Geriatic Trauma

Dr. Dody Firmanda, SpAn

Definisi
Gerontologi : ilmu yang mempelajari proses menua &
semua aspek biologi, sosiologi yang terkait dg proses
penuaan
Geriatri : cabang ilmu kedokteran yang menitikberatkan
pada pencegahan,diagnosis,pengobatan dan pelayanan
kesehatan pada usia lanjut

Penuaan
Suatu proses menghilangnya secara perlahan-lahan
kemampuan jaringan untuk memperbaiki, mengganti diri
dan mempertahankan struktur dan fungsi normalnya.
Dengan demikian menua ditandai dengan kehilangan
secara progresif lean body mass (LBM = jaringan aktif
tubuh) yang sudah dimulai sejak usia 40 tahun disertai
dengan menurunnya metabolisme basal sebesar 2% setiap
tahunnya yang disertai dengan perubahan disemua sistem
didalam tubuh manusia.

KARAKTERISTIK
PASIEN GERIATRI

1. Usia > 60 tahun

2. Multipatologi
3. Tampilan klinis tidak
khas
4. Polifarmasi
5. Fungsi organ menurun
6. Gangguan status
fungsional
7. Gangguan nutrisi

FISIK

FUNGSIONAL
PSIKO
- LOGIK

SOSIO EKONOMIK

FAKTOR-FAKTOR BERINTERAKSI SECARA KOMPLEKS

SINDROM GERIATRI
Kumpulan gejala dan atau tanda klinis, dari satu atau
lebih penyakit, yang
pasien geriatri.

sering dijumpai pada

- Perlu penatalaksanaan segera

- Identifikasi penyebab
- Comprehensive geriatric assessment

SINDROM GERIATRI
Immobility
Instability
Incontinence
Intellectual impairment --- DEMENSIA
Infection --- PNEUMONIA
Impairment of hearing & vision
Isolation (depression)
Inanition (malnutrition)
Impecunity
Iatrogenic
Insomnia
Immune deficiency
Impotence
Irritable colon

Perubahan komposisi tubuh & fisik usia

lanjut
Masalah medis

Immobility
instability
intellectual impairment
insomnia
Isolation / depression
Impotence
incontinence

inanition
Iritabel colon
immune deficience
infection
impairment of vision &
hearing

Iatrogenic
impecunity

Rapuh rentan thd peny

Mati

Bagaimana Proses Menjadi Tua?

GENETIK
Gaya hidup

LINGKUNGAN

Sel menjadi
Mengkerut
Jaringan menjadi
Rusak
Organ tubuh
Menjadi tua

INTERNAL FACTORS
GENETIC
BIOLOGICAL

NORMA
L
AGING
EXTERNAL FACTORS
ENVIRONMENT LIFE STYLE
SOCIOCULTURAL
ECONOMIC
Boedhi Darmojo (modified)

Teori Radikal Bebas

Radikal bebas : senyawa kimia yg berisi elektron yg tidak
berpasangan
Produk sampingan berbagai proses selular atau
metabolisme normal yg melibatkan O2
Bersifat merusak, sangat reaktif, dapat bereaksi dengan
DNA, protein, asam lemak tak jenuh
Contoh : superoksida (O2), hidroksil (OH), peroksida
hidrogen (H2O2)

Teori Glikosilasi
Proses glikosilasi nonenzimatik, yg menghasilkan
pertautan glukosa-protein advanced glication end
products (AGEs)
AGEs menyebabkan penumpukan protein & makromolekul
disfungsi pada hewan/manusia yg menua
AGEs berakumulasi di jaringan (kolagen,hemoglobin,lensa
mata)
Jaringan ikat kurang elastis & kaku

Teori DNA repair

Dikemukakan Hart & Setlow
Ada perbedaan pola laju repair kerusakan DNA yg
diinduksi sinar UV
Spesies yg mempunyai umur terpanjang laju
DNA repair terbesar (mamalia & primata)

Pemanjangan Telomer
Setiap sel mempunyai kemampuan untuk
membelah (50 kali)
Setiap sel membelah, telomer semakin pendek
Akhirnya telomer tidak dapat memendek lagi
kematian sel (proses menua)

