ACEP ID:

Trauma & Injury Prevention

Trauma Challenges in the Geriatric Patient: Predicting Short-Term Adverse Outcomes Prior to ED Discharge

Carpenter_Headshot2Christopher R. Carpenter, MD, MSc, FACEP, FAAEM, AGSF
Washington University School of Medicine
Division of Emergency Medicine, Associate Professor
Past-Chair, ACEP Geriatric Section


Case Scenario
An 80-year-old female presents to your emergency department (ED) after a standing level fall. She reports multiple prior falls in the preceding 12-months and states that she is walking more because her children took away her driver’s license 2 years ago after she had a minor car accident. Today’s triage note listed a history of atrial fibrillation treated with warfarin and her INR is 2.9. In addition, her medications included treatment for hypertension and hyperlipidemia. Your primary and secondary exam reveals left hip tenderness and a coccyx contusion, but no other injury. After observing her for 4-hours in the ED and noting an unremarkable hip and pelvic x-ray, CT-head and C-spine imaging, and no free fluid on POC FAST exam, you ambulate her and note no difficulty with the Get-Up-and-Go test. She wants to be discharged home and her primary care physician agrees via telephone that she should be discharged with follow-up in his office the next day. Her family has reservations about her home safety, but also agree that her perspectives should be respected and she is discharged home with next day follow-up.

Unfortunately, overnight she returns to the same ED with another fall that occurred at 3AM while trying to get from her bed to the bathroom. She is unresponsive upon arrival and family note that she went to bed early because of her long day in the ED. CT reveals a large SDH, which continues to expand over the next 4-hours despite aggressive management with Vitamin K and Protein Complex C. Neurosurgery recommends conservative management based upon her presenting GCS. Later that day family withdraws care and she expires. Could anything have been done to prevent this death at the time of the first ED evaluation?

Epidemiology

Geriatric adults represent 23% of trauma admissions, and traumatic injury is the fifth leading cause of death in this age group.1,2 In the 85 and older subset of geriatric adults, 1 in 5 is treated in an ED for injury every year in the United States (U.S).3 Injury-related hospitalizations for geriatric adults continue to increase.4 Standing level falls and motor vehicle accidents (MVA) are the most common mechanisms of trauma in this age-group.5,6 The challenges of an aging population are not isolated to the U.S. either; geriatric trauma is the most common presenting complaint for older adults worldwide.7,8

Prognostic Assessment – History and Physical Exam

When adjusted for Injury Severity Scores, geriatric trauma patients have twofold increased mortality and significantly longer hospital LOS compared with younger populations.9 Even the seemingly minor trauma of a ground level fall often (as in the case above) represents a sentinel event for older adults: up to 35% of older adults with minor blunt trauma who are discharged from the ED experience functional decline within 3-months.10-12 Functional decline increases ED recidivism.13 Surprisingly, despite decades of research to develop risk-stratification tools like the Identification of Seniors at Risk and the Triage Risk Stratification Tool, no accurate instruments exist to identify the subset that is most at risk for post-ED functional decline while they are still in the ED.14-16 In fact, emergency medicine cannot currently even predict short-term fall-risk amongst elderly non-fallers17 or fallers,18,19 so layers of complexity must be unraveled to move from what we believe that we understand to what we can actually measure and understand to what we can do to improve the outcomes for these vulnerable patients.

Diagnostic and Prognostic Labs & Imaging Resources

Most laboratory tests are of low utility in the identification of specific injuries or their seriousness in geriatric trauma patients, but anticoagulation status should always be assessed.20 Although warfarin use alone does not predict mortality, the duration and degree of anticoagulation do predict adverse outcomes in head injury patients.21-25 A low threshold for CT scanning in all geriatric patients is encouraged, but particularly for those who are on anticoagulants.26-28 Unfortunately, a normal brain CT scan at the time of the initial ED evaluation does not eliminate the risk of a delayed intracranial hemorrhage in subsequent days. Head injury patients, and more importantly their caregivers, must be advised to carefully monitor the patient’s mental status in the days following a traumatic head injury. While it has been thought prudent to arrange an observation admission and repeat CT scan for those on anticoagulation therapy, this strategy has not been adopted by most hospitals due to cost and crowding concerns.

Vital signs are inaccurate to predict injury severity in geriatric patients. The product of age multiplied by shock index is a slightly more accurate predictor of mortality.29 A base deficit of ≤ -6 has been used as a laboratory marker of trauma-related mortality and anticipated prolonged ICU care.30 While there is controversy over the value of central venous pressure monitoring, it is a particularly challenging modality of care in the elderly who can least afford an iatrogenic complication on top of their trauma.31 More recently venous lactate appears promising. As opposed to shock index and traditional vital signs, venous lactate is an independent predictor of geriatric trauma mortality when adjusted for age, Glasgow Coma Scale and Injury Severity Score.32 Using venous lactate-guided therapy to identify occult hypoperfusion with early trauma surgeon involvement is associated with improved survival.33 Researchers are also developing nomograms to predict mortality-related complications such as wound infection, empyema, urinary tract infection, deep venous thrombosis, pressure ulcer, and pneumonia based on age, gender, and number of pre-existing co-morbidities.34,35

