Geriatric trauma: Initial evaluation and management

INTRODUCTION — In almost every developed country, the proportion of people over 60 years of age is growing faster than any other age group because of longer life expectancy and declining birth rates [1]. As a result, more older individuals are presenting to emergency departments following trauma [2]. In addition, advances in the care of chronic diseases have increased the number of older adults with active lifestyles, which predispose them to injury [3].

Although trauma remains a leading cause of morbidity and mortality across all ages, geriatric patients differ significantly from their younger counterparts in their greater number of comorbidities [4,5], and higher risk of severe disability and death [6,7]. Older adult patients are more susceptible to injury from minor mechanisms and less able to compensate from any injury. To manage their chronic ailments, older adult patients are more likely to take multiple medications, some of which may blunt their response to the physiologic stress of trauma and increase their risk for complications [8].

This topic will review important issues involved in the initial assessment and management of trauma in older adult patients. Detailed discussions of trauma care in the adult and of the management of specific injuries are found separately. (See "Initial management of trauma in adults".)

DEFINITION — Debate continues regarding the exact age at which a trauma patient should be considered an older adult, with some suggestions starting as low as 50 [9]. One large observational study showed increased mortality, adjusted for injury severity, starting at age 70, suggesting this age is an appropriate cutoff for defining the older adult population [9]. As most studies use 65 as the threshold to define the geriatric patient (albeit often without providing evidence to support the choice), we too will use this age for the purposes of the following discussion.

It is likely more important to consider the patient's age in the context of their overall health when determining their relative risk of injury following trauma than to consider age alone. Observational studies suggest that frail older trauma patients fare worse than their healthier counterparts and that pre-existing comorbidities may be more important than chronological age [10-13].

EPIDEMIOLOGY AND MECHANISMS OF INJURY — Falls and motor vehicle crashes are the most common mechanisms of injury among older adults. However, most importantly, older adult trauma patients experience higher mortality than their younger counterparts regardless of the mechanism involved [7,14,15]. Up to one-third of all older adult patients presenting with an Injury Severity Score (ISS) greater than 15 can be expected to die while in the hospital.

Falls are the most common cause of injury in patients over the age of 65, accounting for nearly three-quarters of all trauma in this population [14,16]. According to a systematic review of 18 studies, the probability of falling at least once in any given year for individuals 65 years and older is approximately 27 percent [17]. In the United States, over 28 percent of adults aged 65 and over fell in 2014, and age-adjusted mortality from falls in older adults increased from 2000 to 2016 [18]. Older adult patients requiring emergency department evaluation for a fall are at high risk for recurrence with one study reporting a readmission rate of 14.4 percent for patients initially admitted for a fall-related injury [19]. Falls in older adults most often occur from a standing position on a level surface, with orthopedic injury (eg, hip or long bone fracture) the most common significant complication. Despite the seemingly benign mechanism in many cases, falls can lead to dire medical and economic consequences for older adult patients, including the need for tracheal intubation or blood transfusion, cervical spine or thoracic injury, and death [5,14,20,21]. Falls in older individuals are discussed in detail separately. (See "Falls in older persons: Risk factors and patient evaluation".)

Motor vehicle crashes are the second most common mechanism of injury among older patients, and the most common cause of traumatic mortality [5,14,22]. About one-quarter of all older adult victims of motor vehicle crashes sustain a chest injury (most often rib fractures), which can exacerbate preexisting cardiopulmonary disease and increases the risk of significant complications, including pneumonia and respiratory failure [23,24]. Older adults are second only to children as victims of automobile-pedestrian accidents, but account for the largest percentage of the auto-pedestrian fatalities [14,25-28]. The highest mortality rate in geriatric trauma is among pedestrians struck by a vehicle.

With all types of blunt trauma, geriatric patients are more likely to sustain injuries of all types, particularly fractures, than their younger counterparts [5,29-31]. Based largely upon retrospective data, it appears that fractures of the spine (especially of the cervical spine), ribs, hip, and extremities are among the injuries more likely to occur in older patients. (See 'Common and high-risk injuries' below.)

Burns can have a devastating effect on geriatric patients, in whom mortality is significantly higher for any size burn than in younger adults [32,33]. The authors of a retrospective study of a predictive model for older adult burn patients reported that the median lethal dose (LD₅₀) for patients aged 60 to 70 was 43.1 percent total body surface area (TBSA) burned, for those aged 70 to 80 the LD₅₀ was 25.9 percent TBSA, and for those 80 and older the LD₅₀ was only 13.1 percent TBSA [32]. (See "Emergency care of moderate and severe thermal burns in adults".)

While assaults and penetrating trauma are less common in geriatric patients, they are associated with higher morbidity and longer hospital stays than that experienced by younger adults [34,35]. Physicians should always consider the possibility of older adult abuse and suicide attempt when caring for older trauma victims. (See "Elder abuse, self-neglect, and related phenomena".)

CLINICAL ANATOMY AND PATHOPHYSIOLOGY — A number of the anatomic and physiologic changes that accompany aging place the geriatric trauma patient at greater risk of injury and death and impair their capacity to respond to the stress of severe injury. The physiology of aging is discussed in detail separately, but changes of particular relevance to trauma and their implications are briefly described below and summarized in the following table (table 1). (See "Normal aging" and "Immune function in older adults".)

