Geriatric Trauma Guideline

 

VBMC TRAUMA CARE SERVICES GUIDELINE

Geriatric Trauma Guideline

1.     Purpose

Elderly patients can suffer significant injury despite relatively trivial mechanism.  The physiologic response of older trauma victims might differ from that seen in younger patients.  Alterations in mentation are more often attributed to dementia or delirium so recognition of shock or traumatic brain injury may be delayed.  Under-triage (allocation of elderly trauma victims to lower level trauma centers or non-trauma centers) is associated with a two-fold increase in the risk of death.  It is important to recognize the potential severity of even minimal rib fractures in the elderly and to have a low threshold for hospitalization, ICU admission, and aggressive pain management strategy.

2.     General Guidelines for Managing Elderly Trauma Patients (from EAST)

 

·         Advanced patient age is not an absolute predictor of poor outcomes following trauma and should not be used as the sole criterion for denying or limiting care in this patient population. (Level 3 recommendation, EAST)

·         An initial aggressive approach should be pursued for management of the elderly patient unless in the judgment of an experienced trauma surgeon it seems that the injury burden is severe and the patient appears moribund. (Level 3 recommendation)

·         In patients aged 65 years or older with a GCS less than 8, if substantial improvement in the GCS is not realized within 72 hours of injury, consideration should be given to limiting further aggressive therapeutic interventions. (Level 3 recommendation)

·         All patients ≥ 65 with significant chest, abdomen, pelvic or extremity injuries warrant Trauma Alert activation. EAST recommends a lower threshold for trauma activation for injured patients aged 65 years or older than for patients younger than 65 (Level 2 recommendation, EAST).

·     The primary survey is the same for any injured patient.

The secondary survey should emphasize the following:

3.     Determine medications that affect initial evaluation and care:

Ø  Coumadin

Ø  Clopidrogrel

Ø  Other anticoagulants

Ø  ASA

Ø  Beta blockers 

Ø  ACE inhibitors

4.     Consider common, acute, non-traumatic events that could complicate the patient’s presentation, including:

Ø  Acute coronary syndrome (EKG)

Ø  Hypovolemia/dehydration

Ø  Urinary tract infection

Ø  Pneumonia

Ø  Acute renal failure

Ø  Cerebrovascular event

Ø  Syncope

 

5.     Lab assessment:

Hypoperfusion is often underappreciated in the elderly.  Base deficit (BD) should be assessed quickly to identify those patients in shock who need resuscitation, abbreviated evaluation, and admission to an ICU.  Assess BD via VBG in Trauma Alerts, ABG in TA-Reds or by specific order in non-activated (non-alerted) patients. Base deficit may provide useful information in determining the status of initial resuscitation and risk of mortality for geriatric patients.  ICU admission should be considered for patients aged 65 years or older with an initial base deficit of 6mEq/L or more (at or below -6, Level 3 recommendation).  The following should be considered for all elderly patients with injury:

Ø  Liberal use of lactic acid level (Initial lactate measurements may increase the accuracy of recognizing occult hypoperfusion and shock and provide better insight into the perfusion status of geriatric patients.)  

Ø  The following lab tests are included in the TA and TAR panels. Use liberally in geriatric trauma victims, even when non-activated, Level 3 recommendation):

o   PT/PTT/INR)

o   Renal function (BUN, Cr, estimated GFR) 

o   Blood alcohol

o   Urine toxicology

o   Serum electrolytes

In addition to the above, in all patients > or = 65, add lactic acid. 

 

6.     Imaging:

Initial imaging should include liberal use of CT scanning for blunt injury.  Occult injuries are common in the elderly and radiation exposure is of minimal risk.

Ø  NEXUS criteria may be equally sensitive in geriatric patients as in non-geriatric patients. That being said, NEXUS has received recent criticism. Guidelines recommend liberal use of spine CT in elderly patients, even in same height falls. Ligament injury is a separate problem. Vanguri et al from VCU advocate liberal CT scanning (as a single cervical spine diagnostic tool, and limited concern for ligamentous injury in those with negative CT’s).