Kromosom -- Telomere

Kematian sel/apoptosis

Banyak teori proses menua

Aging by program
Teori gen & mutasi gen
Cross-linkage theory
Teori autoimun, dll
Tidak ada 1 teori tunggal yang dapat menjelaskan seluruh
proses menua

Implikasi Klinik Proses Menua

ORGAN
Paru-paru

Saluran
nafas

PERUBAHAN
Daya pegas dinding dada menurun
Kekuatan otot pernapasan menurun
Kekakuan iga meningkat
Daya pegas jaringan elastik paru
menurun
Paru-paru lebih mengembang,
namun kaku

Refleks batuk menurun

Mudah tersedak
Gerakan bulu getar melambat

Jantungpembuluh
Implikasi
darah

Katup jantung kaku

Jumlah sel pacu berkurang
Sistem konduksi menurun
Penumpukan jar. Ikat di otot jantung
kaku
Pembuluh darah kurang lentur
TD
naik
Isi sekuncup menurun; curah jantung
ber<

Klinik Proses Menua

Ginjal

Jumlah nefron, glomerulus <

Fungsi filtrasi menurun
Kepekaan tubulus terhadap ADH <
Reabsorbsi <
LFG menurun 7,5 mL/m/dekade

Tulang, sendi,
otot

Keropos, cairan <, massa otot <, cairan

sendi <, tulang rawan mulai rusak

Implikasi Klinik Proses

Menua
Produksi
air liur <
Saluran

Osteoporosis tulang rahang, gigi

cerna
tanggal
Gerakan kerongkongan & lambung
melambat
Produksi enzim pencernaan <
Gerakan usus besar <
Saluran Kemih & Kelenjar prostat membesar
Kelamin
Selaput mulut rahim kering
Otot dasar panggul melemah
Susunan Saraf
Pengerasan pembuluh darah otak
Pusat
Demensia (neurofibril tangie,
amyloid)
Mengisut (atrofi)

Sistem
Cardiovascular

Perubahan fisiologis
normal
Pe elastisitas arteri :
Pe afterload
Pe Tek.darah sistolik
Hypertropi ventrikel kiri
Atherosklerosis
Penyakit Jantung
koroner
Hypertensi essensial
Congestive Heart
Failure
Cardiac Aritmia
Stenosis Aorta
Pe aktifitas adrenergic :
Pe Resting HR

Patofisiologi
yang sering ada

Sistem

Perubahan fisiologis normal

Respiratory

Pe elastisitas paru :
Pe luas permukaan alveolar

Pe Volume residual

Pe Closing Capacity

Ventilasi / perpusi yang tidak

sesuai.

Pe tekanan O2 atrteri

Emphisema

Bronkitis kronik

Pe
Pe

Pneumonia
kekauan dinding dada
kekuatan otot :
Pe Batuk

Pe Kapasitas maksimal
pernapasan
Kurang respon terhadap hiperkapni
dan hipoksia

Patofisiologi yang
sering ada

Sistem
Ginjal

Perubahan fisiologis normal

Pe Aliran darah ginjal :
Pe Aliran plasma ginjal

Pe GFR

Nephropati Diabetik

Nephropati Hipertensi

Obstruksi prostat

Congestive Heart Failure

Pe Masa ginjal
Pe Fungsi tubulus :
Penangan Na yang lemah

Penangan cairan yang lemah

Pe Kemampuan mengkonsentrasi

Pe Kapasitas dilusi

Pe Ekskresi obat

Pe Respon Renin-Angiotensin :
Gangguan ekskresi Kalium

Patofisiologi yang sering ada

 Peningkatan resistensi insulin menjadi penyebab terjadinya penurunan yang progresif

dalam kemampuan untuk mengatasi peningkatan glukosa dalam tubuh.
Respon neuroendocrine terhadap stress tampaknya dipertahankan atau sedikit
menurun dibandingkan dengan pasien tua yang masih sehat.
Penuaan dihubungkan dengan penurunan respon terhadap obat-obat -adrenergik
(endogenous blockade). Kadar norepineprin dalam sirkulasi dikatakan akan
meningkat pada pasien-pasien tua.