Older adults have reduced vital capacity, functional residual capacity, and forced expiratory volume (FEV1), which diminishes respiratory reserve and limits the ability to tolerate even minor trauma [16,36]. Responses to hypoxia, hypercarbia, and acidosis are often blunted in older adults [37]. In addition, they are less able to compensate for metabolic disturbances and more likely to present with a normal respiratory rate despite becoming progressively hypoxic and hypercarbic, making clinical assessment challenging [38].

The myocardium of older adults becomes stiff, compromising cardiac output, and less sensitive to catecholamines, which often results in a less profound tachycardic response to hemorrhage, pain, or anxiety following trauma. The absence of an absolute tachycardia due to this blunted response may create a false sense of security on the part of clinicians. Systemic vascular resistance is increased, often contributing to baseline hypertension, which can lead to the misinterpretation of blood pressure readings following trauma when expected declines may not manifest despite the onset of shock. Put another way, the values that should be considered abnormal for vital signs are different in older patients. As an example, according to a large retrospective review of geriatric blunt trauma patients, heart rates above 90 beats per minute and systolic blood pressure less than 110 mmHg correlate with increased mortality in this population. Among younger trauma patients, comparable increases in mortality are not seen until the heart rate reaches 130 beats per minute and systolic blood pressure drops below 95 mmHg [39].

In older patients, the dura adheres tightly to the skull and bridging veins become stretched, thereby increasing the risk of subdural hemorrhage from head injury, while reducing the risk of epidural hemorrhage. In addition, there is approximately a 30 percent reduction in brain size between the ages of 30 and 70 [40]. This brain atrophy increases the space in which blood can accumulate and may delay the development of symptoms and signs associated with subdural hemorrhage. In some older adults, dementia complicates medical assessment following trauma. Cerebrovascular autoregulation declines with age, making the brain potentially more susceptible to injury during periods of systemic hypotension [41]. (See 'Head injury' below.)

Lower bone density and compliance results in increased risk for all types of fractures, particularly those of the hip, vertebra, and wrist [42]. Rib fractures are more common and associated with higher complication rates. (See 'Cervical spine injury' below and 'Chest trauma' below and 'Musculoskeletal injuries of the pelvis, hip, and extremities' below.)

AGE-RELATED RISK FACTORS

Medication and disease-related — Older individuals are more likely to have chronic disease and to take multiple medications to manage these ailments. Medications that pose special risks to the older adult trauma patient include anticoagulants, antiplatelet agents, beta blockers, calcium channel blockers, and glucocorticoids. Pre-injury beta blockade has been shown to increase the odds of death, likely due to the masking of normal physiologic responses to shock [43]. Chronic glucocorticoid use, as might be seen in patients with chronic obstructive pulmonary disease, also increases mortality in trauma [44].

Drug metabolism is altered in older adults. The increase in total body fat and reduction in lean body mass that occurs with aging increases the volume of distribution of many medications, which can prolong their duration of effect. Declines in hepatic and renal function alter the metabolism and elimination of many medications. These changes not only complicate the management of older trauma patients but also increase their risk for sustaining trauma, as found in a meta-analysis published in 2009 that reported a strong association between the use of benzodiazepines, sedative-hypnotics, and antidepressants and falls in older adults [45]. The addition of any medication is associated with a significant increase in the risk of falls among older adult patients [46]. (See "Falls in older persons: Risk factors and patient evaluation".)

Although hypertension and heart disease are the most common preexisting conditions among older adult trauma patients, hepatic disease, renal insufficiency, and cancer confer the greatest mortality risk of all comorbid medical conditions [47]. In addition, decompensated (congestive) heart failure increases mortality substantially, particularly in patients taking anticoagulants, beta blockers, or both [48].

Impact of frailty — Among older adults, evidence suggests that frailty may be a better predictor of both short- and long-term morbidity and mortality following trauma than age alone. Several scores intended to provide insight into patient frailty and its impact on trauma outcomes have been developed [49]. The Trauma-Specific Frailty Index (TSFI) is one example of a validated measure that uses a combination of comorbidities, daily activities and function, health attitude, and nutrition to create a frailty score. In a prospective, multicenter, observational study of 1321 geriatric trauma patients (mean age 77), the TSFI was an independent predictor of worse outcomes, as patients categorized as frail (n = 494) had significantly higher mortality (OR 1.93, 95% CI 1.12-3.32) and major complications (OR 3.55, 95% CI 2.26-5.57) compared with their non-frail counterparts [50]. In a small, retrospective study, use of a modified TSFI score was associated with lower 30-day readmission rates compared with the Emergency Severity Index (ESI) [51]. Although the exact clinical implications for frailty assessment await clarification, such assessment may be a useful tool when determining disposition and follow-up for older adult trauma patients.

ASSESSMENT AND INITIAL INTERVENTIONS

Problem of under-triage — Traditional physiologic parameters used to identify high risk trauma patients, such as systolic blood pressure below 90 mmHg or heart rate above 120 beats per minute, do not account for the declining physiologic capacities of older adult patients. Although there is limited prospective data to guide triage decisions about geriatric trauma patients, given the increased risk for severe injury and death in this population, we suggest that trauma patients over the age of 70 be evaluated at a trauma center with trauma team activation whenever possible, regardless of the mechanism (ie, falls from standing warrant such evaluation). A number of large, observational studies support this approach [9,52,53].

