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| Christopher Colwell, MD FACEP |
Author: M. Kaitlin Parks, MSIV
Medical Student
Oklahoma State University COM
AAEM/RSA Publications and Social Media Committee
Interviewee: Dr. Christopher Colwell, MD FACEP
Chief of Emergency Medicine
San Francisco General Hospital and Trauma Center, Professor, UCSF
Just as any pediatrician would tell you, “a child is not just a small adult”. The same goes for the geriatric population. There are many physiologic differences in the geriatric population that are important to understand in order to deliver the best and most tailored care. An area where this is especially pertinent to the emergency physician is in the setting of trauma. A lot of what we know about trauma has come from military medicine, which sees a strong bias towards the young and healthy. As our population ages, we are seeing an increasing number of geriatric trauma patients in the emergency department (ED).[1,2] Older patients have higher morbidity and mortality in the setting of trauma.[3] Our geriatric patients are also more likely to have comorbidities and medications that both worsen their response (such as anti-coagulation and clotting) or blunt their capacity to compensate (such as beta-blockers and heart rate).[4] Age has been integrated into Trauma Triage criteria but many criteria are based on vitals that may not adequately measure the severity of select trauma cases in the geriatric population.[5]
While working in emergency medical services (EMS) before medical school, I saw trauma patients very early in their course. I often wondered if a “walking-talking” patient with no sign of injury really needed to go to a trauma center only because of their age. Now as a medical student, with some exposure to EDs around the country, I have seen examples that have certainly changed that perspective. Curious to learn more, I thought I’d ask an expert in geriatric trauma in the ED to weigh in on what I’ve read. Dr. Chris Colwell, Chief of Emergency Medicine at Zuckerberg San Francisco General Hospital and Trauma Center, serves on several state and national EMS and trauma committees. He holds many awards for his contributions to EMS and trauma care and has published over 100 manuscripts and book chapters in the areas of prehospital, emergency, and trauma care.
Kaitlin Parks (KP): How has the aging population affect the incidence of trauma related diagnoses that you see? For example: types of head injury, incidence of intrathoracic injuries, types of fractures?
Dr. Christopher Colwell (CC): The geriatric population has changed our look at trauma. We are seeing that in San Francisco as much as any place I’ve worked. One of the important things to remember is that for every injury, our geriatric trauma patients don’t tolerate them as well. Some things like head injuries that might otherwise not even need to be seen in the hospital can be life threatening for these patients. A fall from a standing position in a young person is rarely significant, yet it’s the most common presentation for an elderly trauma patient. Our geriatric patients are at risk for injuries from relatively minor mechanisms. These changes in geriatric trauma are not as impressive as far as having different types of injuries. It’s not that they break different bones, it’s that they just break all bones a lot easier and they don’t tolerate it very well.
KP: In terms of their tolerance, are you meaning complications arising from these injuries or recovery, or all aspects?
CC: It’s really all of those. Take rib fractures as an example: they are much more likely to have respiratory complications related to those rib fractures, more likely to develop atelectasis and pulmonary problems. So overall, they are going to struggle a lot more with what would otherwise be pretty straightforward fractures in younger patients.
KP: So we know this patient population is at high risk for significant injury from apparently benign mechanisms. How do you balance a thorough workup and management with their vulnerability to complications from the medical interventions, infections, and just being in the hospital in general?
CC: You’ve got to balance each patient’s presentation and risk for complications with the situation your patient is in. That’s a great challenge because the instinct is to get more CT scans, yet they don’t tolerate the contrast as well as younger patients do. So you can’t just CT scan them more and not recognize the significant complications. But we do image them more and it’s important to recognize that undiagnosed injuries in the elderly have far more serious outcomes and are far more likely to be a fatal outcome if we miss it. You have to recognize how much higher risk they are for these injuries. You have to recognize they don’t tolerate the complications from procedures as well and then balance all of those in your decision to work them up.
KP: In working on the ambulance I’ve experienced that it is often challenging to get a good history in geriatric trauma cases. You might not know [the patient’s] baseline and family members sometimes say different things. What kind of tips do you have in gathering your history of these patients to guide how aggressive a work-up you’re going to do?
CC: Both your history and your physical exam are more challenging in geriatric patients which makes it all the more important to gather what you can. In pediatric patients, your physical exam will help you rule out different issues or concerns, whereas in geriatric patients, you will run into situations where your physical exam can’t compensate for an imperfect history, or their physical exam yields less because they just aren’t as sensitive to pain.
There are certain things that can help. Use the resources you have: bring in family members, bring in EMS. I believe that is always a tool that’s under-appreciated and especially important in situations where you need all the aspects of the history that you can get. You may need to look other places like the medical record, caretakers, etc. One of the most important components to track down is the patient’s baseline. Because of the increased incidence of dementia and other chronic medical issues it’s important to appreciate what’s different from their baseline.
There’s not a truly magical way of getting a good history out of these patients. In some ways, you need an approach where you accept the information is going to be limited. It’s important to have an awareness, for example, that their peritoneum is not as sensitive so they may have significant hemoperitoneum and not express abdominal pain when you examine them. They may not be able to verbalize what they are experiencing well because of an underlying dementia — but if you are very aware of your limitations and their risk then you can work your patient up recognizing that.