FUNGSI GINJAL.
RBF dan masa ginjal (spt. Jumlah glumerulus dan panjang tubulus) menurun sesuai dengan Usia.
Perubahan yang mencolok terutama terjadi kortek ginjal dimana disini akan diganti oleh lemak dan
jaringan fibrosis. Fungsi ginjal ditentukan oleh GFR dan penurunan kreatinin serum menjadi
menurun (tabel 45-2).
Kadar kreatinin serum tidak berubah dikarenakan adanya penurunan masa otot dan produksis
kreatinin. Sebaliknya kadar BUN (Blood Urea Nitrogen) perlahan meningkat (0.2 mg/dL per tahun)
Gangguan terhadap pemeliharaan natrium, dan kemampuan untuk mengkonsentrasi dan
kemampuan dilusi mempengaruhi pasien-pasien tua untuk terjadinya dehidrasi atau kelebihan cairan
(Fluid Overload).

 Respon terhadap hormon antidiuretik dan aldosteron menurun.

Kemampuan untuk reabsorbsi gula menurun.
Kombinasi antara penurunan RBF dan dan penurunan masa nefron, meningkatkan resiko
pasien tua untuk terjadinya ARF pada periode post operatif.
Karena menurunnya fungsi ginjal, yang mempuyai fungsi untuk mengekskresikan obatobatan.
Menurunnya kemampuan dalam menangani cairan dan elektrolit, membuat penanganan
atau penatalaksaan terhadap cairan harus lebih kritis/serius; pasien tua lebih cenderung
terjadi hypokalemia dan hyperkalemia. Ini merupakan Komplikasi lebih lanjut terhadap
seringnya penggunaan diuretik pada pasient tua.
Pada akhirnya elektrolit serum, Cardiac Filling Pressures, dan output urin harus lebih
sering di monitor.

FUNGSI GASTROINTESTINAL.
Massa hati menurun pada orang tua sesuai juga terjadinya penurunan aliran
darah ke hati (Hepatic Blood Flow). Dan Fung hati (cadangan) menurun sesuai
dengan penurunan masa dari hati. Sehingga biotransformasi dan produksi
albumin menurun.
Kadar Choline esterase plasma menurun pada laki-laki tua.
pH lambung cenderung meningkat, sedangkan pengosongan lambung
memanjang. Walaupun menurut bebarapa penelitan pada pasien-pasien tua
mempunyai volume lambung yang rendah dibandingkan dengan pasien muda.

SISTEM SARAF.
Masa otak menurun sesuai dengan usia; neuron yang berkurang menonjol di kortek
cerebral, terutama lobus frontal. CBF menurun sekitar 10 20% sesuai dengan
berkurangnya sel saraf. Ini berhubungan erat dengan metabolisme ; autoregulasi masih
baik. Neuron menurun dalam ukuran dan kehilangan beberapa kompletisitas dari
cabang-cabang dendrit dan jumlah sinaps. Pembentukan beberapa neurontransmiter
seperti dopamin dan sejumlah reseptor berkurang. Ikatan Serotonergic, adrenergic dan
amino-buteric acid (GABA) juga berkurang. Jumlah sel Astrocyt dan sel mikroglia
meningkat.
Degradasi sel-sel saraf perifer mengakibatkan panjangnya kecepatan konduksi dan
atropi dari otot skeletal.
Penuaan dihubungkan dengan peningkatan threshol / ambang dari hampir semua
sensorik, termasuk sentuh, sensasi temperatur, propioseptif, pendengaran dan
penglihatan. Perubahan presepsi nyeri adalah sangat komplek dan masih belum dapat
dimergerti benar. Proses Mekanisme di pusat dan perifer seperti perubahan.