In addition we concur with guidelines published by the United States Centers for Disease Control (CDC) calling for direct transport to a trauma center for any patient 65 or older with a systolic blood pressure <110 mmHg [54]. We also believe it is reasonable to use a pulse of 90 or above as the threshold defining tachycardia, which may be a sign of hemorrhage or significant injury warranting careful investigation. We make these suggestions in the hope of helping clinicians to avoid under-triage, which is a significant problem in the management of geriatric trauma patients [55].  

Multiple observational studies demonstrate the problem of under-triage [52,56-59]. As an example, one retrospective study of 26,565 trauma patients reported an under-triage rate of 49 percent in patients older than 65 [56]. Under-triage may be due in part to lack of recognition that older adult patients are at greater risk of injury and in part to traditional triage tools (eg, vital signs, mechanism of injury, or the American College of Surgeons Committee on Trauma triage criteria) that may be relatively insensitive for signs of injury in older patients. The impact of insensitive triage criteria is supported by several retrospective studies, including a review of 51,227 adult trauma cases in which many of the classic physiologic criteria used for trauma team activation, such as blood pressure and heart rate, failed to predict hospital mortality in geriatric trauma patients [52,57]. In this study, trauma team activation occurred significantly less often for older adult patients (14 versus 29 percent) despite a similar percentage of severe injuries (defined as Injury Severity Score >15). Under-triaged geriatric patients injured from ground-level falls have a higher mortality rate than younger adults injured from more severe mechanisms and evaluated by a trauma team [60]. It is likely that under-triage has multiple causes. Some researchers suggest that inadequate training of clinicians and age bias contribute to the problem [61,62].

Under-triage is particularly concerning given studies that show improved outcomes when older adult patients with significant injuries are taken to level one or level two trauma centers [63]. In addition, advancing age is associated with an increasing risk of death even among minimally injured patients, according to another large retrospective study [55].

Another problem in geriatric trauma is the implementation and consistent use of appropriate triage criteria. In an observational study comparing the periods before and after geriatric trauma criteria were introduced to a state EMS system, researchers found that the proportion of older adults meeting the criteria for trauma center transport increased substantially after the introduction but no actual increase in trauma center transports occurred [64].

History — It is important to obtain a precise history whenever possible, although this can be challenging with some older adult trauma patients. A general discussion of the history in adult trauma is found separately. (See "Initial management of trauma in adults", section on 'History'.)

In addition to standard inquiries about events and mechanism, important questions to ask older patients (or their family members, emergency medical services (EMS) personnel, or others who may have insight) include:

●What happened immediately before the trauma (eg, altered consciousness, difficulty breathing, change in vision)?

●What medications is the patient taking (eg, anticoagulant, antiplatelet, beta blocker, calcium channel blocker)?

●What underlying illnesses does the patient have (eg, cardiovascular or renal disease, diabetes)?

●What was the patient's baseline level of motor and cognitive function prior to the traumatic event?

●Does the patient have a written advanced directive or a health care proxy that may be useful for determining the goals of care?

Prehospital management — Emergency medical services (EMS) providers must be taught that minor trauma, such as falls from standing and minor motor vehicle accidents, can cause significant injuries and even death in geriatric patients. We suggest that trauma patients over the age of 70 be evaluated at a trauma center whenever possible, regardless of the mechanism of injury [65]. (See 'Problem of under-triage' above.)

In addition to the relatively common injuries sustained in trauma, older adult patients are more likely to sustain otherwise rare injuries, such as C1 or C2 cervical spine fractures, which may result from a simple fall onto a hard surface. At the same time, older adult patients do not tolerate standard cervical spine motion restriction procedures as well as their younger counterparts. While there are no hard and fast rules, provider judgment may be needed to determine when spinal motion restriction is necessary and how this can best be accomplished. This might entail allowing for slight (<30 percent) elevation of the head of the bed or foregoing a rigid backboard or cervical collar.

Based upon evidence of increased morbidity and mortality among older trauma patients, a number of specialists advocate transport to a trauma center and activation of the trauma team based solely upon patient age regardless of the mechanism of injury [52,55,66]. As an example, one retrospective observational study of 883 trauma patients aged 70 or older reported a mortality rate of 16 percent among the 660 "stable" patients who did not meet any standard trauma team activation criteria [52]. Another retrospective cohort study of 87 geriatric patients with significant pelvic fractures reported a lower complication rate among those transported directly to a level one trauma center compared to those brought to a non-trauma center [67].

Nevertheless, evidence about the appropriate transport and evaluation of older trauma patients is limited and other groups use different criteria. As an example, the American College of Surgeons (ACS) recommends transport to a designated trauma center for trauma patients over the age of 55 regardless of mechanism or apparent severity [68].

Primary survey

Overview — The standard primary survey is appropriate for the management of older trauma patients and is reviewed in detail separately. Issues of special importance in older trauma patients are discussed here. Although older trauma patients are at increased risk of death and disability, many respond well to resuscitative measures and aggressive management is appropriate [69,70]. Of note, blunted responses to hypoxia, hypercarbia, and acidosis can delay clinical signs of distress in older trauma patients. Therefore, providers should assume that serious injuries are likely to be present even when concerning clinical findings are not apparent initially. (See "Initial management of trauma in adults", section on 'Primary evaluation and management' and "Normal aging", section on 'Respiratory system'.)