Some have argued, and I think reasonably so, that age ought to be a predominant factor in trauma center designation. Some say maybe over 65, maybe over the age of 75, some say maybe any trauma should be sent to a designated trauma center. I think that’s a little bit much but I think it recognizes the high risk these patients are in.
KP: Along the lines of determining your workup, do you use things like CT head rules or other tools?
CC: Well that’s the problem — the best validated CT head rules are not studied in geriatric trauma patients, so you really can’t apply them perfectly here. You also have to acknowledge the fact that they are more likely to be on anticoagulants, which adds to the complications. So unfortunately, the best head rules we have don’t apply to geriatric patients. It doesn’t mean to totally throw them out but when we are talking about applying these to geriatric patients we have to recognize that the rules weren’t validated in geriatric patients so you’re taking a little bit of risk.
KP: Is there anything else with your physical exam or clinical clues that you use, especially if they have dementia, to evaluate their neurologic status after their injury?
CC: Sometimes it’s as simple as doing something we should be doing anyway (but absolutely in geriatric patients) such as observing the subtle things. Picking up a long bone fracture, maybe even a significant one, may be as subtle as noticing they aren’t really moving their left leg and obviously, a potential spinal injury is part of what you have to think about with that. So it’s paying attention to detail and recognizing signs that they are telling you that’s what’s hurting them.
What might be considered “normal vital signs” might be grossly abnormal in the geriatric patient. And what are often considered “dangerous vital signs,” such as hypotension or tachycardia, are a lot harder to achieve in geriatric patients. So if you, a young medical student, have a blood pressure of 128/70 and a heart rate of 80, that might be perfectly normal after an injury. But in a 78-year-old, those same numbers might represent significant hypotension and significant tachycardia. So don’t be falsely reassured. Recognize that if they are on beta blockers or calcium channel blockers for underlying hypertension, they’re not going to show the vital signs that we would normally expect in a really sick trauma patient. Again, it comes down to awareness, but a specific awareness to where we get into trouble. We get into trouble by being lulled into complacency in geriatric trauma patients.
There are some laboratory tests and imaging (particularly x-rays but also in some cases CT scans) where we can take a little more liberal approach to managing these patients. I think base deficits and lactates are overused in trauma, but probably not in the elderly. Recognize that a base deficit in the elderly patient is a bad sign, and an elevated lactate might be your first clue as to a base deficit. These are areas we recognize as “not good” in anybody, but need to be seen as “really bad” in the elderly.
KP: So it seems like awareness is a big theme with these patients. Is that correct? Is there any other advice you use that helps you manage elderly patients with many comorbid conditions?
CC: Yes, I think that’s true. A careful physical exam and recognizing you’re going to use some alternative sources for history (and pursue those) are probably the two most important things. Again, if you’re walking into a 23-year-old that tripped and fell on a sidewalk and an 83-year-old that tripped and fell on the sidewalk, you’re going in with a very different sense of potential injury there. There isn’t a great answer to this outside of paying particular attention to the subtle findings you’re going to pick up. And again, it’s something we should be doing in all of our patients, but recognizing how easy it is to miss something in geriatric patients. Nobody’s found a magic touch yet to how we can do a better job with these patients other than awareness.
KP: So does that mean you think this is an area that needs more research or investigation?
CC: Certainly we need more research and specific studies in how to recognize this, but I also think we need to be careful looking for a magic answer. Maybe that’s been part of what we’ve tried so hard to figure out, whether there is that one study or that one thing we can do on every patient. We’ve tried so hard to do that, however, we may just have to take a step back and look at the big picture, understanding that overall they’re at a higher risk. They get the same kind of injuries in most cases, but they don’t tolerate any of those injuries as well.
So there you have it: geriatric patients are not just older adults! They break more easily, have less reserve, more comorbidities, and higher morbidity and mortality in the setting of trauma. Emergency providers must advocate for this patient population, starting with our own education and maintaining a high level of suspicion when it comes to the geriatric trauma patient. We would love to hear your thoughts on this. Does this change your practice or perspective? How do you make sure to provide the best emergency care to the geriatric trauma patient?
References
1. National Center for Health Statistics: Health, United States 2013 Table 88. Available at https://www.cdc.gov/nchs/data/hus/2013/088.pdf.
2. An aging nation: the older population in the United States: population estimates and projections; current population reports. Available at www.census.gov/prod/2014pubs/p25-1140.pdf.
3. Heron M. Deaths: leading causes for 2010. Natl Vital Stat Rep. 2013(62):1-96.
4 American College of Surgeons, Committee on Trauma. Advanced trauma life support (ATLS) student course manual. 9th ed. Chicago: American College of Surgeons.
5. Zarzaur, BL, Crose MA, Magnotti LJ, et al. Identifying life-threatening shock in the older injured patient: an analysis of the national trauma data bank. J Trauma.2010(68):1134-8.