 Dosis yang diperlukan diturunkan untuk anestesi lokal (Minimum anesthetic

Concentration) dan anestesi General (Minimum Alveolar concentration). Pada pasien
usia tua pemberian anesthesi epidural cenderung menyebar ke arah cephal, tetapi dengan
durasi analgetik dan blok motorik yang pendek. Lamanya duration of action harus
dipikirkan pada spinal anesthesi.
Bila tidak ada penyakit penyerta, penurunan fungsi kognitif adalah normal, tetapi berbeda
setiap orang. Memori jangka pendek yang biasanya paling sering terganggu. Aktivitas
secara fisik dan intelektual yang berkelanjutan tampaknya mempunyai efek yang baik
terhadap pemeliharaan fungsi kognitif.
Pada pasien yang sudah tua memerlukan waktu yang lebih lama untuk pemulihan sistem
saraf pusat dari efek tindakan anesthesi umum, terutama pada mereka yang mengalami
kebingungan dan disorientasi pada preoperatif. Ini merupakan hal penting pada pasien
geriatik yang akan dilakukan tindakan pembedahan rawat jalan, dimana faktor sosioekonomi
yang merupakan faktor utama/tertinggi yang menyebabkan pasien diharuskan dirawat
dirumah.
Banyak pasien tua/geriatri mengalami bermacam-macam derajat dari Acute confusional
state, delirium atau gangguan Kognitive setelah pembedahan.

 Penyebab dari Disfungsi kognitif postoperatif (POCD = Post Operative Cognitive

Dysfungsion) adalah multifaktor dan termasuk efek obat, nyeri, demensia,
hypotermia dan gangguan metabolik.
Rendahnya kadar neurotransmiter utama, seperti asetilkolin, mungkin juga
memberikan kontribusi.
Pada pasien tua terutama sensitif terhadap obat obat bekerja sebagai anti
kolinergik yang bekerja dipusat seperti scapolamin atau atropin.

MACROSCOPIC CHANGES OF AGING BRAIN

ADULT BRAIN

AGING BRAIN

Patients Condition during the Final

Days and Hours

Fatique
Anorexia
Dehydration
Dysphagia
Death rattle-noisy breathing
Apnea, Cheyne-Stokes respiration,dyspnea
Urynari or fecal incontinence
Agitation or delirium
Dry mucosal membrane

Cardinal sign of death

Cessation of cardiac function and respiration

Pupils become fixed

Body becomes cool
Ashen white and waxy
Muscle relax
Incontinence

What is Geriatric Trauma?

No. 5 cause of death for age > 65.
Mortality in most series averages 15 to 30%.

4 to 5 X mortality of younger patients.

Mortality start to increase at age 45 for males.
ACS - MTOS

Geriatric Trauma - Questions

What is old?
Does age matter and what age?
Physiology of aging.

Triage of elderly trauma victims.

Injury patterns and physiologic responses.

What is the optimal resuscitation of the older trauma
patient?

Outcomes in the elderly trauma patient?

Geriatric Bias
Documented bias in medical care:

Rehabilitation placement.
Breast cancer management.
Thrombolytics.
Trauma triage.

Therapeutic Nihilism

Epidemiology
Age > 65: 12.5% population (30 million)
2020 - 52 Million (20% population)
At age 85 life expectancy is 5 to 7 years.
Better health and increased activities.
65+ are hospitalized for trauma at 2X the rate of younger patients
25% of all trauma deaths
ICU beds 15% of all hospital beds and 30% of hospital costs

Epidemiology
>65 use 33% of all health care dollars and 25% of all
trauma care money.
Medicare - DRG based- grossly underpays hospital costs
for trauma, esp. in the elderly
Avg. reimbursement 40 to 65% of total hospital costs.
Increased age and ISS - worse reimbursement.

Geriatric Recidivists
Washington state Medicare population.
> 65 injured - 2X more likely to be admitted with a new injury
than uninjured person in next 24 months.
ISS 16 to 24 - new injury risk 4x normal population.
Inc risk in patients with COPD, liver disease, age.

J. Trauma 1996: 41(6) p. 952

Physiology of Aging
Aging is the progressive loss of individual organ function.
Gradual and continuous.
Not directly related to age.
Significant age related mortality differences are apparent by age
40 in males.
Co-morbidities: 15% at age 35, 70% at 75.

J. Trauma 1990: 30(12) p. 1476

Physiology of Aging
The extent of physiologic alterations and he onset of those
alterations are highly variable.

Most elderly well compensated for changes

in aging but have very limited physiologic reserve that
becomes evident during times of stress or illness.

Cardiovascular
Most prominently affected.
Myocardial degeneration:

Inelastic heart - decreased cardiac output.

Diastolic dysfunction.
Altered conduction system
Maximal HR decreases
Beta adrenergic receptor function decrease.
Coronary artery disease.
Hypertension - Meds

Pulmonary System
Decreased functional reserve.
Thoracic cage - more brittle, stiff.

