EM · Geriatric trauma
Geriatric trauma
The geriatric trauma: the physiological changes of aging, the comorbidity and the polypharmacy (the anticoagulants, the beta-blockers that mask the tachycardia), the low-energy fall that produces the significant injury, the increased TBI risk, the frailty assessment, and the higher mortality for the same injury.
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The geriatric trauma is the injury of the patient over 65, and it is one of the fastest-growing presentations in the emergency department, as the population ages and the activity is maintained. The elderly patient is injured by the lower-energy mechanism (the ground-level fall) but suffers the higher-severity injury and the higher mortality than the younger patient with the same mechanism, because the physiological changes of aging and the comorbidity reduce the reserve. The Fellowship candidate must know the physiological changes, the polypharmacy effects, the atypical presentation, the frailty concept, and the principles that govern the management and the disposition of the injured elderly.[1][1]
The physiological changes of aging
The aging alters every system in ways that affect the trauma management. The brain atrophies (the cortical volume shrinks, the subdural space enlarges), so the bridging veins are stretched and the minor head injury produces the subdural haematoma with more room to expand before the signs appear. The cardiovascular system stiffens (the less-compliant aorta, the fixed cardiac output), so the tachycardic response to the hypovolaemia is limited (and the beta-blocker or the pacemaker abolishes it entirely). The respiratory reserve falls (the reduced vital capacity, the reduced cough, the chest-wall stiffening), so the rib fracture that is minor in the young produces the pneumonia in the elderly. The renal function declines (the reduced GFR, the reduced concentrating ability), so the nephrotoxic contrast and the medications accumulate. The bone density falls (the osteoporosis), so the ground-level fall fractures the hip, the pelvis and the ribs.[1]
| System | The change of aging | The trauma consequence |
|---|---|---|
| Brain | The cortical atrophy, the stretched bridging veins, the enlarged subdural space | The subdural haematoma from the minor head injury, the delayed presentation |
| Cardiovascular | The stiffened aorta, the fixed cardiac output, the conduction disease | The absent tachycardia, the relative hypotension at the 'normal' SBP, the shock at the lower heart rate |
| Respiratory | The reduced vital capacity, the weakened cough, the stiffened chest wall | The pneumonia, the atelectasis, the respiratory failure after the rib fracture |
| Renal | The reduced GFR, the reduced concentrating ability | The accumulation of the contrast and the nephrotoxic drugs, the acute kidney injury |
| Musculoskeletal | The osteoporosis, the sarcopenia, the slow gait | The hip, the pelvic and the rib fractures from the ground-level fall |
| Integument | The thin skin, the fragile subcutaneous vessels | The extensive bruising, the torn bridging veins, the large scalp haematoma |
| Immune | The blunted febrile response, the reduced T-cell function | The atypical presentation of the sepsis (the confusion, the fall), the delayed diagnosis |
The comorbidity and the polypharmacy
The elderly patient carries the comorbidity (the hypertension, the diabetes, the ischaemic heart disease, the COPD, the chronic kidney disease) and the medications that interact with the trauma. The anticoagulants (the warfarin, the DOACs) increase the risk and the severity of the intracranial and the intra-abdominal bleeding and require the early reversal.[2] The beta-blockers prevent the tachycardic response to the shock, so the heart rate is an unreliable sign (the normal heart rate in the elderly patient on the beta-blocker does not exclude the 30 per cent blood-volume loss). The ACE inhibitors and the diuretics cause the postural hypotension and the electrolyte disturbance (and may be the cause of the fall). The polypharmacy interacts with the anaesthesia, the analgesia and the resuscitation drugs.
