EM Trauma 17: Elderly

Question 1

Define frailty

Answer 1

The state of decreased physiologic reserve and resistance to stressors.

Question 2

Most common cause of fatal and nonfatal injury in people ≥65 years of age

Answer 2

Falls

Question 3

Most common fracture in elders hospitalized for injury

Answer 3

Hip fractures
but the overal incidence of nonhip, nonspine fractures in women >55 y/o is 5x greater than hip fractures

Question 4

Leading cause of mortality in elderly

Answer 4

Motor vehicle crashes
with a case fatality rate twice that of those under 65 ya4rs

Question 5

Remarks on BP cutoffs in the elderly trauma

Answer 5

1. In blunt trauma patients ≥65 y/o, there is an association between hypotension and mortality starting with SBP <110 mm Hg and HR >90 bpm
2. A decrease in BP of 30 mm Hg below a known baseline or a falling trend is also a maker of instability

Question 6

TBI in the elderly

Answer 6

1. Elders are less prone to develop epidural hematomas than the general population because of the denser fibrous bond between the dura mater and the inner table of the skull.
2. There is, however, a higher incidence of subdural and intraparenchymal hematomas in the elderly
3. Immediate non-contrast head CT is recommended for patients who take warfarin or clopidogrel and have a minor head injury mechanism, even if asymptomatic

Question 7

Remarks on cervical spine injuries

Answer 7

1. Odontoid fractures are particularly common in geriatric patients.
2. The CCS rule, but not the NEXUS criteria, excludes patients age ≥65 from being considered low-risk for cervical spine injury
3. Thus, liberal imaging of the cervical spine in geriatric pateints is warranted.
4. Many fractures in one section of the spine are accompanied by fractures in another secdtion, so identification of one fracture should prompt imaging of the entire spinal column

Question 8

These account for almost half of all osteoporotic fractures

Answer 8

Thoracic and lumbar spine fractures.
- most common at the thoracolumbar junction (T12-L1) and midthoracic areas (T7-T8)

Question 9

Most common pelvic bone fracture

Answer 9

Pubic ramus

Question 10

Most common pelvic fracture mechanism

Answer 10

lateral compression

Question 11

single most common injury diagnosis that leads to hospitalization in the elderly

Answer 11

Hip fractures
- significant cause of mortality, with about 25% of elderly patients dying within a year of injury
- Femoral neck (intracapsular) and intertrochanteric fractures are about equally common, with subtrochanteric fractures comprising the remaining 5% to 10%

Question 12

Most common fractures in women up to age 75

Answer 12

Distal radius fractures (Colles’ fractures)
with a lifetime risk of about 15%

Question 13

Remarks on shoulder injuries

Answer 13

Note that the initial 18 degrees of shoulder abduction are generated by the supraspinatus muscle, so movement in this range may still be possible with an axillary nerve injury.

Question 14

Useful initial indicators of shock in the elderly

Answer 14

Base deficit and lactate levels
BASE DEFICIT
-3 to -5 - mild
-6 to -9 - moderate
≤10 - severe
*vital signs are an unreliable marker of shock in the elderly

Question 15

Most important determinants of morbidity and mortality in head injury

Answer 15

The volume of intracranial blood and hematoma expansion

Question 16

Remarks on rib fractures in the elderly

Answer 16

1. Maintain a low threshold for admitting elderly patients with rib fractures for a period of observation until good pain control and pulmonary toilet are ensured
2. Pain control after chest wall trauma is vital to encourage ventilation in order to reduce atelectasis and the risk of infecdtion

Question 17

Remarks on disposition of elderly trauma patients

Answer 17

1. Have a low threshold for admitting geriatric trauma patients.
2. ICU: polytrauma, significatn chest wall injuries, abnormal vital signs, evidence or occult hypoperfusion