Decreased compliance
Increased work of breathing.
Dec. alveolar ventilation
Inc. V/Q mismatch.

Renal System
40 to 50% nephron loss by age 65.

RBF decreases to 50%

Dec. GFR, CrClr.
Serum creatinine - poor indicator of renal function.
Dec ADH sens, dec. thirst - chronic dehydration.

Musculoskeletal
Dec. muscle mass and strength.
Progressive deterioration of cartilage and ligaments
starts at age 30.
Age related bone loss.

Dec. reaction times.

Widened, unsteady gate.

Misc.
Glucose intolerance.
Dec. LBM, BMR, need for calories.
Need for other nutrients unchanged.
Vit A, Vit C, Zinc deficiencies.

Immune senescence

T cell and B cell function.

Misc.
Thyroid hormone dec, tissue response decreases.
Increased intra-cranial space - atrophy.
Increased movement of brain during injury.
Increased risk of subdural hematomas.
Decreased cognitive ability, memory and judgment.
Senescence of senses

Etiology of Trauma
Age 65 to 75 - MVCs - most common
Elderly have the highest rate of accidents / miles driven
Age 75+ - falls number one.

MV vs Pedestrians
Suicide - biphasic incidence

Increasing incidence in males >65.

Increased incidence of penetrating trauma, elder
abuse.

Falls
Most common mechanism overall.

65+: 30 % sustain a fall each year requiring medical treatment

85+: 50 % fall each year
40% of all nursing home admissions related to falls.
Most falls are single level or low bilevel.

J. Am. Geriatric Soc. 1986: 34 p 119

Falls
Risk Factors

Dementia, visual impairments

Lower extremity and foot diseases
Gait and balance problems.
Meds, med. problems, postural hypotension, neuro- muscular
disease.

Usual falls - ladders, roofs, stairs

Injury patterns are more severe for all levels of falls.

Falls

Population based study:

336 people average age 78
108 (32%) fell in past year
48% - once, 29% - twice, 25% - three +
77% falls at home.
Risk factors:
sedative use
- Palmomental reflex
Cognitive impairment - Foot problems
LE disability
- Balance / gait

NEJM 1988: 319(26) p.1701

Falls
Falls: 159 / 333 adms- age 65+ (48%)
83 falls age < 65 (7% total)
ISS > 15: 50(32%) elderly, 12 (15%) young.
Falls are 2/3 of all elderly w ISS > 15
Same level w ISS >15 - old (30%), young (4%).
Fall deaths: 11 (7%), younger - 4%
11/20 deaths overall due to falls (55%)

J. Trauma 2001: 50(1) p. 116

MVCs
Age 75+ - second highest crash rate
Highest accident rate per miles driven.
Highest fatal accident rate.
Changes in perception, judgment, decision making ability
and reaction times.

MV vs pedestrians:
Most severe of all elderly injuries.
Highest fatalities
Majority occur in cross walks.

MVA- Driver Characteristics

I year period - Level 1 trauma center
84 drivers age >60
67/ 84 (80%) - at fault according to police.

Running stop signs, red lights, failure to yield - most common

35 ( 42%) - single car crash.
Daytime- 80%
Good weather - 95%
ETOH - 5%
Low speed / intersections common

Am.Surgeon 1995: 61(5) p. 935

Elderly Abuse
Estimated 1 million cases / year.
Physical violence
May not be as apparent as child abuse.
Emotional abuse
Threats of abandonment or institutionalization.
Material exploitation.
Neglect (may be unintentional)
Dehydration / malnutrition, mental status changes.

Elderly Abuse
2020 elderly - 3.7 % reported abuse
2.2% physical, 1.1 % emotional
2/3 spouse, 1/3 adult child

Risk Factors
Physical frailty and cognitive impairment.
Living with abuser
Substance abusers, mental disease.
Adult kids who are financially dependent.

