Medical Director Message April 2022

Dr. Jeffrey Luk

Geriatric Trauma - April 4, 2022

Dr Luk is the EMS Medical Director for departments under UH Cleveland Medical Center

Good morning,

Welcome to April! We will be focusing on geriatric trauma. Our objectives will be:

In developed countries, people over the age of 60 years are the fastest-growing age group and people are having a longer life expectancy. In addition, there is a declining birth rate occurring, and advances in chronic disease care are allowing people to live longer. As a result, the number of geriatric trauma patients is growing fast. 

Some details regarding geriatric physiology:

Next week we will take a look at some specific geriatric trauma situations and how the elderly patient is uniquely affected by those events.

Jeffrey Luk, MD

 Geriatric Trauma - April 11, 2022

Good morning,

Last week we discussed the anatomic and physiologic differences and this week we will focus on geriatric trauma.

The elderly experience much higher morbidity and mortality than the younger trauma patient. Up to one-third of geriatric trauma patients are expected to die if their Injury Severity Score is greater than fifteen. Pre-existing diseases lead to more severe injuries and alter their response to trauma. Co-morbid diseases can complicate recovery as well. Medications alter “normal” function and vital signs. Medications can lead to the event causing the injury, interfere with the patient’s ability to compensate for the injury, and lead to complications in the injured patient. A patient’s physiological age is the estimate of the patient’s age based on their body’s health and life expectancy. Very importantly, stable geriatric patients may become unstable, and non-lethal injuries may be lethal.

The four top mechanisms of injury for geriatric patients are: 

Falls are the most common cause of injury in patients over 65 years old. They are the underlying cause of 9,500 deaths per year and represent 75% of all geriatric trauma. The risk of falling over 65 years old is 27% in any given year. Twenty-five percent who fall sustain a significant injury, and most occur while on ground level. The incidence of males falling equals that of females, but females are more likely to be injured. Falls can be due to postural instability, medications, decreased vision, hearing, and reaction time. Injuries tend to include head injury and fractures of the hip, femur, and wrist. It is VERY IMPORTANT to determine whether a fall is a result of a syncopal episode (i.e., “faint and fall”) vs. a purely mechanical fall (i.e., “trip and fall”). If the patient suffered from a faint and fall, examination of the geriatric patient for the reason for the fall is of the utmost importance. a blood sugar and EKG should be done in the prehospital setting for these patients. For both types of falls, the standard trauma evaluation should be performed. 

Common sites for fractures are the humerus, wrist, and hip (i.e., pelvis, hip, and femur). Three percent of all falls cause fractures. Approximately 95% of hip fractures that occur in individuals over 65 years of age are the result of a fall. Patients with a hip fracture are 5-20% more likely to die in the first year following injury than any other reason in the same age group. Falls impact patients psychologically, including fear of injury, loss of confidence, decreased mobility and functionality, and loss of independence. 

MVCs are the second most common mechanism of injury among older patients. They are the most common cause of traumatic mortality. About 25% of the elderly sustain chest injuries with ribs being the most common. Rib fractures are significantly related to complications, including pneumonia and respiratory failure. Elderly individuals are second only to children in car vs. pedestrian events, and the highest mortality is an elderly pedestrian vs. car. Common causes of MVCs are poor vision, slower reaction times, and judgment changes. Older people are more easily tired, so driving long distances is a challenge. They potentially fall asleep at the wheel. However, alcohol intoxication as a cause for MVCs is usually not a problem in this age group. 

Forty-six percent of elderly trauma occurs at the cross-walk when a motor vehicle hits an elderly pedestrian since the average walk speed for a geriatric individual is 4 feet per second. This type of injury also frequently occurs in parking lots.

Next week we will continue to look at burns and spinal injuries in the geriatric trauma patient as well as how blood thinners affect our geriatric trauma patients.  

Jeffrey Luk, MD

Geriatric Burns and Head Trauma - April 18, 2022

Good morning,

This week we will discuss the devastating effects of burns and head injuries affecting the elderly. 