Specific Injuries

Head Injuries

Hospitalization rates for older adults with head injuries are increasing.36 Traumatic brain injury (TBI) in geriatric patients leads to over 80,000 ED visits in the U.S. every year and 75% result in hospitalization.37 Standing level falls and to a much smaller degree MVA are the leading causes of head injuries in the elderly.36,38,39 The length of time that patients are anticoagulated and the extent of anticoagulation increase head injury related mortality.24,25 Patients over the age of 75 are less likely to survive surgical intervention than younger populations following head injury.38 In one review of geriatric TBI victims with initial Glasgow Coma Scale ≤ 8, the overall mortality was 71%, and no patients over the age of 85 survived with or without surgery.40 Surprisingly, the recovery potential of geriatric TBI patients has remained static for decades.39

Cervical Spine Injuries

Standing level falls are the most common injury mechanism preceding C-spine fractures and C1 or C2 fractures are more common in geriatric trauma patients than in younger patients.41 Even minor degrees of trauma can cause fracture in a neck already damaged by osteoarthritis or other kinds of joint disease. If the goal is to identify every possible C-spine injury than CT scan and MRI are ideal.42 However, many injuries identified on CT scan that are missed by x-ray alone are clinically inconsequential, and require neither operative intervention nor spine immobilization that would not otherwise have been recommended.

Special Situations

Elder Abuse and Neglect


Up to 1.2 million older adults (4% of all senior citizens) suffer mistreatment in the U.S. with 450,000 new cases every year.43 Elder abuse and neglect is a complex issue with multiple potential risk factors within the geriatric patient, perpetrator, relationship, and environment.44 Most abuse does not occur in nursing homes, but in the home of community-dwelling older adults. Abuse is more likely in developed countries45 and in urban settings.46 Types of abuse include abandonment, psychological, financial, neglect, physical, sexual, or resident-to-resident aggression.43 Physical abuse is less common than psychological abuse and financial exploitation.45 The elder abuse suspicion index is a 6-question screen for this problem.47 and the American Medical Association has also developed a screening instrument.43,48

Driver safety

Large and increasing numbers of older adults, including those over age 85, are current drivers.49 Older adults are overall less likely to be the driver in MVAs on a per-accident basis because they drive less frequently than younger populations. Most (78%) geriatric MVA victims are discharged home from the ED.50 After assessing and treating MVA-related injuries, emergency providers have an obligation to assess the role of age and age-related co-morbidities to prevent future MVA-related injuries to the patient and to society.51 Multiple resources exist to guide clinicians, patients, and families to assess driving safety.52 Office based testing for driver safety is increasingly available and cutoff norms are being established to increase the accuracy to predict future MVAs.53,54 If time, space, and personnel are available, ED-based driver safety testing is also possible.55

Fall risk

Fall-related injuries are common geriatric patient presenting complaint in EDs worldwide and one-third of home-dwelling older persons fall every year.56 However, older adults in the ED usually do not have a fall-risk assessment obtained as part of their ED evaluation.57,58 As previously noted, one significant barrier to routine fall-risk stratification in the ED is that instruments designed to do so lack validation in the emergency setting.19

Case Scenario


Although our 80-year-old fall victim could have been encouraged to remain in the hospital for serial exams, fall prevention nursing, physical therapy assessment of future fall risk, and a repeat head CT, research evidence does not support empiric decisions based on age-alone. There is also no certainty that an admission at the time of the first ED visit would have prevented the second fall or detected the SDH earlier than the outpatient approach, since the SDH could have been a result of the initial (or any of several prior) falls. Furthermore, being hospitalized is also a risk for adverse events like delirium and iatrogenic infections. Most importantly, admitting this patient at the time of the first ED visit would have clearly been in direct opposition to her preference to be discharged home and family reluctantly agreed. Nonetheless, 21st Century Medicine can and must become better equipped to deliver the appropriate disposition to those patients most likely to benefit in the short time that we have to evaluate them in the contemporary ED.

The Future


Effective geriatric trauma management and efficient injury prevention continue to evolve and solutions will require the mutual and sustained engagement of both the ACEP Trauma and Injury Prevention Section and the ACEP Geriatric Section. Several potentially high-yield questions exist which could substantially improve the outcomes for these vulnerable trauma patients.59,60 Which 1-in-3 blunt trauma patients without injury sufficient to justify admission would benefit from short-term post-ED interventions to reduce adverse outcomes? How do providers accurately identify future fall-risk? If accurate screening instruments can be derived to identify these subsets, how will they be used in the busy ED environment? Do most EDs have access to resources upon which high-risk subsets will depend once identified? What is the role of Geriatricians, Trauma Surgeons, and other specialists to improve the outcomes of this subset that is discharged from the ED? Lacking a National Institute of Acute Trauma, who will fund such research? Unfortunately, most current evidence is retrospective and single center so TIPS has an immediate opportunity to join the Geriatric Section to render meaningful answers to these questions.

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