Mortality -Factors
Consistent

TS (< 7)
SBP < 90
Shock
RR < 10
Head injury
Base deficit

Less Consistent

ISS

Male sex
Ped vs MV
Non trauma center
admission
PEC

Pulmonary complications
J. Trauma 1998: 45(5) p 873, J. Trauma 1990: 30(12) p 1476 J. Trauma 1999: 46(4) p 702
CCM 1986: 14(8) p 681 Arch. Surg 1994: 129(4) p 448, J. Trauma 2002: 52(1) p 79

Pre Existing Conditions

Elderly patients are more likely to have underlying
medical problems that affect survival.
PECs may affect survival independent of age or injury severity.
May be underlying cause of an injury.
Need to be treated aggressively.
Coumadin does not adversely effect mort.

PECs
Hepatic*
Renal*

ARF as a complication is the most lethal.

Cancer*
CHF
COPD
Diabetes
J. Trauma 1992: 32(2) p 236
Dementia
1998: 45(4) p 805

2002: 52(2) p 242

Triage
Philips - Florida- statewide
Overtriage 7.5%, undertriage - 71%
Triage tool identified only 103 / 355 major trauma patients.
< 65 - 11% / 33%.
Triage guidelines were most sensitive to GSW and least sensitive to
falls.

J. Trauma 1996: 40(2) p 278

Triage
Compliance studies:
MD - statewide study
Injury factors- high compliance
Physiology, mechanism - poor.
15- 54 - 2X more likely to be triaged to a TC.
Compliance decreases with increasing age.
Portland - city wide study
Undertriage- 21% (< 65- 15%, >65- 56%)
Non TC deaths- elderly with ISS 1- 9

J. Trauma 1995: 39(5) p 922; 1999: 46(1) p 168

Brain Injury and the Elderly

Age related mortality increases sharply at age 60+.
Prognosis depend on initial severity and age.
Subdural, contusions and SAH more likely.
Epidural, skull fractures - uncommon.
2 or 3 injuries common on CT scan
High incidence of associated injuries- chest most common,
cspine, upper extremities.

Brain Injury and the Elderly

GCS < 7 - high mortality, survivors are all severely
disabled or PVS.
Death rate is biphasic.
Early from head injury, late from MSOF

Arch.Surg. 1993: 128(7) p 787

J. Trauma 1996: 41(6) p 957

Rib Fractures
Very common injury in elderly- due to brittle rib cage
Most commonly due to MV vs peds, MVCs.
Compared to younger patients

ISS same
Increased mortality, ICU days, LOS, Vent days.
Mortality increased at 5 ribs fxs. (35% vs 10%)
Mortality decreased with epidural use.

J. Trauma 2000: 48(6) p 1040

In younger patients, nature often

saves the day after minor surgical
errors. In the aged, every error
is a major danger in life.

Aging and Surgery

1921: Oschner

Herniorraphy was not indicated in patients greater than age 50.

Currently - age 65+ in general surgery:
1/3 of all operative cases.
50% of all surgical emergencies.
75% of all operative deaths.

Surgical Risks
148 patients for elective surgery - all cleared by internistshad preop swan.
20 had normal physiology - no mortality.
94 had mild to moderate dysfunction - 8.5% operative mortality.
34 had severe dysfunction
7 had lesser ops- survived.
8 had scheduled surgery- all died.

Preop evaluation did not correlate with physiologic

parameters

JAMA 1980: 243(13) p 1350

Initial Evaluation
History
PMH
Premorbid functioning
Medications
Drug - drug interactions, cause of injury
PMD

Initial Evaluation
Physical Exam:
Elderly patients have less dramatic physiologic response to injury.
Don't be fooled by a patient that appears to be stable and
minimally injured.
80 yo female in MVA, no bleeding, poor perfusion status but BP, HR
ok. Swan- CI of < 1L/min

Resuscitation
Very little literature on trauma resuscitation in elderly
patients.
Contradictory
Not very current
Need for better studies
Avoid therapeutic nihilism

Preop Monitoring
70 patients with hip fractures
randomized to preop monitoring and optimization with SG
catheter
Nonmonitored- 67 (40 to 89)
Monitored - 78 ( 40 to 95)
No difference in premorbid conditions.
Mortality was 2.9% vs 29%
Cause of deaths not listed
Operation was at 3.5 days vs 7 days

J. Trauma 1985: 25(4) p. 309

Resuscitation
1985- 60 elderly trauma patients at Kings County - 44%
mortality, 85% in high risk.
Ped vs MVA, SBP < 130, acidosis (pH < 7.3), head injury, multiple
fractures.