Airway and breathing — When performing the primary survey in an older adult trauma patient, clinicians should look for airway anomalies that are likely to complicate management, such as limited mouth-opening (temporomandibular arthritis) and dentures. Laryngoscopy and intubation are more difficult in patients with limited mouth opening. Bag mask ventilation is often more difficult once dentures are removed; intact dentures should be kept in place should assisted ventilation become necessary. Geriatric patients have limited respiratory reserve, making early administration of supplemental high flow oxygen of great importance. According to one retrospective study of geriatric trauma patients, a respiratory rate below 10 breaths per minute is associated with a greater risk of death [71]. (See "Basic airway management in adults" and "Rapid sequence intubation in adults for emergency medicine and critical care", section on 'Preoxygenation'.)

Diminished respiratory reserve often prevents geriatric patients from compensating adequately for chest injuries. Early aggressive airway management, including tracheal intubation, may be necessary. Should rapid sequence intubation be required, the doses for drugs that may cause hemodynamic compromise, such as benzodiazepines, barbiturates, and even etomidate, should be reduced between 30 and 50 percent to minimize the risk of cardiovascular depression. (See "Rapid sequence intubation in adults for emergency medicine and critical care" and "Airway management in the geriatric patient for emergency medicine and critical care" and "Overview of advanced airway management in adults for emergency medicine and critical care".)

Although evidence is scant, older trauma patients not in need of immediate intubation but suffering from some respiratory difficulty may benefit from noninvasive positive pressure ventilation (NIPPV). In one prospective observational study of 22 patients with blunt thoracic trauma, use of noninvasive bilevel positive pressure ventilation substantially improved gas exchange and vital signs enabling 18 patients to avoid tracheal intubation [72]. (See "Noninvasive ventilation in adults with acute respiratory failure: Benefits and contraindications".)

Circulation — "Normal" vital signs in geriatric trauma patients may be substantially different from their younger counterparts, and recognizing early shock can be more difficult. Baseline hypertension is common among older patients and in the setting of trauma may contribute to a false sense of comfort on the part of clinicians when a blood pressure in the "normal" range actually represents relative hypotension. Thus, trends of vital signs are likely to be more useful than any individual measurement. Repeat measurements should be obtained frequently and all readings interpreted in light of the patient's baseline and previous readings.

The effect of medications the patient takes regularly can further obscure the meaning of vital sign measurements. Beta blockers and other antihypertensive medications commonly taken by geriatric patients can blunt the normal tachycardic response to hemorrhagic shock. This effect is compounded by the decreased sensitivity of older myocardium to circulating catecholamines. (See 'Clinical anatomy and pathophysiology' above.)

Multiple studies demonstrate the unreliability of vital signs in older trauma patients. According to one retrospective study, mortality increases among older trauma patients when their heart rate rises above 90 beats per minute and systolic blood pressure falls below 110 mmHg, while the same increase in mortality is not evident in younger patients until heart rates reach 130 beats per minute and systolic blood pressure falls below 95 mmHg [39]. Another study found evidence of tissue hypoperfusion despite "normal" blood pressures in older adult trauma patients without isolated head injury [73].

Given that vital signs may be an unreliable guide to hemodynamic status, it is important to look for signs of shock in patients who would otherwise be considered "normotensive." Signs such as subtle alterations in mental status (eg, mild confusion, somnolence, or agitation), mild tachypnea, delayed capillary refill, and low urine output may reflect hypoperfusion and early shock. (See "Approach to shock in the adult trauma patient".)

Using ultrasound as part of the primary survey to look for evidence of internal hemorrhage in older patients, who may not manifest signs of shock, is a sound approach. Ultrasound is both sensitive and specific for detecting significant hemoperitoneum in blunt trauma and is useful for detecting pneumothorax. In addition, geriatric trauma patients are at increased risk of cardiac dysfunction and ultrasound can be useful for identifying such problems. Serial examinations improve the sensitivity and accuracy of ultrasound. (See "Emergency ultrasound in adults with abdominal and thoracic trauma".)

Other tools that can help to identify hypoperfusion and shock in older adults include serial diagnostic testing using a blood lactate concentration or a venous or arterial blood gas. (See 'Diagnostic testing' below.)

Aggressive resuscitation is appropriate for the initial treatment of older adult trauma patients with hypotension or signs of hypoperfusion. One reasonable approach is to rapidly infuse a bolus of 500 mL and assess the patient's response (eg, measure blood pressure, auscultate for lung crackles), and then repeat the bolus, if needed. However, preexisting conditions such as ischemic heart disease, heart failure, or renal dysfunction can cause older adult patients to decompensate from excessive fluid administration or blood loss. Therefore, it is reasonable to begin transfusing blood products early if hypotension or signs of hypoperfusion exist, even before any crystalloid is infused. Standard ratios for transfusion of blood products are appropriate and effective in older adult trauma patients [74]. Transfusion for trauma patients with severe bleeding is discussed separately. (See "Initial management of moderate to severe hemorrhage in the adult trauma patient".)

While hemorrhage remains the most important cause of shock in older trauma patients, clinicians should be aware of other potential causes, including myocardial ischemia and pneumothorax. (See "Approach to shock in the adult trauma patient".)