| Drug class | The trauma interaction | The action on the arrival |
|---|---|---|
| Warfarin | The elevated risk of the intracranial and the intra-abdominal bleed; the slow reversal | The INR, the early PCC + vitamin K, the haematology consult |
| DOAC (apixaban, rivaroxaban, dabigatran) | The elevated bleed risk; the uncertain reversal; the unreliable routine coagulation tests | The specific reversal (idarucizumab, andexanet), the anti-Xa or the thrombin time, the timing of the last dose |
| Antiplatelet (aspirin, clopidogrel) | The modestly elevated ICH risk; the platelet dysfunction | The platelet transfusion is not routine (it does not help and may harm in the spontaneous ICH); consider in the TBI |
| Beta-blocker | The absent tachycardia; the masked shock; the negative inotropy | The lactate, the base deficit; the cautious fluid; do not stop abruptly (the rebound ischaemia) |
| ACE inhibitor / diuretic | The volume depletion, the orthostasis, the AKI with the contrast | The fluid assessment, the electrolytes, the renal dosing of the drugs |
| Sedative / opioid | The fall, the delirium, the respiratory depression | The reversible-cause workup; the delirium screen; the cautious dosing |
The mechanism and the injury pattern
The ground-level fall from the standing height is the most common mechanism of the geriatric trauma (the trip, the slip, the syncopal episode), and it produces the hip fracture, the head injury and the rib fracture. The practitioner who dismisses the mechanism as minor misses the significant injury — the mechanism alone does not determine the severity in the elderly. The motor-vehicle collision and the pedestrian struck produce the multi-system injury. The injury pattern reflects the fragile skeleton and the reduced reserve: the TBI (the atrophic brain, the anticoagulant), the rib fractures with the respiratory failure (the osteoporosis, the reduced reserve), the hip and the pelvic fractures (the osteoporosis), the cervical-spine injury (the degenerative spine, the stenosis), and the occult injury (the delayed presentation, the atypical symptom — the confusion instead of the pain).[1][1]
The TBI, the anticoagulation and the reversal therapy
The TBI in the elderly is more frequent, more severe and more likely to require the surgical intervention. The atrophic brain provides the subdural space for the venous bleed to accumulate, and the signs may be delayed or subtle (the confusion, the gradual decline, rather than the rapid deterioration). The anticoagulated patient with the head injury has the significantly elevated risk of the intracranial haemorrhage, so the head CT is obtained liberally after the fall and the reversal of the anticoagulant is started early if the ICH is confirmed: the 4-factor prothrombin complex concentrate at 25 to 50 units/kg with the vitamin K 5 to 10 mg intravenously for the warfarin; the idarucizumab 5 g (two 2.5 g vials) for the dabigatran; and the andexanet alfa — the low dose 400 mg or the high dose 800 mg bolus — for the apixaban and the rivaroxaban, with the PCC as the alternative where the andexanet is unavailable.[2][1]
The reversal of the anticoagulant in the geriatric trauma — the agent, the dose, and the speed
The reversal strategy is dictated by the specific anticoagulant. The warfarin is reversed by the 4-factor prothrombin complex concentrate (4F-PCC) at 25 to 50 units per kilogram intravenously (the dose is based on the INR and the weight), together with the vitamin K 5 to 10 milligrams intravenously (slowly, over 20 minutes, to avoid the anaphylactoid reaction) — the 4F-PCC reverses the INR within minutes, and the vitamin K sustains the reversal over the 6 to 12 hours (the PCC is consumed; the vitamin K restores the hepatic synthesis). The dabigatran is reversed by the idarucizumab 5 grams (two 2.5-gram vials) intravenously — the monoclonal antibody fragment that binds the dabigatran with the 350-fold higher affinity than the thrombin. The apixaban and the rivaroxaban are reversed by the andexanet alfa (the low dose 400 milligrams bolus then 4 milligrams per minute for 120 minutes, or the high dose 800 milligrams bolus then 8 milligrams per minute for 120 minutes, based on the dose and the timing of the last factor-Xa inhibitor), with the 4F-PCC as the alternative where the andexanet is unavailable. The heparin is reversed by the protamine sulfate (1 milligram per 100 units of the heparin, up to 50 milligrams).[2][3][4]