1986 - invasive monitoring - ED to ICU was 5.5 hours - 93%

mortality
1987 - Monitoring early before diagnostic workup - ED to ICU47% mortality

J. Trauma 1990: 30(2) p. 129

Resuscitation
CI < 3.5 L / min or MVO2sat < 60 %

Fluids, blood, inotropes, afterload reducing agents.

Hct- 35%
CI > 4L / min.
Increased mortality
ISS not calculated.
No group comparisons available.
Hayes, MA: NEJM: 1994 330(24) p 1717

J. Trauma 1990: 30(2) p. 129

Therapeutics
Imaging.
Early and often.
Early tracheostomy?

Pain management

Epidurals ?
Vena cava filters ?

Pain Management
Myth: Elderly patients experience less pain
Realities:
Acute and chronic pain is common in the elderly.
Pain in the elderly is often under diagnosed and under
treated.
Pain is often responsible for agitation, delirium and
depression.

Pain Management
Narcotics - elderly are more sensitive to pain relieving
aspects.
MSO4 - still gold standard.
Altered pharmacodynamics - inc. half life.
Need bowel regimen with narcotics.
Avoid Darvon (propoxyphene), Talwin (pentazocine), Demerol
(meperidine) and long acting drugs.

NSAIDs - side effects more severe and common in elderly.

Outcomes

Oreskovich: 100 patients over 60 over a 2 year period at a

Level 1 trauma center.
age 74
Falls 64%
Independent- 94%
MVC 8 %
Home assistance- 6% MVC vs Ped 9 %
ISS - 19
Burns 13%
Mortality- 15%
Assaults - 4%
Discharge:
Independent 8 %, Home assist. 20%, NH 72%

J.Trauma 1984: 24(7) p. 565

Outcomes
vanAalst - 98 pts age 65+ with ISS >16
48 alive 1 to 6 yrs later (49%)
Assessed independence and functionality.

Ind / Maintained - 8
Ind / declined - 24
Moderately dependent - 10
Custodial - 6

J. Trauma 1991: 31(8) p. 1096

Outcomes
DeMaria - 63 patients, 97 % independent
Discharge:

33% independent, 37 home but dependent

19 (30%) to NH
12/19 NH patients went to home after 3-4 months.
Age 80 + survivors , n = 12.
4 required permanent NH
8 home independent or with assistance.

J. Trauma 1987: 27(11) p. 1200

Outcomes
Why the big difference between Oreskovich and vanAalst /
DeMaria?
Falls- 66% falls vs <40%
Falls are a marker of severe underlying cardiac, pulmonary and
neurologic diseases.

Death may often be preceded by a cluster of falls.

No 1 cause of NH admissions (40%)

Outcomes
Battista - 23% mortality / 93 independent
47% of survivors dead at 2.5 years
83% of those alive at home alone or with family.
10% retirement home, 4% at NH.
Shapiro - 22% mortality
53% home
14% home assistance
20% rehab
8% NH

J. Trauma 1998: 44(4) p.618, Am. Surg. 1994: 60(9) p.696

Summary / Recommendations
Advanced age is associated with increased mortality at all
injury levels.
Elderly have higher ISS for comparable mechanism of injury.
There may be fewer physiologic abnormalities than expected for
injuries.
PEC are associated with worse outcomes for each level of injury.

Summary / Recommendations
Elderly trauma victims should be triaged to trauma
centers
There should be a lower threshold for activation of the trauma
team for elderly trauma patients.
Blood gas analysis should be obtained for any patient with a
significant injury or mechanism.

Summary / Recommendations
Aggressive hemodynamic monitoring and resuscitation
may be beneficial in the elderly trauma patient.
Shock, BD < -6
AIS > 3, high risk mechanism of injury
Uncertain cardiac or volume status
Optimize cardiac output and O2 delivery.

Recommendations
Advanced age alone is NOT a predictor of poor outcome
and should NOT be used as a factor to deny or limit care.
Up to 85% of survivors may return to independent living.
Limiting care may be considered when:
GCS < 8 TS < 7 RR < 10