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ACEP Now: Vol 40 – No 10 – October 2021

Lateral compression pelvic ring injury and left-sided T-shaped acetabulum fracture.
Wiznia et al. Case Rep Orthop. 2016;2016:9706392. CC BY 4.0

The oldest Americans are the fastest-growing population in the United States.¹ Older persons are more likely to experience trauma and to have worse outcomes after a trauma.² Under-triaging may be the single most important modifiable factor associated with mortality and morbidity in our trauma systems. Observational studies suggest that when injured older patients are cared for at a regional trauma hospital, there is as much as a 25 percent reduction in mortality, a reduction in delirium, and fewer discharges to long-term care.³ In Ontario, where I work, more than two-thirds of older adults with major traumatic injuries (often related to minor mechanisms of injury such as ground-level falls) are triaged by EMS to a nontrauma center, and fewer than 50 percent of these patients are then transferred to a trauma center.⁴ This month, we’ll explore five myths about trauma and triage in older patients. Next month, we’ll bust myths about falls and other injuries common in this population

Myth 1: Transfer to a Trauma Center Is for Lifesaving Emergency Surgery Only

A pervasive myth is that patients need only be transferred to a regional trauma center if emergency surgery is likely to be required. Older patients with nonoperative injuries benefit from specialized trauma care from coordinated multidisciplinary teams at a regional trauma center.⁵ The lack of need for emergency surgery should not preclude consideration for transfer to a lead trauma center. I believe we should be advocates for our older trauma patients by ensuring that regional trauma transfer guidelines include frailty as a high-risk factor that should warrant the consideration of transfer at a lower threshold.

Myth 2: Prognostication of Trauma Patients Can Be Accurately Assessed Based on Age and Comorbidities in the ED

We have all cared for 90-year-old patients who seem to have the physiology of 70-year-olds and vice versa. While both age and frailty are somewhat predictive of poor outcomes after trauma, multiple studies using frailty scores have shown frailty to be more predictive of poor outcomes after trauma than age and even comorbidities.^6–9 It has been suggested that the combination of a frailty index such as the Trauma-Specific Frailty Index and Geriatric Trauma Outcome Score may improve prediction of long-term outcomes, but this has yet to be studied.^10,11 Prognostication scores following traumatic brain injury such as the International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) Score have been validated in adults with a Glasgow Coma Scale score ≤12 and can predict six-month mortality when calculated in the first 24 hours of admission; however, this rarely applies to ED care.¹²

Myth 3: Volume Replacement in Trauma Patients with Hemorrhagic Shock Should Only Be Accomplished Utilizing Blood Products

While blood products are generally favored over crystalloid in the young trauma patient showing signs of hemorrhagic shock for volume replacement, older patients are often fluid-deplete at baseline and may be taking medications such as diuretics that further deplete their volume.¹³ In the initial resuscitation of an elderly trauma patient who may be volume-depleted at baseline, it is reasonable to give a small bolus of crystalloid (250–500 cc) followed by frequent reassessments of volume status using a combination of clinical parameters, point-of-care ultrasound, an arterial line, and urine output.

Myth 4: Isolated Pelvic Fractures Are a Rare Cause of Hemorrhagic Shock and Mortality in Trauma Patients

While young patients with isolated pelvic fractures rarely suffer from hemorrhagic shock and death, and isolated pubic ramus fractures are generally benign injuries, it is not uncommon for older trauma patients to suffer a lateral compression fracture of the pelvis leading to unrecognized retroperitoneal bleeding.¹⁴ Older trauma patients are more likely to have lateral compression fractures of the pelvis than younger patients and are more likely to suffer complications of pelvic fractures leading to death.¹⁵ These fractures in older patients carry a risk of retroperitoneal bleeding requiring angiography that cannot be detected by point-of-care ultrasound during the initial ED resuscitation. It is prudent to maintain a high level of suspicion for pelvic fractures with associated vascular injury and retroperitoneal bleeding in older trauma patients, especially if they are taking anticoagulant medications. Binding the pelvis early in the ED resuscitation of older polytrauma patients suspected of pelvic fractures should be considered.¹⁶

Myth 5: Opioid Analgesics Should Be Withheld from Older Trauma Patients Due to Potential Adverse Effects

Undertreating and overdosing analgesics in older trauma patients are common pitfalls.¹⁷ All trauma patients should have their pain treated regardless of age. Side effects from opioids are minimized in older patients by appropriately lowering the standard adult dosages. Both treating pain and proper dosing of analgesics help reduce the risk of delirium and agitation in these patients.¹⁸ Early pain control with multimodal analgesia, access to regional analgesia, and regular pain assessments are paramount in managing the older trauma patient. Goals of pain management include the ability of the patient to sit up and roll over independently.

A special thanks to Dr. Barbara Haas, Dr. Bourke Tillman, and Dr. Camilla Wong for their expert contributions to the EM Cases podcast from which this article was inspired. 

References

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3. Currie L. Fall and injury prevention. In: Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality; 2008:Chapter 10.
4. Lenartowicz M, Parkovnick M, McFarlan A, et al. An evaluation of a proactive geriatric trauma consultation service. Ann Surg. 2012;256(6):1098-1101.
5. Bach JA, Leskovan JJ, Scharschmidt T, et al. The right team at the right time—multidisciplinary approach to multi-trauma patient with orthopedic injuries. Int J Crit Illn Inj Sci. 2017;7(1):32-37.
6. Cheung A, Haas B, Ringer TJ, et al. Canadian study of health and aging clinical frailty scale: does it predict adverse outcomes among geriatric trauma patients? J Am Coll Surg. 2017;225(5):658-665.e3.
7. Rickard F, Ibitoye S, Deakin H, et al. The Clinical Frailty Scale predicts adverse outcome in older people admitted to a UK major trauma centre. Age Ageing. 20215;50(3):891-897.
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10. 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(1):10-17.e1.
11. Zhao FZ, Wolf SE, Nakonezny PA, et al. Estimating geriatric mortality after injury using age, injury severity, and performance of a transfusion: the Geriatric Trauma Outcome Score. J Palliat Med. 2015;18(8):677-681.
12. Sun H, Lingsma HF, Steyerberg EW, et al. External validation of the international mission for prognosis and analysis of clinical trials in traumatic brain injury: prognostic models for traumatic brain injury on the study of the neuroprotective activity of progesterone in severe traumatic brain injuries trial. J Neurotrauma. 2016;33(16):1535-1543.
13. Schlanger LE, Bailey JL, Sands JM. Electrolytes in the aging. Adv Chronic Kidney Dis. 2010;17(4):308-319.
14. Mohanty K, Musso D, Powell JN, et al. Emergent management of pelvic ring injuries: an update. Can J Surg. 2005;48(1):49-56.
15. O’brien DP, Luchette FA, Pereira SJ, et al. Pelvic fracture in the elderly is associated with increased mortality. Surgery. 2002;132(4):710-714; discussion 714-715. 
16. Coccolini F, Stahel PF, Montori G, et al. Pelvic trauma: WSES classification and guidelines. World J Emerg Surg. 2017;12:5.
17. Keene DD, Rea WE, Aldington D. Acute pain management in trauma. Trauma. 2011;13(3):167-179.
18. Sampson EL, West E, Fischer T. Pain and delirium: mechanisms, assessment, and management. Eur Geriatr Med. 2020;11(1):45-52.