| Anticoagulant | The reversal agent | The dose | The speed of onset |
|---|---|---|---|
| Warfarin (INR elevated) | 4F-PCC + vitamin K | 4F-PCC 25–50 units/kg IV; vitamin K 5–10 mg IV over 20 min | Minutes (PCC); the vitamin K sustains |
| Dabigatran | Idarucizumab | 5 g IV (two 2.5 g vials), as two boluses | Minutes (the 100% reversal of the dilute thrombin time) |
| Apixaban / rivaroxaban | Andexanet alfa (or 4F-PCC) | Low dose 400 mg bolus + 4 mg/min × 120 min; high dose 800 mg bolus + 8 mg/min × 120 min | Minutes (the 89–93% reduction of the anti-Xa) |
| Unfractionated heparin | Protamine sulfate | 1 mg per 100 units heparin (max 50 mg), slow IV | Minutes |
| Enoxaparin (LMWH) | Protamine sulfate (partial) | 1 mg per 1 mg enoxaparin (within 8 h); ~60% neutralisation | Partial |
| Antiplatelet (aspirin, clopidogrel) | Desmopressin / platelet transfusion (selective) | Not routine; considered in the TBI with the ongoing bleed | Variable; the evidence is weak |
The anticoagulated elderly with the head injury — the reversal in steps
Recognise and resuscitate
The ABCDE; the cervical spine; the GCS and the pupils. The fall with the head strike in the patient on any anticoagulant is the indication for the immediate head CT. The two large-bore cannulae, the blood group and the crossmatch, the venous lactate and the coagulation profile (the INR, the anti-Xa, the thrombin time, the platelets), and the haematology and the neurosurgery consult are activated in parallel with the imaging.
CT head — the decision point
The non-contrast CT head is the decisive test. The intracranial haemorrhage (the subdural, the epidural, the intraparenchymal, the subarachnoid, the intraventricular) on the anticoagulated patient is the indication for the immediate reversal. The negative CT in the anticoagulated patient with the persistent symptom (the confusion, the headache, the focal deficit) mandates the repeat CT at 6 to 24 hours, because the delayed expansion is the well-described event.
Reverse the specific agent
The warfarin: the 4F-PCC 25–50 units/kg plus the vitamin K 5–10 mg IV. The dabigatran: the idarucizumab 5 g IV. The apixaban or rivaroxaban: the andexanet alfa (the low or the high dose by the timing) or the 4F-PCC where the andexanet is unavailable. The reversal is given within minutes of the CT confirmation — the delay is the preventable harm. The tranexamic acid 1 gram is given if the massive transfusion protocol is activated.<Cite id="2" />
Neurosurgical referral and the disposition
The neurosurgical referral is made immediately for the surgical evacuation (the subdural over 10 mm or the midline shift over 5 mm, the declining GCS, the pupillary asymmetry). The ICU admission for the serial GCS (hourly), the repeat CT at 6 and 24 hours, the blood-pressure control (the systolic below 160 to limit the haematoma expansion), and the seizure prophylaxis in the selected case. The anticoagulation is held; the decision to restart (and when) is the multidisciplinary one, balancing the thrombotic and the bleeding risk.
Find and treat the cause of the fall
The geriatric fall is the symptom, not the diagnosis. The syncope workup (the ECG, the orthostatic vitals, the cardiac monitoring), the metabolic workup (the glucose, the sodium, the calcium), the infection workup (the urine, the chest X-ray), and the medication review identify the reversible cause. The recurrence prevention (the pacemaker for the heart block, the dose adjustment of the antihypertensives, the physiotherapy and the home-safety assessment) begins in the hospital, not after the discharge.
