Advanced Trauma Life Support ATLS Student Course Manual 2018

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CHAPTER 11 n Geriatric Trauma
Nearly every country in the world is experiencing
a growth in the proportion of older people
in their population. Older adults comprise
the fastest-growing segment of the United States’
population. In fact, by 2050 almost one-half of the
world’s population will live in a country where at
least 20% of the population is older than 60 years,
and one-fourth will live in a country where older people
comprise more than 30% of the population.
Aging of the population is expected to be one of
the most significant social transformations of the
21st century. This generation will live longer than the
preceding one and will have access to high-quality
health care. In addition, the ever-increasing mobility
and active lifestyles of today’s elderly individuals
places them at increased risk for serious injury.
Injury is now the fifth leading cause of death in the
elderly population.
Geriatric trauma patients pose a unique challenge
to trauma teams. Although the mechanisms of injury
may be similar to those for the younger population,
well-established data demonstrates increased mortality
with similar severity of injury in older adults. Failure
to properly triage elderly trauma patients, even those
with critical injuries, may be responsible in part for
the attributable mortality. Of course, failure to triage
is just one factor that impacts mortality from geriatric
trauma. Senescence of organ systems, both anatomically
and physiologically, preexisting disease
states, and frailty all play a part in placing older adults
at higher risk from trauma. Depression, substance
abuse, and maltreatment are additional factors
to consider, and screening can be accomplished
through several different tools. Acceptable outcomes
Men
depend upon proper identification of the elderly
patient at risk for death and a well-coordinated,
frequently multidisciplinary, aggressive therapeutic
approach. For these reasons, thorough evaluation
of geriatric patients at a trauma center improves
their outcomes.
Effects of Aging and Impact
of Preexisting Conditions
Declining cellular function, eventually leading to organ
failure, is part of the aging process. Therefore, aging is
characterized by impaired adaptive and homeostatic
mechanisms that cause an increased susceptibility
to the stress of injury. This condition is commonly
described as decreased physiologic reserve. Insults
commonly tolerated by younger patients can lead to
devastating results in elderly patients.
There is a large body of evidence documenting that
preexisting conditions (PECs) impact morbidity and
mortality. In a recent study, investigators identified five
PECs that appeared to influence outcomes in trauma
patients: cirrhosis, coagulopathy, chronic obstructive
pulmonary disease (COPD), ischemic heart disease,
and diabetes mellitus. In the study of more than 3,000
patients, one-fourth of individuals over the age of 65
years had one of these five PECs. Patients with one
or more of these conditions were nearly two times
more likely to die than those without PECs. The same
researchers reported on the interaction between injury
and host factors, which included age, gender, and PECs
(n FIGURE 11-1). Although injury severity was the primary
Women
Predicted increased mortality
A
0.5 3+ conditions
1-2 conitions
0 conditions
0.4
0.3
0.2
30% risk
0.1
20 30 40 50 60 70 80 90
Age (by decade)
Predicted increased mortality
B
0.5 3+ conditions
1-2 conitions
0 conditions
0.4
0.3
0.2
30% risk
0.1
20 30 40 50 60 70 80 90
Age (by decade)
n FIGURE 11-1 Risk of mortality-associated geriatric complications or death, by age and number of preexisting conditions for A. Males, and B.
Females. Note the risk of death increases with an increasing number of preexisting conditions and age. Source: Adapted with permission from
Min L, Burruss, S, Morley E, et al. A simple clinical risk nomogram to predict mortality-associated geriatric complications in severely injured
geriatric patients. J Trauma Acute Care Surg 2013;74(4):1125–1132. Copyright © 2013 Lippincott Williams & Wilkins.
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