Ø  Imaging should include all CT scans needed to rule out injury in appropriate areas at risk

Ø  Level 3 recommendation (EAST): All elderly with suspected head injury who were taking medication for systemic anticoagulation before their injury should be evaluated with head CT as soon as possible after admission

7.     Anticoagulation assessment and reversal:

The frequent use of warfarin, antiplatelet agents, direct thrombin inhibitors, and direct factor Xa inhibitors in the elderly puts them at higher risk for significant bleeding events, even in the context of minor injury. 

Reversal should be initiated immediately (within 2 hours of arrival is an EAST Level 3 recommendation). 

8.     Resuscitation and Inpatient monitoring:

Ø  In patients 55 years of age and older, an admission base deficit > 6 is associated with a 66% mortality. Patients in this category may benefit from in-patient triage to a high-acuity nursing unit (EAST Level 3 Recommendation).

Ø  Age should not be used as a criterion to deny geriatric trauma patients non-operative management of splenic injuries

Ø  Any geriatric patient with physiologic compromise (relative hypotension, tachycardia, tachypnea/dyspnea, elevated BD/lactate), significant injury, and high-risk mechanism of injury (rollover, ejection, high speed), uncertain cardiovascular status, or chronic cardiovascular or renal disease should undergo close monitoring, in ICU. (Level 2 recommendation) For hemodynamic compromise, consider using a pulmonary artery catheter, ScvO2 monitoring or other invasive monitor.

StO2 has also been described as a valuable (and noninvasive) tool to assess perfusion in geriatric trauma victims but is not locally available. 

Ø  Elderly patients have a two-fold increase in the incidence of nosocomial infection compared to younger patients.  Reduction of invasive monitoring as soon as possible is recommended.

Ø  Parameters for shock in the elderly should be considered:  SBP ≤110 may represent hypotension mm Hg and /or pulse ≥ 120 beats/min.  Elevated lactate: ≥ 2.5 mMol/L.  Base deficit >6.

Ø  Consider a higher threshold for ‘hypotension’ in elderly.  

Ø  Repeat lactate liberally early after injury, pre-op and 24hr post-op.

Ø  Maintain a lower threshold for angioembolization in pelvic fracture (Henry et al, J Trauma 2002). 

9.     Specialized Inpatient Geriatric Care-the Comprehensive Geriatric Assessment

In 22 randomized trials involving over 10,000 inpatients, comprehensive geriatric assessment (CGA) followed by appropriate treatment and follow-up increases the likelihood of a patient being alive in their home after 1 year by 25%. In trauma, proactive geriatric consultation reduces the number of episodes of delirium, decreases in-hospital falls, reduces the risk of discharge to a LTC facility and shortens LOS. 

If the response to 2 or more of the questions below is ‘yes’, a comprehensive geriatric assessment should be obtained:

1.      Before you were injured, did you need someone to help you on a regular basis?

2.      Since the injury, have you needed help more than usual to help take care of yourself?

3.      Have you been hospitalized for one or more nights in the past 6 months?

4.      In general, do you have problems seeing well?

5.      In general, do you have serious problems with your memory?

6.      Do you take more than 3 different medications every day?

In ALL geriatric patients, obtain a thorough past medical history by involving family and/or PCP and obtain an accurate medication list including OTC medications.

Use the following geriatric medication prescribing guidelines: 

1.      Follow Beers Criteria and use them in decision-making. http://www.americangeriatrics.org/files/documents/beers/BeersCriteriaPublicTranslation.pdf

2.      Discontinue non-essential meds.

3.      When possible, continue meds with withdrawal potential, including SSRI’s, TCA’s, antidepressants, BDZ’s, anti-psychotics, MAOI’s, beta blockers, clonidine, statins and steroids.