Mortality is significantly higher in older burn patients. Some statistics:

Burns are the third leading cause of dementia in the elderly and risk factors are multifactorial. Comorbid conditions, such as dementia, cardiorespiratory disease, smoking, and alcoholism are well-known contributors to the incidence and severity of burns. Even in otherwise healthy individuals, age-related declines in reaction time, mobility, mentation, hearing, smell, and visual acuity may impair risk assessment and lead to delays in escaping harm and accessing medical care. 

If a patient has other associated injuries in conjunction with burns, treat the other injuries first. Use the Rule of Nines to estimate the amount of burn. Fluid requirements = TBSA burned (%) x Wt (kg) x 4mL. Give 1/2 of the total requirements in 1st 8 hours, then give 2nd half over the next 16 hours. Early fluid resuscitation is critical in burn patients but uniquely challenging for older adults due to the precarious balance between under resuscitation (leading to intravascular collapse and organ failure) and fluid overload (leading to pulmonary edema and congestive heart failure).

Optimizing pain control in elderly burn patients can also be exceptionally difficult. There is poor tolerance of narcotics among older adults, and they are susceptible to delirium and over sedation. Fentanyl is the preferred analgesic as the metabolites are fewer, and it spares the cardiovascular system. Because of the skin changes, such as dermal atrophy, loss of dermal appendages, and thinning of subcutaneous fat, there is little protection against thermal insults among the elderly, which increases the likelihood of full-thickness injury. 

Many elderly people suffer from peripheral vascular disease and diabetes, and their slow wound healing and poor immunological response can lead to sepsis. Underlying respiratory disease is also common and may lead to prolonged intubation, particularly if superimposed on inhalation injury, acute respiratory distress syndrome, and/or sepsis. Limiting the period of intubation is desired as pulmonary infections (resulting in sepsis and multi-organ failure) are the leading cause of death among older adults with burns. 

Older people also suffer from frequent head injuries. Dura adheres tightly to the skull in the elderly. It stretches the bridging vessels and sets them up for subdural hematomas. An approximate 30% decrease in brain size occurs from ages 30 to 70 years. This brain atrophy increases the space for blood occupying lesions and delays symptoms that help in rapid diagnosis. Dementia in the elderly can also complicate assessment. Additionally, autoregulation declines and makes the elderly even more susceptible to hypotensive events in head injury.

The use of blood thinners also increases elderly patients’ risk for subdural hematomas and bleeding in the brain. They need an aggressive reversal of coagulopathy with medications, such as Vitamin K, fresh frozen plasma, and K centra. Treatment of brain bleeds depends on its size and the rate of growth. Small ones can be monitored as they are re-absorbed. Others may be evacuated by drilling a small hole through the skull and placing a small catheter and sucking out the hematoma. Large hematomas, or those causing symptoms, are treated via a craniotomy; the hematoma is removed and sites of bleeding are controlled. 

For spinal injuries, drastically less force is needed to cause fractures in the elderly. The absence of cervical spine discomfort or pain with or without palpation should NOT be used as the sole determinant that the patient’s cervical spine is without injury. High cervical fractures (especially of C1 and C2) are more common in the elderly and can occur with a minimal mechanism. A fall from a standing position is unlikely for a young person, but it is not uncommon in the elderly. There is also a higher instance of Central Cord Syndrome, which causes a deficit of strength and sensation in the upper extremities more than in the lower extremities. This syndrome is due to age-related narrowing of the cervical canal and vascular disease of spinal arteries. 

Next week we will conclude our discussion on geriatric trauma. We will look at some other common injuries as well as some special considerations for the geriatric trauma patient. 

Jeffrey Luk, MD

Geriatric Chest Trauma - April 25, 2022

Good morning,

This week completes our discussion on geriatric trauma. This week we focus on chest injuries. 