RE-VERSE AD (Pollack, NEJM 2015) — idarucizumab for the dabigatran reversal
Design
Prospective cohort — 90 patients on dabigatran with the serious bleeding (group A) or the urgent procedure (group B)
Intervention
Idarucizumab 5 g IV (two 2.5 g vials)
Primary result
The maximum reversal of the dabigatran anticoagulant effect was 100% (the dilute thrombin time and the ecarin clotting time), within minutes of the administration
Key secondary
The haemostasis restored at the median of 11.4 hours; the unbound dabigatran remained below 20 ng/mL at 24 h in 79%
Bottom line
The idarucizumab completely and rapidly reverses the dabigatran — it is the specific antidote for the dabigatran-associated bleed. The thrombotic risk is real but small; the anticoagulation is restarted once the bleeding is controlled.
ANNEXA-4 (Connolly, NEJM 2016) — andexanet alfa for the factor-Xa inhibitor bleed
Design
Prospective, single-group — 67 patients with the acute major bleeding within 18 h of a factor-Xa inhibitor (rivaroxaban, apixaban, edoxaban, enoxaparin); mean age 77 years
Intervention
Andexanet bolus followed by the 2-hour infusion (the low or the high dose)
Primary result
The anti-Xa activity reduced by 89% (rivaroxaban) and 93% (apixaban) after the bolus; the clinical haemostasis excellent or good in 79% at 12 h
Safety
The thrombotic events in 18% at 30 days — the rebound thrombosis is the real concern, and the anticoagulation is restarted early
Bottom line
The andexanet reverses the factor-Xa inhibitor and achieves the effective haemostasis, but the thrombotic rate is significant — the 4F-PCC remains the alternative, and the anticoagulation is restarted as soon as the bleeding permits.
The frailty and the disposition
The frailty (the reduced physiological reserve across the multiple systems, measured by the Clinical Frailty Scale or the trauma-specific frailty index) is a better predictor of the outcome than the chronological age or the Injury Severity Score. The frail patient has the higher mortality, the longer hospital stay, the higher complication rate and the higher discharge-to-the-facility rate for the same injury. [1]
The disposition: the elderly trauma patient is admitted more readily (the observation for the occult injury, the rib-fracture analgesia and the respiratory support, the anticoagulation reversal, the physiotherapy, the social support). The goals of care discussion is held early and honestly — the resuscitation that is appropriate for the fit 70-year-old may not be appropriate for the frail 90-year-old with the advanced dementia, and the family is involved in the shared decision-making.[1][1]
The rib fractures in the elderly — the significant injury, not the minor one
The rib fracture is the injury that the junior doctor dismisses and the experienced trauma surgeon fears, when the patient is over 65. The Bulger cohort (the elderly over 65 with the rib fractures at the level-1 trauma centre) demonstrated the mortality of 22 per cent in the elderly versus the 10 per cent in the young, and the pneumonia rate of 31 per cent versus the 17 per cent, for the same number of the rib fractures and the same Injury Severity Score. Each additional rib fracture increased the odds of the death by 19 per cent and the odds of the pneumonia by 16 per cent. The rib fracture in the elderly is therefore the high-stakes injury that demands the admission, the aggressive analgesia, and the respiratory support — the under-treatment of the pain is the direct path to the splinting, the atelectasis, the pneumonia, the respiratory failure, and the death.[5]
The elderly rib-fracture management — the analgesia, the toilet, the escalation
The assessment and the admission
The mechanism, the rib count on the CT (the chest X-ray misses up to half of the the rib fractures, so the CT is the imaging of choice in the elderly chest trauma), the oxygenation, the chronic-lung-disease history, the anticoagulant status. The admission for the analgesia and the observation is the default in the patient over 65 with the rib fracture, especially the three or more, the anticoagulated, or the chronic-lung-disease.
The aggressive regional analgesia
The regional block (the serratus anterior plane block or the erector spinae plane block) is the transformative intervention — it blocks the somatic pain of the rib fractures without the sedation or the respiratory depression of the opioid, allowing the patient to breathe deeply and cough. The thoracic epidural is the gold standard for the severe flail chest or the bilateral fractures. The multimodal regimen (the paracetamol, the NSAID if no contraindication, the regional block, the cautious opioid via the PCA) is the baseline.
