Background and Pathophysiology:
- Comorbidities, physiologic changes, and medication-associated effects leave elderly patients more susceptible to injury from “minor” mechanisms. Diminished functional reserves decrease compensatory ability for any injury, regardless of severity.1
- Despite adjustments for injury severity, significantly increased mortality occurs ≥70 years regardless of mechanism, compared to younger counterparts. ATLS and many prehospital guidelines recommend >55 years criteria for referral to a dedicated trauma center due to lack of clear age cutoff in existing data/studies.2
- In patients ≥65 years, falls are the most common cause (>75% of all trauma), followed by motor vehicle crashes. Despite a “benign” mechanism, falls lead to dire medical economic and quality of life consequences for older patients, who sustain more injuries of all types, compared to younger patients.3
- 5% of adults aged ≥65 years report at least one fall in the past year, and 10.2% of those report a fall-related injury. More than 1/3 of geriatric trauma patients presenting to the ED after a fall return to the ED or die within one year of initial evaluation.4
- Elderly patients, who comprise only 8-12% of total ED major trauma cases, represent a disproportionate 15-30% of trauma mortalities and costs.5
- Compared with hospitalization due to other conditions, hospitalizations from falls resulting in a hip fracture or other injuries lead to worse outcomes and greater chance of nursing home admissions.6
Assessment and Initial Evaluation: What’s different?
- Geriatric Trauma is highly under-triaged due to traditional triage tools that are insensitive for signs of injury in older patients (vital signs, mechanisms of injury, ACTLS criteria). Multiple studies suggest activating Trauma Teams for all trauma patients ≥70 years old regardless of mechanism/vital signs, due to the physiologically blunted responses to hypoxia, hypercarbia, and acidosis.7
- History and physical examinations of geriatric trauma patients are less sensitive for injury compared to younger counterparts
- Traumatic brain injury is common in older adults, can occur with minimal head trauma, and may be asymptomatic.
- In the thorax, there is a higher risk for sternal and rib fractures, pulmonary contusions, and pneumothorax, and an increased risk for pneumonia.
- In the abdomen, the goal is early diagnosis, close monitoring, as examination can be unreliable. FAST should be part of the initial evaluation, with a low threshold to obtain advanced imaging.
- Extremity fractures are more common due to osteopenia.
- Vertebral Fractures/Spinal cord injury (SCI): cervical spine fractures can occur from seemingly minor mechanisms (including fall from standing). Age-related changes to vertebrae, intervertebral disks, and the spinal canal place older adults at greater risk of fractures, resulting in a greater likelihood of SCI. Liberal CT use is advocated.8
Primary and Secondary Surveys:
Trauma examination for all Geriatric Trauma should include:
- Airway / Breathing: should intubation be required, the dose of induction drugs, even etomidate, may require reduction by ~30-50% to minimize risk of cardiovascular depression in this age group.9
- Circulation: Recognizing shock can be more difficult, as older patients can present with a “normal” blood pressure that actually represents relative hypotension. Mortality increases in Geriatric Trauma when the heart rate rises above 90/min, while the same increase is not evident in younger counterparts until heart rate reaches 130/min.10 Evaluate other signs: mental status, capillary refill, tachypnea, and urine output. Adjuncts should evaluate occult shock (e.g., VBG, lactate, base deficit).
- Disability: GCS is a less sensitive indicator in geriatric patients.
- Ensure all Geriatric trauma patients are gowned on arrival and examined carefully from head-to-toe regardless of mechanism/vitals.
- Assess medications that can compromise initial evaluation and further care (anticoagulants, antiplatelets, antihypertensives, antiglycemics, etc.).
Management and Disposition Considerations:
- All patients who present after a fall need a complete trauma assessment, in addition to evaluating potential triggers/cause of the fall (e.g., syncope)
- The window to intervene is narrow in Geriatric trauma patients. Do not delay recognition of shock through false reassurance of “normal” vitals: VBG, lactate, and base deficit should be used as adjunct to VS early, and ECG may be necessary for subtle signs of ischemia
- Increased incidence of intracranial bleeding and cervical injuries, even in minor cases, should prompt liberal CT scanning use.11
- Geriatric trauma patients require increased immediate and delayed ICU resources compared to younger counterparts with the same injuries.12
- Anticipate ambulatory needs, assist devices, PT/OT, pain control strategies, and care coordination early as part of disposition planning12
1.Perdue &al. Differences in mortality between elderly and younger adult trauma patients: geriatric status increases risk of delayed death. J Trauma. 1998;45:805.
2. Caterino &al. Identification of an age cutoff for increased mortality in patients with elderly trauma. Am J Emerg Med. 2010;28:151.
3. Sterling &al. Geriatric falls: injury severity is high and disproportionate to mechanism. J Trauma. 2001;50:116.
4. Liu &al. Frequency of ED revisits and death among older adults after a fall. Am J Emerg Med. 2015;33:1012-1018.
5. CDC Data and Statistics (WISQARSTM): Cost of Injury Reports Data Source: NCHS Vital Statistics System for Numbers of Deaths. https://www.cdc.gov/injury/wisqars/index.html.
6. Gill &al. Association of injurious falls with disability outcomes and nursing home admissions in community-living older persons. Am J Epidemiol. 2013;178:418-25.
7. Demetriades D &al. Old age as a criterion for trauma team activation. J Trauma. 2001;51:754.
8. Goode &al. Evaluation of cervical spine fracture in the elderly: can we trust our physical examination? Am Surg. 2014;80:182.
9. Hasegawa &al. Increased incidence of hypotension in elderly patients who underwent emergency airway management: an analysis of a multi-centre prospective observational study. Int J Emerg Med 2013; 6:12.
10. Heffernan &al. Normal presenting vital signs are unreliable in geriatric blunt trauma victims. J Trauma. 2010;69:813.
11. Li &al. Mild head injury, anticoagulants, and risk of intracranial injury. Lancet. 2001; 357:771-2.
12. Konda &al. Who Is the Geriatric Trauma Patient? An Analysis of Patient Characteristics, Hospital Quality Measures, and Inpatient Cost. Geriatr Orthop Surg Rehabil. 2020 Sep 15;11:2151459320955087.