consider common, acute, non-traumatic events that may impact assessment. Documentation of past medical history must be documented on H&P. Acute coronary syndrome (EKG) Dehydration UTI Pneumonia ARF CVA/Syncope G-60 Trauma Labs: Minimum lab set for all G-60 traumas Lactic acid or blood gas for baseline base deficit PT/PTT/INR BUN, Creatinine, estimated GFR Blood alcohol level Urine toxicology Serum electrolytes G-60 Imaging: Occult injuries are common therefore initial imaging should include liberal use of CT scanning for blunt injury. CT scans and other appropriate radiographs needed to rule out injury in the appropriate risk area will be obtained. Anticoagulant assessment and reversal: Use of warfarin, antiplatelet agents, direct thrombin inhibitors and direct factor Xa inhibitors in the elderly put them at higher risk for bleeding events, even in the context of what might appear as a minor injury. In addition, with the exception of Warfarin, the assessment of the level of anticoagulation is not possible with lab investigations that are routinely part of the initial evaluation of the injured patient. INR: Normal INR should exclude presence of significant levels of Dabigatran or other novel anticoagulants in most, but not all, patients. INR might be only minimally increased in the presence of therapeutic doses of Dabigatran. Rivaroxaban increases the INR at therapeutic levels but the effects are not equivalent to target levels on Warfarin. Thrombin Time: Dabigatran increases the thrombin time. A normal thrombin time excludes Dabigatran Rivaroxaban does not prolong the thrombin time
TEG: TEG is useful in identifying the presence of Dabigatran or Rivaroxaban TEG will also identify the presence of effects of platelet inhibitors like Clopidrogel Anticoagulant Reversal: See Anticoagulant Reversal Specialized G-60 Inpatient Care: All admitted patients will be screened utilizing a modified Seniors at Risk (ISAR) screening tool. A positive ISAR (>2) requires a consult request to the inpatient Hospitalist service. o Before you were injured, did you need someone to assist you on a regular basis? o Since the injury, have you needed more help than usual to take care of yourself? o Have you been hospitalized for one or more nights during the past six months? o In general, do you have problems sleeping well? o In general, do you have serious problems with your memory? o Do you take more than three different medications every day? Consider ICU admission for patients who sustained 3 or more rib fractures Medications: Beers Criteria will be used in decision making about pharmacotherapy (attached) Discontinue use of all nonessential medication Continue medications with withdrawal potential o SSRI s o Triclyclic antidepressants o Benzodiazepines o Antipsychotics o MAOIs o Clonidine o Corticosteroids o Continue Beta Blockers or start if indicated o Continue Statins when appropriate o Adjust doses of medications for renal function based on GFR Pain Medication: Use elderly-appropriate medications and dose Avoid benzodiazepines unless regular home medication Monitor use of narcotics; consider early implementation of patient-controlled analgesia, start at lower doses and titrate upwards as appropriate Consider use on non-narcotics, NSAIDs, adjuncts and Tramadol Epidural analgesia should be considered for patients with multiple rib fractures to avoid respiratory failure
Prevention of iatrogenic complications and functional decline: Nursing to ensure ambulation within 48 hours of admission unless clinically contraindicated. Order to non-ambulation will be placed Fall risk assessment will be completed and documented on all patients, nursing Aspiration precautions will be implemented Head of the bed elevated at all times unless contraindicated, order placed on chart for no elevation Sitting upright while eating and two hours after completion of eating unless contraindicated, order on chart Consider evaluation for swallowing deficits Complete and document use of incentive spirometer or deep breathing exercises Initiate bowel regimen if given opiates Daily Screening: Presence of pressure ulcers with Braden scale within 24 hours of diagnosis Daily documentation of skin integrity Evaluation of sleep patterns and indications for delirium Care Preferences: A family/caregiver/decision maker and health care team meeting will take place within 72 hours of admission or, as soon as family arrives if after 72 hours, to discuss goals of care. Discussion will be done by admitting faculty or faculty member making rounds when family is available. Details of the discussion will be documented in the EMR and will include the following Patient s priorities and preferences regarding treatment options (including operative and nonoperative alternatives) Post injury risk of complications, mortality and temporary/permanent functional decline Advanced directives or living will and how these will affect initial care and life-sustaining preferences, including mechanical ventilation, cardiopulmonary resuscitation, hemodialysis, blood transfusions, permanent enteral feeding, and transition to comfort care should complications occur Identify family/caregiver primary point of contact and decision maker document in the chart Reason for family meeting held after 72 hours of admission Discharge Planning: Begin discussion for developing a plan for transition to post hospital care during the initial family meeting Assess the following discharge planning issues within 48 hours of admission Home environment, social support, and possible need for medical equipment and/or home health services Consider patient acceptance/denial of nursing home or skilled nursing facility placement
References: ACS TQIP Geriatric Trauma Management s Evidence Based Care of Geriatric Trauma Patients, Surgery Clinics of N. America (97) 2017