The pulmonary toilet and the monitoring
The incentive spirometry (the target tidal volume), the coughing and the deep breathing every hour, the early mobilisation (the chair on the day of the admission), the humidified oxygen. The pain score and the respiratory rate and the oxygen saturation are monitored hourly. The deterioration (the rising respiratory rate, the falling saturation, the fever, the rising inflammatory markers) triggers the chest X-ray and the blood cultures for the pneumonia.
The respiratory escalation
The non-invasive ventilation (the CPAP or the BiPAP) reduces the intubation rate in the elderly rib-fracture patient with the respiratory distress and the preserved mental state — it splints the chest, reduces the work of breathing, and improves the oxygenation. The intubation and the lung-protective ventilation (the low tidal volume) is reserved for the refractory hypoxaemia, the exhaustion, or the falling GCS. The high-flow nasal cannula is the intermediate option.
The trauma team activation and the triage of the elderly — the over-triage is the strategy
The elderly trauma patient is the most under-triaged group in the trauma system, because the mechanism is judged 'minor' (the ground-level fall) and the vital signs are judged 'normal' (the SBP of 115, the heart rate of 78), and the patient is therefore routed to the low-acuity area, seen late, and the occult injury is missed. The EAST geriatric guideline and the ACS field-triage criteria mandate the lower threshold for the full trauma-team activation in the patient over 55 to 65: the systolic below 110 mmHg, the GCS below 15, the anticoagulant with any head strike, the rib fractures, the long-bone fracture, and the pedestrian struck — each is the standalone indication for the trauma-team activation, regardless of the apparent mechanism severity. The deliberate over-triage (the activation for the patient who turns out to be uninjured) is the acceptable cost; the under-triage (the missed activation) is the preventable death.[1]
The occult hypoperfusion — the lactate, the base deficit, and the silent shock
The elderly trauma patient may be in the shock with the reassuring vital signs — the SBP of 120, the heart rate of 80 (on the beta-blocker), the warm peripheries. The occult hypoperfusion is revealed only by the venous lactate (over 2 mmol/L) and the base deficit (worse than minus 5 mmol/L) — the markers of the anaerobic metabolism that the compensating elderly patient hides. The serial lactate and the base deficit are the standard on the arrival of the geriatric trauma patient, and the failure to clear the lactate over the first 24 hours is the predictor of the mortality, the multi-organ failure, and the complication — independent of the vital signs. The practitioner who is reassured by the blood pressure and the heart rate, and does not measure the lactate, misses the shock until the decompensation (the sudden, the irreversible collapse of the fixed-output heart).[1][1]
Common pitfalls
The recurring errors are: accepting the normal heart rate as excluding the shock (the beta-blocker); dismissing the ground-level fall as minor; not obtaining the head CT in the elderly with the fall and the anticoagulant; not reversing the anticoagulant early; under-treating the pain of the rib fracture (leading to the splinting, the atelectasis, the pneumonia); missing the occult injury (the delayed or the atypical presentation); and not assessing the frailty or discussing the goals of care. [1]
Differential diagnosis
- The mechanical fall vs the medical fall — the trip over the rug or the curb is the mechanical fall, but the syncope (the arrhythmia, the orthostatic hypotension, the vasovagal episode), the stroke or the hypoglycaemia is the medical cause of the fall, and the underlying medical cause is sought in every geriatric fall, because the recurrence is prevented only by treating the cause.
- The traumatic head injury on the anticoagulant vs the spontaneous intracranial haemorrhage — the subdural or the intraparenchymal bleed discovered after the fall may be the traumatic consequence of the impact or the spontaneous haemorrhage that caused the fall, and the CT appearance (the location, the contrecoup pattern) and the history are weighed to distinguish them, as both drive the reversal and the neurosurgical referral.