As with all trauma patients, excessive crystalloid administration may be harmful. The potential benefit of permissive hypotension, and how best to define hypotension, has not been clearly established in the older trauma patient.

Disability — Obtaining an accurate assessment of neurologic function can be difficult in older trauma patients. Such patients can sustain a significant intracranial injury (eg, subdural hemorrhage) and yet manifest no neurologic deficits during their initial examination [75]. Furthermore, performing the examination can be complicated by comorbidities such as underlying dementia or changes such as reduced sensation that are part of normal aging. (See "Normal aging" and "The mental status examination in adults" and "The detailed neurologic examination in adults".)

Monitoring — Particularly in older trauma patients, who may not manifest obvious signs of injury, close monitoring is essential. Monitoring should include serial examinations, including vital signs, mental status, and reassessment of any areas of concern. There is inadequate evidence to support firm guidelines, and the frequency and intensity of reevaluation will vary depending upon the baseline health of the patient, the clinical scenario, and available resources. As a general guideline, we suggest that a relatively healthy 70 year old without an apparent severe internal injury but who was involved in significant trauma (eg, motor vehicle collision) receive a focused reassessment approximately every 5 minutes while the primary and secondary surveys are performed, every 15 minutes during the first hour after the surveys are completed, and hourly thereafter until the patient is discharged or admitted, and assuming no problem arises while in the emergency department.

In addition to a cardiac monitor and pulse oximeter, we suggest using an end-tidal CO2 monitor for any older patient with the potential for respiratory problems. This may include patients complaining of mild shortness of breath or those who sustained a seemingly minor fall with a possible chest wall injury. (See "Carbon dioxide monitoring (capnography)" and "Initial evaluation and management of chest wall trauma in adults".)

Secondary survey — Older individuals have decreased pain perception and may have difficulty localizing the pain they do experience, which increases their risk for occult injuries [48]. Thus, the clinician must perform a thorough systematic secondary survey in all older trauma patients. A detailed description of the secondary survey is provided separately; elements of particular importance in older adult patients are discussed here. (See "Initial management of trauma in adults", section on 'Secondary evaluation and management'.)

Older adult patients have a limited capacity to compensate for the physiologic stress of injury, and the secondary survey should focus on detecting signs of injury that may not be readily apparent. Among the important items to assess are alterations in mental status, especially compared to presentation, trends in vital signs, urine output, and any worsening symptoms including pain and respiratory difficulty.

Important and common injuries to keep in mind while performing the secondary survey include:

●Head (including intracranial) injury (see 'Head injury' below)

●Cervical spine injury (see "Suspected cervical spine injury in adults: Choice of imaging" and "Cervical spinal column injuries in adults: Evaluation and initial management" and "Spinal column injuries in adults: Types, classification, and mechanisms")

●Burns (see "Emergency care of moderate and severe thermal burns in adults")

●Clavicle and rib fractures (see "Initial evaluation and management of chest wall trauma in adults" and "Clavicle fractures" and "Inpatient management of traumatic rib fractures and flail chest in adults" and "Initial evaluation and management of rib fractures")

●Hip fracture (see "Overview of common hip fractures in adults")

●Pelvic fracture (see "Pelvic trauma: Initial evaluation and management" and "Minor pelvic fractures (pelvic fragility fractures) in the older adult")

The use of systematic management protocols (eg, checklist of examinations to perform during secondary survey) may improve outcomes for older adult trauma patients. A retrospective study reported improved survival and lower disability rates by adding age above 70 to the criteria for trauma team activation and instituting early intensive monitoring for these patients [76]. Another retrospective study reported reduced mortality after instituting a high-risk protocol for injured patients over the age of 75 based upon comorbidities, physiologic parameters, and the results of laboratory tests [61].

Analgesia — Pain control is essential to the management of injured older adults. Failure to provide analgesia is inhumane and increases the risk of delirium in this population. Nevertheless, some observational studies suggest that older trauma patients receive inadequate analgesia [77,78].

Opioids are best for older patients with significant pain. Fentanyl is a good choice in trauma patients because it has a rapid onset, a relatively short duration of effect, and does not cause histamine release so it is less likely to cause hypotension. Hydromorphone may also be used but has a longer duration of effect. Morphine has a toxic metabolite that is renally cleared and can cause respiratory depression and seizures if it accumulates. Sedation, urinary retention, and nausea are among the side effects of opioids. (See "Pain control in the critically ill adult patient".)

Physiologic changes (eg, decreased renal or hepatic function and altered body fat distribution) may result in higher serum drug concentrations in older adult patients given the same dose of a medication as younger individuals, so standard doses should be reduced by approximately 30 to 50 percent and then titrated to effect. Depending upon the patient's age, weight, comorbidities, and other clinical factors (eg, chronic opioid use), fentanyl doses of 25 to 100 mcg IV are reasonable for older trauma patients. (See 'Clinical anatomy and pathophysiology' above and 'Age-related risk factors' above.)

We prefer to avoid nonsteroidal antiinflammatory drugs (NSAIDs) in older adult trauma patients. Such patients are likely to have some degree of compromised renal function and are likely to be at increased risk of gastrointestinal bleeding and therefore are more susceptible to complications from NSAIDs. (See "Nonselective NSAIDs: Overview of adverse effects".)