4.      Continue beta blocker or start if indicated. 

5.      Continue statins when appropriate.

6.      Adjust dosages for renal function based upon GFR. 

The following pain medication strategies are recommended:

1.      Use elderly-appropriate drugs and dosages.

2.      Avoid benzo’s, unless already dependent.

3.      Monitor opiates and consider PCA. 

4.      Consider early use of non-narcotics

5.      Epidural is preferable in those with 4 or more rib fractures at age 65, or lesser numbers of ribs in older patients

Establish a past history of elderly-specific comorbidities, including:

1.      Pulmonary disease

2.      Chronic renal failure

3.      Chronic anemia

4.      Depression

5.      Baseline cognitive impairment

6.      Baseline functional impairment

7.      Baseline frailty score

8.      Baseline nutritional status

9.      Alcohol, tobacco or drug abuse/dependence

10.  Thyroid dysfunction

11.  Glucose intolerance

12.  Decubitus ulcer

Cognition and Stress/mental health can be assessed in the following ways:

For Cognition, two options: 

1.      Most use the Montreal cognitive assessment (MoCA)

2.      Mini-COG (also quick and good).

 

For depression, 2 options:

1.      PHQ-2 (followed by PHQ-9) is simple, quick, and very sensitive but less specific than the GDS

2.      (Brief) Geriatric Depression Scale (GDS) - validated, easy to use, and score. More specific than PHQ-2 in elderly but more challenging to administer.

Use these criteria as part of a formal geriatric assessment conducted by a multi-disciplinary trauma team. 

 

10.Patient Decision-Making Capacity and Care Preferences

1.      Discuss with family, surrogates and healthcare team and document the following:

a.       Patient’s priorities and preferences regarding treatment options.

b.      Post-injury risks of complications, mortality and temporary/permanent functional decline.

c.       Advance directives or living will and how these affect initial care and life-sustaining preferences, including mechanical ventilation, CPR, dialysis, blood transfusion, permanent enteral feeding and transition to comfort care should complications occur. 

d.      Identify surrogate decision-maker

e.       Make liberal use of palliative care options

f.        In appropriate setting, present hospice as a positive active treatment

g.       Hold family meeting within 72 hours of admission and discuss goals of treatment

2.      Regularly evaluate and address delirium risk factors (cognitive impairment and dementia, depression, alcohol use, polypharmacy, psychotropic meds, poor nutrition, hearing and vision impairment)

3.      Regularly monitor for reversible causes of delirium (wake-sleep cycle disruption, sleep deprivation, immobilization, hypoxia, infection, uncontrolled pain, renal insufficiency, dehydration, electrolyte abnormalities, urinary retention, presence of a Foley, fecal impaction/constipation, use of restraints)

4.      Monitor the patient’s fluid status (daily input/output, daily weight, consider noninvasive CO in the ICU in order to achieve euvolemia).

5.      Post-injury complications in the elderly trauma patient negatively impact survival and contribute to longer lengths of stay in survivors and nonsurvivors compared to younger trauma patients. Specific therapies designed to prevent and/or reduce the occurrence of complications (particularly iatrogenic complications) should lead to optimal outcomes in this patient population (EAST, Level 3 Recommendation). Protect patients from iatrogenic complications:

a.       Mobilize early, ambulate within 48 hours

b.      Assess and address fall risk

c.       Avoid aspiration (HOB up, upright during and 2 hours after eating, evaluate dysphagia)

d.      Perform spirometry or chest PT

e.       Use a bowel regimen if opiates in use

f.        Screen for pressure ulcers and document skin integrity

 

11.Discharge

1.      Begin discharge planning immediately post-injury (including assessment of home environment, social support, medical equipment needs and patient acceptance of options)

2.      Provide a discharge document to the patient including: 

a.       Diagnoses

b.      Meds with dosing and possible reactions

c.       Reconciliation of inpt/outpt meds

d.      Directions for wound care

e.       Diet and mobility instructions

f.        Therapy needs

g.       Contact information for the clinic

h.      Appointments with specialty surgeons

i.         Follow-up at 6 weeks after surgery

j.         Pending labs/radiography/diagnostics

3.      Communicate with PCP including findings. Verbal contact is very helpful. 

4.      Provide a discharge summary to the receiving facility if applicable. Verbal contact can be very helpful. 

5.      Arrange for follow-up visit OR phone call within 3 days of discharge to assess:

a.       Pain control

b.      Tolerance of food

c.       Ability to ambulate

d.      Mental status

e.       Understanding of post-discharge medications/instructions 

 

12.Predicting Outcomes:

TQIP guidelines suggest against making prognostic decisions based upon age. However, after careful assessment by the trauma team, dialogue with patient and family is essential and goals of care should be discussed, at least preliminary, within 24-48 hours of admission. The following tools can be used to predict discharge disposition and mortality. They are only predictors and are not absolute indicators. 

