Geriatric Trauma

Introduction

• Elderly patients in the United States are increasingly active later in life due to improved health, better management of chronic diseases, and improved nutrition. The population aged 65 years and older is projected to double by 2060, and the population aged 85 years and older to triple over the same period.¹
• This more independent population is thus more prone to trauma exposures, notably ground-level falls and motor vehicle collisions. The number of elderly trauma patients has risen annually and accounts for over 25% of all trauma emergency department (ED) visits.²
• These patients, even without previously diagnosed comorbidities, bring unique physiology and injury patterns requiring tailored management.

Physiology of Aging

• The aging process results in decreased physiologic reserve, impaired homeostasis under stress, and diminished crosstalk between organ systems, which predisposes to worse outcomes for a given injury.
• Frailty is a state of vulnerability to internal and external stressors due to decline in reserve and function and is a key predictor of poor outcomes.
• Frail patients are more likely to experience complications, prolonged stays, intensive care unit admissions, functional decline, and need for skilled nursing placement.³
• A variety of instruments exist to evaluate frailty. One such tool is the Trauma-Specific Frailty Index, which has been shown to correlate with higher adjusted odds of mortality, major complications, readmissions, and fall recurrence.

• Sarcopenia is characterized by a loss of muscle mass that both predisposes one to trauma while also correlating with worse functional status after trauma.⁵
• Osteoporosis and falls are common causes of fragility fractures, particularly of the distal radius, hip, and pelvis. Hip fractures carry a high one-year mortality and substantial functional loss and morbidity.
• Older adults are frequently under-triaged at every point of care (prehospital, ED, and inpatient). Blunted tachycardic responses, baseline hypertension, impaired autoregulation, and medication use (such as beta blockers) can mask shock. Revised thresholds (systolic blood pressure less than 110 mmHg, heart rate more than 90 bpm) and age-adjusted shock indices improve detection.⁴

Preoperative Evaluation

• Table 2 summarizes the physiologic changes in the geriatric population and their clinical implications.
• Please see the OA summaries on the cardiovascular, pulmonary, and central nervous system changes with aging.

• Identification of any relevant medical directives and healthcare proxy documentation, with careful review and consideration of these factors, to guide further therapy
• Anesthesia providers should be aware of the potential for the use of alcohol or recreational drugs, whether acutely or chronically.
• Elder abuse is not uncommon and should be considered a differential diagnosis with all medical staff having an obligation to act if there is concern.
• Falls with prolonged down times are associated with dehydration, pressure injury and necrosis, rhabdomyolysis, hypothermia, renal injury and electrolyte derangements.

Anesthetic Implications

• The current literature best analyzes hip fractures in the context of geriatric trauma.
• The 2021 RAGA study did not show a significant difference in delirium rates between patients receiving general anesthesia or regional anesthesia for hip fractures.⁵
• The REGAIN trial and subsequent analyses concluded that spinal anesthesia was not superior to general anesthesia with respect to mortality, independent walking, delirium, or length of hospital stay.⁶
• The 2020 HIP ATTACK trial did not show a mortality or major complication benefit for accelerated surgery timelines (<6 hours). However, data showed lower rates of postoperative delirium, fewer urinary tract infections, shorter hospital stays, and earlier mobilization in the accelerated timeline group.⁷
• No appreciable difference was found between TIVA and volatile anesthetics.⁸
• The 2019 ENGAGES trial did not show a reduction in postoperative delirium rates with the use of processed EEG, and a follow-up analysis did not show a mortality benefit at 1 year.⁹

Reversal of Anticoagulation

• Reversal of anticoagulation is often indicated with these patients who may have uncontrolled hemorrhage or intracranial bleed. However, this needs to be balanced against the risk of clotting associated with anticoagulation reversal, which is particularly important for patients who have undergone recent arterial stenting.
• Please see the OA summary on anticoagulants for more details. Link
• Reversal of Common Medications

Transfusions in the Elderly

• Blood transfusion is a core component of trauma management and hemorrhagic shock.
• The 2019 review of the Trauma Quality Improvement Program database found that in-hospital mortality increased proportionally with both age and the amount of blood transfused.¹⁰
• Balanced resuscitation in a 1:1:1 fashion (packed red blood cells: fresh frozen plasma: platelets) should be used in damage-control resuscitation.
• Restrictive resuscitation guidelines with transfusion thresholds of hemoglobin less than 7g/dL apply to hemodynamically stable patients and should be used with caution in acute trauma patients. Traumatic brain injury and patients displaying signs of myocardial ischemia may benefit from a higher Hb threshold (9g/dL).

Practical Tips for Trauma Anesthesia in the Elderly

• A thorough preoperative evaluation should be undertaken whenever possible, particularly the patient’s past medical history, medication history, and frailty.
• The invasiveness of the procedure should be in keeping with the patient’s stated goals of care, and this should be discussed with the surgical team before proceeding.
• The urgency of surgery must be balanced against the need for further workup and testing.
• Perioperative blood requirements and cardiac arrest resuscitation should be discussed with the patient before anesthesia.
• Morbidity and potential complications, in particular post op delirium and cognitive decline, need to be discussed with the patient and legal decision maker.
• Preoperative bedside point-of-care ultrasound can help guide fluid resuscitation.
• Elderly patients have multiple reasons for decompensation, and these need to be systematically considered for appropriate management to avoid harm.
• Invasive monitoring (arterial and central lines) may need to be placed prior to induction.
• Anesthetic drug selection and dosing should take into account the physiology and pharmacokinetics of the elderly patient.
• See the OA summary “Pharmacological Changes With Aging: Inhalational and Intravenous Anesthetics.” Link
• EEG monitoring can help avoid excess sedation.
• Perioperative risk stratification should be undertaken, and the patient should be admitted to the intensive care unit for postoperative monitoring if reaching thresholds as per institutional policy.
• Multimodal analgesia and regional techniques may decrease postoperative complications.