Diagnostic testing — In general, we obtain the following laboratory studies in older adult trauma patients with known or at significant risk for major injuries:

●Blood type and crossmatch

●Blood lactate

●Arterial or venous blood gas

●Serum hemoglobin concentration and hematocrit

●Serum creatinine and BUN

●Serum glucose

●Basic serum electrolyte concentrations (including Na+, K+, Cl-, HCO3-)

●Prothrombin time with international normalized ratio (PT and INR)

●Electrocardiogram (ECG)

Indiscriminate laboratory testing is rarely helpful in initial trauma management, but additional tests may be needed depending upon clinical circumstances. As an example, it is reasonable to obtain a creatine kinase to assess for rhabdomyolysis in an older patient who may have been lying on the ground for several hours following a fall.

Lactate concentrations and base deficit measurements can be helpful in the management of geriatric patients with multi-system trauma, who are at increased risk of occult injury. For patients with signs of hypoperfusion or patients without such signs but whose initial serum lactate or blood gas results suggest hypoperfusion, we suggest obtaining repeat measurements every one to two hours. Combined with clinical parameters (eg, heart rate, urine output), serial laboratory values can help clinicians determine whether resuscitation is adequate. Rising or persistently elevated serum lactate measurements (≥2.4 mmol/L) strongly suggest ongoing hypoperfusion. (See "Initial management of trauma in adults", section on 'Laboratory tests'.)

Both lactate and base deficit are sensitive markers of hypoperfusion, even in situations where the older adult patient is "normotensive" [79]. In addition, both may help clinicians to gauge the patient's response to initial resuscitation efforts, and determine appropriate disposition (ie, whether ICU admission is necessary) and mortality risk [80]. According to one review, a base deficit greater than -6 on the admission arterial blood gas is associated with a 60 percent mortality rate in trauma patients 55 years and older [8].

Imaging studies — Given the increased risk of severe occult injury and less concern about the effects of radiation exposure, it is reasonable to use a lower threshold for performing extensive imaging studies of older trauma patients [81,82]. Older patients at risk for significant internal injury and whom it is difficult (eg, dementia, head injury) or impossible (eg, intubated) to assess adequately should be imaged liberally if possible and consistent with the goals of care. When performing computed tomography (CT) imaging in this population, contrast nephropathy is a concern and all suitable steps to prevent this complication should be taken. (See "Prevention of contrast-associated acute kidney injury related to angiography".)

COMMON AND HIGH-RISK INJURIES

Head injury — Older age is an independent risk factor for morbidity and mortality in patients with head trauma, both major and minor [21,83]. According to large retrospective studies, older adult patients with severe traumatic brain injury (defined as a sustained Glasgow Coma Scale [GCS] <9) have at least an 80 percent likelihood of death or major disability leading to placement in a long-term care facility [84]. Most head trauma in older adult patients occurs from falls. Early diagnosis and intervention is critical to reducing the dangers associated with intracranial hemorrhage. (See "Management of acute moderate and severe traumatic brain injury".)

Of note, the GCS may be less accurate in geriatric patients. Given the physiologic changes in this population, significant intracranial injury may be present even in the setting of a normal or relatively high GCS score [85,86]. (See "Stupor and coma in adults", section on 'Glasgow Coma Scale'.)

Whom to image — In nearly all cases of head trauma in geriatric patients, it is prudent to obtain a computed tomography (CT) scan of the head. In addition to the increased risk of injury in this population, the neurologic examination can be unreliable for detecting signs of significant intracranial hemorrhage [75,87]. Observational studies strongly suggest that patients with a minor mechanism of injury and no abnormalities on neurologic examination may still have significant subdural or epidural bleeding.

Although several well-validated clinical practice guidelines may be used to reduce the number of CT scans performed on younger patients with head trauma (eg, New Orleans Criteria, NEXUS II, and the Canadian CT Head Rule), they cannot be so used for older patients, as older age is an explicit criteria for obtaining imaging (>60 years in the New Orleans Criteria, >65 years in the Canadian rule and NEXUS II). (See "Acute mild traumatic brain injury (concussion) in adults", section on 'Imaging'.)

Patients taking anticoagulants

Risk of bleeding — Nearly 10 percent of older adult patients presenting with head trauma are taking warfarin, while a significant percentage take other anticoagulants or antiplatelet agents [88]. The rate of intracranial hemorrhage in asymptomatic head injury patients on warfarin approaches 15 percent in some studies [89]. Intracranial hemorrhage can occur following minimal trauma [90]. Even therapeutic anticoagulation is associated with adverse outcomes in the geriatric patient with a head injury, according to retrospective data [91]. Reversal of anticoagulation should be performed as soon as the need is recognized, as the rate and volume of bleeding are among the most important determinants of morbidity and mortality from intracranial hemorrhage [92].

Treatment of life-threatening bleeding — We concur with management guidelines from the Eastern Association for the Surgery of Trauma, which suggest that all older adult patients taking warfarin who have evidence of a post-traumatic intracranial hemorrhage on CT have their international normalized ratio (INR) corrected toward a normal range (eg, <1.6 x normal) within two hours of admission [80]. We suggest the same approach be taken with older trauma patients taking warfarin who manifest any decline in mental status or develop a neurologic deficit, or who have a supratherapeutic INR and sustained head trauma of any kind [75,93]. In resource-limited settings, reversal of anticoagulation may be necessary without confirming the presence of intracranial hemorrhage by CT.