Rib fractures are the most common, and are more easily broken and underlying tissue is easily damaged. If more than three ribs are fractured, there is an increase in mortality. Rib fractures are associated with higher morbidity and mortality due to the physiological changes of osteoporosis, decreased muscle mass, thinned vertebral bodies, and decreased physiological reserve (i.e., low cardiopulmonary status and lower immunity). Rib fractures increase the risk of death by 19% and the incidence of pneumonia by 27% in geriatric trauma patients. Three-point restraint belts have been shown to cause significant chest trauma, and that which would otherwise be considered minor chest injury can be more significant in the elderly. 

The elderly will not show the same signs and symptoms in abdominal and pelvic injuries. Abdominal trauma will be influenced by a variety of factors, including the mechanism of injury and the patient’s overall condition. The abdominal exam is very unreliable, so it is recommended to use diagnostics liberally once evaluated in the emergency department. Elderly patients may not have tachycardia, even in the setting of significant blood loss. If the patient is normally hypertensive, normotensive blood pressure could represent a significant drop in blood pressure In addition, waiting to act for traditional hypotensive and tachycardic values in the elderly trauma patient could be catastrophic. Furthermore, pelvic fractures have a very high mortality rate; little impact is necessary for pelvic and hip fractures to occur.

Unfortunately, prehospital providers should also be cognizant of possible elder abuse. Signs and symptoms include frequent arguments or tension between the caregiver and the elderly person, changes in personality or behavior in the elder, or the attribution of changes to be symptoms of dementia or signs of the elderly person’s frailty — or caregivers may explain them to you that way. Elder abuse can take many forms, including physical abuse, emotional abuse, sexual abuse, financial exploitation, healthcare fraud and abuse, and neglect. 

For the general approach to the geriatric trauma patient, it is imperative to understand their past medical history and events leading to the injury. Manage the ABCs like any trauma patient; consider early intubation, anticipate myocardial compromise, and manage shock states. The elderly are UNDERTRIAGED as trauma patients. Comorbidities are often the inciting cause of the injury. A blunted pain response may hide injuries. Additionally, the response to pain medications will be exaggerated. Start low and go slow. You can always give more but cannot take away medications already given. 

When looking at the Classes of Shock, patients can lose up to 15% of their blood volume in Class I Shock, and all vital signs will be normal. In Class II Shock, 15-305 of blood volume will be lost. The heart rate may increase or stay the same. Typically, blood pressure will remain the same. Pulse pressure, however, will decrease. Do not attribute a narrow pulse pressure to machine or technological error. A narrow pulse pressure could mean that the patient is in Class II Shock. In Class III Shock, 31-40% of blood volume will be lost. The heart rate should increase, and the pulse pressure will be narrow. The blood pressure may decrease but also may be normal. Blood pressure changes in shock patients is a late finding. Do not wait for this to change before starting to treat the patient. Blood pressure does not definitively decrease until Class IV Shock when more than 40% of a patient’s blood volume decreases. If you wait for the blood pressure to change before treating the patient, you are already behind in treating the patient.  

Above all, remember that “normal vital signs” may be abnormal for geriatric trauma patients. A normal blood pressure could represent hypotension in patients whose blood pressure is usually hypertensive. Similarly, a normal heart rate could be tachycardic in elderly patients who have a low baseline heart rate, possibly due to being on beta blockers. 

In summary, geriatric patients have higher complication rates, higher mortality, and longer hospital stays for any injury when compared to younger patients. Their premorbid status is more important than chronological age. Consider early transfer to a trauma center. Consider why the accident occurred. Syncope may be responsible for almost 20% of MVCs involving elderly patients. If a geriatric trauma patient is discovered to be having a STEMI, hold all blood thinners, including Aspirin, until evaluation at the hospital. Falls and related injuries (e.g., fractures) are significant health hazards to the aging society. Identifying fall risk factors help evaluate the problems and plan personal and community intervention strategies. 

Jeffrey Luk, MD