Predicting Discharge Disposition

Frailty Scoring-The Trauma Specific Frailty Index TSFI described by Joseph et al at University of Arizona at Tucson helps predict unfavorable discharge disposition (subacute nursing facility). Total the score for all categories and divide by the total possible-15. A score > .27 predicts SNF at discharge. Early, aggressive resource allocation and patient/family counseling is warranted in this group. 

Trauma-Specific Frailty Index

Comorbidities

1.      Cancer history 

Yes 1

No 0 

2.      Coronary heart disease 

Myocardial infarction 1 

Coronary artery bypass grafting 0.75 

Percutaneous coronary intervention 0.5 

Medication 0.25 

No medication 0 

3.      Dementia 

Severe 1 

Moderate 0.5 

Mild 0.25 

None 0 

 

Daily activities 

4.      Help with grooming 

Yes 1 

No 0 

5.      Help managing money 

Yes 1 

No 0 

6.      Help doing household work 

Yes 1 

No 0 

7.      Help toileting 

Yes 1 

No 0 

8.      Help walking 

Wheelchair 1 

Walker 0.75 

Cane 0.25 

None 0 

Health attitude 

9.      Feel less useful 

Most time 1

Sometimes 0.5 

Never 0 

10.  Feel sad 

Most time 1 

Sometimes 0.5 

Never 0 

11.  Feel effort to do everything 

Most time 1 

Sometimes 0.5 

Never 0 

12.  Falls 

Most time 1 

Sometimes 0.5 

Never 0 

13.  Feel lonely 

Most time 1 

Sometimes 0.5 

Never 0 

14.  Function, sexually active 

Yes 1 

No 0 

15.  Nutrition

Abumin <3 1 

>3 0

Mortality Prediction 

 

This mortality predictor (the Geriatric Trauma Outcome Score) uses age, ISS and requirement for transfusion (yes/no) to assess mortality risk. To calculate ISS, use the manual in the ICU or contact the program office. 

 

(Zhao et al. J Palliative Med 2015-UT Southwestern Trauma)

 

  

References:

1.      ACS-COT Geriatric Trauma Management Guidelines: TQIP

2.      EAST Practice Management Guidelines for Geriatric Trauma, Evaluation and Management. (2012).  Retrieved from www.east.org

3.      Geriatric Trauma Clinical Guideline. (2010) Washington State Department of Health.  Retrieved from www.doh.wa.gov/Publichealthandhealthcareprovider/EmergencyMedicalServicesEMSSystems

4.      Jacobs, D.  (2003). Special considerations in geriatric injury.  Current opinion Critical Care Lippincott, Williams, & Wilkins, 9, 535-539.   

5.      Henry, Sharon M. MD; Pollak, Andrew N. MD; Jones, Alan L. MD; Boswell, Sharon RN; Scalea, Thomas M. MD. Pelvic Fracture in Geriatric Patients: A Distinct Clinical Entity. Journal of Trauma-Injury Infection& Critical Care: 2002; 53:15-20.

6.      Joseph B, Pandit V, Zangbar B, et al. Validating trauma-specific frailty index for geriatric trauma patients: a prospective analysis. J Am Coll Surg 2014;219:10-7.

7.      Zhao FZ, Wolf SE, Nakonezny PA, Minhajuddin A, Rhodes RL, Paulk ME, Phelan HA. Estimating Geriatric Mortality after Injury Using Age, Injury Severity, and Performance of a Transfusion: The Geriatric Trauma Outcome Score. J Palliat Med. 2015 Aug;18(8):677-81.