Several treatments may be used to reverse anticoagulation, including fresh frozen plasma (FFP), vitamin K, cryoprecipitate, prothrombin precipitate complex (PCC), and possibly recombinant human factor VIIa (factor VIIa). Non-crossmatched FFP may be given initially to reduce the time required for reversal [93]. FFP should be administered using the smallest volumes possible to minimize the risk of fluid overload. For the initial treatment of potentially life-threatening bleeding, we suggest stopping warfarin, transfusing FFP (initial dose is 2 to 3 units), and administering 10 mg of vitamin K by slow intravenous infusion (eg, over 20 minutes). PCC or factor VIIa can be given instead of FFP if they are available, and the bleeding is life-threatening. The following table summarizes the initial emergency treatment to reverse anticoagulation due to warfarin in patients with life-threatening hemorrhage (table 2). Additional information about reversing warfarin is provided separately. (See "Management of warfarin-associated bleeding or supratherapeutic INR", section on 'Serious/life-threatening bleeding'.)

Some older adult trauma patients may be taking anticoagulants other than warfarin. The management of bleeding due to these agents is discussed separately, while emergency treatment to reverse anticoagulation from direct oral anticoagulants (eg, dabigatran) is summarized in the following table (table 3):

●Heparin (see "Heparin and LMW heparin: Dosing and adverse effects", section on 'Bleeding')

●Low molecular weight heparin (see "Heparin and LMW heparin: Dosing and adverse effects", section on 'Bleeding')

●Direct thrombin inhibitors (eg, dabigatran) and factor Xa inhibitors (eg, rivaroxaban, apixaban, edoxaban) (see "Management of bleeding in patients receiving direct oral anticoagulants", section on 'Anticoagulant reversal')

Observation in patients without bleeding initially — Largely due to the limited evidence available, debate continues about what constitutes appropriate observation for patients on warfarin who sustain a closed head injury but whose initial CT scan shows no acute intracranial hemorrhage. We suggest a 12-hour period of observation for such patients, with reassessment (including a focused, standardized neurologic examination) every two hours. Patients who remain clinically stable with no change in their neurologic examination during this period may be discharged.

Evidence to determine the optimal approach to observation is scant, but includes the following:

●A prospective observational study of 97 consecutive patients who sustained minor head trauma while on warfarin used a protocol of 24-hour observation followed by a second CT scan reported a 6 percent rate of delayed bleeding and identified all but two patients with such bleeding [94]. These two patients were admitted two and eight days later with symptomatic subdural hematomas but neither required surgical intervention. It is not clear from this study whether a shorter observation period or symptoms alone would have identified those with a delayed bleed.

●Another prospective observational study assessed immediate and delayed bleeding in 1064 patients who sustained blunt head trauma while on anticoagulants and found a higher prevalence of immediate hemorrhage in patients receiving clopidogrel (33 out of 276, 12 percent) compared to warfarin (37 out of 724, 5.1 percent) (relative risk [RR] 2.31; 95% CI 1.48-3.63) [95]. The study found few delayed bleeds in either group (4 out of 687 warfarin patients; 0 out of 243 clopidogrel patients).

Cervical spine injury — The major clinical decision rules used to assess cervical spine injury, including the National Emergency X-Radiography Utilization Study (NEXUS) [96] and the Canadian Cervical Spine Rule [97], are less sensitive in excluding cervical spine fractures in older adult patients (>65 years). This is because the incidence of cervical spine injury is greater in geriatric patients, and evaluation is more difficult (history and examination may be less sensitive for injury) [98-101]. The effectiveness and application of these decision rules to trauma patients, including geriatric patients, are discussed separately. (See "Cervical spinal column injuries in adults: Evaluation and initial management", section on 'Clinical decision rules'.)

Older adult patients can sustain cervical fractures from seemingly minor mechanisms, such as a fall from a standing position [24,101,102]. In a systematic review of studies that included adults ≥65 years old who sustained low-level falls (eg, fall from sitting, level ground, or no more than two steps; 21 studies, 17,192 patients), researchers found that approximately 4 percent suffered a cervical spine fracture, dislocation, or ligamentous injury [101].

In particular, high cervical fractures (eg, odontoid) are significantly more common [98]. Type II odontoid fractures are among the most common cervical spine fractures in older adults (image 1) [29]. Conditions such as cervical stenosis and degenerative rheumatoid and osteoarthritis, which are also more common in older patients, make the spine more vulnerable to fracture and the interpretation of plain radiographs more difficult. In addition, both the history and physical examination may be less sensitive for detecting injury in older adult patients [99,100]. Therefore, liberal use of advanced imaging studies (eg, computed tomography) is warranted for those at risk for spinal injury.

Central cord syndrome is a complication of cervical spine injury that occurs more often in older trauma patients. It is most frequently the result of a hyperextension injury in individuals with long-standing cervical spondylosis and is characterized by disproportionately greater motor impairment in upper compared with lower extremities, bladder dysfunction, and a variable degree of sensory loss below the level of injury. (See "Anatomy and localization of spinal cord disorders", section on 'Central cord syndromes'.)