- The occult rib fractures vs the pneumothorax or the pulmonary contusion — the pleuritic chest pain and the splinting after the low-energy fall may be the rib fractures alone, but the dyspnoea and the falling saturation raise the pneumothorax or the pulmonary contusion, and the chest X-ray (often supplemented by the CT, as the initial film misses up to half of the rib fractures) resolves the question and the chest tube or the escalation is considered.
- The cervical-spine injury vs the cervical spondylosis with the canal stenosis — the neck pain and the neurological deficit after the fall may be the fracture or the cord injury, but the chronic cervical stenosis with the central cord syndrome from the hyperextension (the fall, the face-first) produces the same presentation, and the MRI distinguishes the acute cord lesion from the chronic myelopathy.
- The shock from the occult bleeding vs the shock from the medical cause — the hypotension after the fall may be the hypovolaemia from the occult pelvic or the intra-abdominal bleed, but the cardiogenic shock (the myocardial infarction, the arrhythmia) or the septic shock (the pneumonia, the urinary infection) is equally plausible in the elderly, and the lactate, the focused assessment and the ECG are obtained to separate the traumatic from the medical shock. [1]
The exam-focused pearls — the Fellowship viva and the high-yield facts
[1]Exam practice
SAQ — The anticoagulated elderly patient with a head injury after a ground-level fall
10 minutes · 10 marks
A 78-year-old woman is brought to the emergency department 2 hours after a ground-level fall at her nursing home, in which she slipped on a wet floor and struck the left side of her head. She is on apixaban 5 mg twice daily for atrial fibrillation, metoprolol 50 mg daily, and perindopril. On arrival she is GCS 14 (confused), BP 142/88, HR 78 in sinus rhythm, SpO2 97 per cent on room air. There is a 5-cm haematoma over the left temporoparietal region. The CT head shows a thin acute subdural haematoma with a 6-mm midline shift. The apixaban was last taken 4 hours ago.
SAQ — The occult hypoperfusion and the rib fractures in the elderly trauma patient
10 minutes · 10 marks
An 82-year-old man is brought to the emergency department after a fall down five stairs. He is alert and conversational, BP 118/72 (his baseline is 165/90), HR 88 in sinus rhythm, RR 24, SpO2 92 per cent on room air. He has left-sided chest-wall tenderness and the chest radiograph shows three left lateral rib fractures (the 6th, 7th and 8th). The lactate is 3.2 mmol per litre, the base deficit is minus 5, and he is in sinus rhythm with no past beta-blocker use. The FAST is negative.
Red flags
[1]References
- [1]Jacobs DG, Plaisier BR, Barie PS, et al. Practice management guidelines for geriatric trauma: the EAST Practice Management Guidelines Work Group J Trauma, 2003.PMID 12579072
- [2]Rossaint R, Bouillon B, Cerny V, et al. The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition Crit Care, 2023.PMID 36859355
- [3]Pollack CV Jr, Reilly PA, Eikelboom J, et al. Idarucizumab for Dabigatran Reversal N Engl J Med, 2015.PMID 26095746
- [4]Connolly SJ, Milling TJ Jr, Eikelboom JW, et al. Andexanet Alfa for Acute Major Bleeding Associated with Factor Xa Inhibitors N Engl J Med, 2016.PMID 27573206
- [5]Bulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib fractures in the elderly J Trauma, 2000.PMID 10866248
- [6]Rockwood K, Song X, MacKnight C, et al. A global clinical measure of fitness and frailty in elderly people CMAJ, 2005.PMID 16129869
- [7]Nishijima DK, Gaona S, Waechter T, et al. Do EMS Providers Accurately Ascertain Anticoagulant and Antiplatelet Use in Older Adults with Head Trauma? Prehosp Emerg Care, 2017.PMID 27636529