Chest trauma — Rib fractures are the most common chest injury sustained by older adult patients and are associated with an increased risk of complications and death [30,103-106]. Given these risks, admission and close observation is generally indicated for older patients with even one rib fracture, and advanced imaging is warranted in older patients with multiple rib fractures. Many older patients, especially those with three or more rib fractures or any sign of respiratory difficulty, are admitted to an intensive care setting. Disposition of patients with rib fractures is reviewed in greater detail separately. (See "Initial evaluation and management of rib fractures", section on 'Disposition'.)

The initial management of chest wall trauma and thoracic injury are discussed separately. (See "Initial evaluation and management of blunt thoracic trauma in adults" and "Initial evaluation and management of chest wall trauma in adults" and "Initial evaluation and management of rib fractures".)

A systematic review of studies of risk factors for death following blunt chest wall trauma confirmed that older adults are at significant risk of complications (eg, pneumonia, pulmonary contusion) and mortality with even three or fewer non-displaced rib fractures [104]. In this review, the major risk factors for mortality following blunt chest wall trauma were age 65 years or older, three or more rib fractures, and pre-existing cardiopulmonary disease. According to one retrospective cohort study, mortality increases by approximately 19 percent for each rib fracture in patients over the age of 65 [30].

Another systematic review of data from the United States National Trauma Data Bank that included several hundred thousand patients with rib fractures found that control of pain with neuraxial blockade and intensive care unit (ICU) admission were associated with reduced mortality among patients older than 65 years with three or more rib fractures, but that eligible patients often did not receive these interventions [107].

Abdominal trauma — Although abdominal injury patterns are similar in older and younger adult trauma patients, diminished pain sensation and increased laxity of abdominal wall musculature make the abdominal examination less reliable in geriatric patients. Thus, early evaluation to detect intraperitoneal hemorrhage (most often using ultrasound) is important. (See "Emergency ultrasound in adults with abdominal and thoracic trauma" and "Initial evaluation and management of blunt abdominal trauma in adults".)

In stable patients, it is best to obtain a CT scan if intra-abdominal injury is suspected. The risk of contrast-induced nephropathy is higher in older adult patients, particularly in the presence of hypovolemia, chronic renal disease, or diabetes, and measures should be taken to avoid this complication. (See "Initial evaluation and management of blunt abdominal trauma in adults" and "Prevention of contrast-associated acute kidney injury related to angiography" and "Contrast-associated and contrast-induced acute kidney injury: Clinical features, diagnosis, and management".)

It is best to obtain early surgical consultation for known or suspected intra-abdominal injury because such injuries can be difficult to assess in older patients and because operative management of solid organ injuries (eg, splenic injury) may be preferable to non-operative management [108]. Strategies for reversing anticoagulation in older adults with significant bleeding are discussed above. (See 'Treatment of life-threatening bleeding' above.)

Musculoskeletal injuries of the pelvis, hip, and extremities — Musculoskeletal injuries are the most common type of injury sustained by geriatric trauma patients. Many of these injuries are associated with increased mortality in this population [5]. Hip fractures are the most common injury requiring hospital admission [22]. Plain radiographs are often sufficient to identify hip fractures, but magnetic resonance imaging may be needed to assess occult fracture. (See "Overview of common hip fractures in adults".)

Pelvic fracture patterns among older adult patients with major trauma are similar to younger adults, although lateral compression fractures may be more common [109]. Following minor trauma, older adult patients may sustain fractures of the pubic rami or sacral ala, as well as hip fractures and other more common injuries. (See "Pelvic trauma: Initial evaluation and management" and "Minor pelvic fractures (pelvic fragility fractures) in the older adult".)

Regardless of type, pelvic fractures in older adults are associated with significantly greater morbidity, including major hemorrhage, and mortality [37,110,111]. One review of geriatric trauma reported a mortality rate of up to 30 percent in older adult patients from acute or delayed complications of pelvic fractures [112]. A retrospective study of 234 older adult patients with pelvic fractures found that patients over the age of 55 were four times more likely to die from complications of their pelvic fracture than younger patients [110]. The authors suggest that every older adult patient with a pelvic fracture be considered hemodynamically unstable until proven otherwise. Strategies for reversing anticoagulation in older adults with significant bleeding are discussed above. (See 'Treatment of life-threatening bleeding' above.)

Given the increased risks associated with pelvic fractures in this population, we suggest taking an aggressive approach to identifying and stopping bleeding. The approach will vary by institution, but early surgical consultation and investigation (eg, angiography, CT-angiography) is warranted in any geriatric patient with a pelvic fracture, other than a minor fracture of a pubic ramus, and evidence of hemorrhage (eg, elevated heart rate, ongoing transfusion requirements, pelvic hematoma on standard CT) [37].

In addition to hip and pelvis fractures, other common injury sites include the distal radius and ulna, proximal humerus, and clavicle [113]. As many of these extremity injuries too are associated with increased mortality, clinicians should look carefully for such fractures when evaluating geriatric trauma patients [5].

Skin wounds — Older adult trauma victims are more likely to sustain skin tears and other superficial wounds. Although these injuries often require longer to heal than comparable wounds in younger patients, management is essentially the same. (See "Basic principles of wound management" and "Clinical assessment of chronic wounds" and "Minor wound evaluation and preparation for closure".)

DISPOSITION — Disposition of the geriatric trauma patient depends upon their underlying health and the injuries sustained or suspected. Admission or transfer to a trauma center is appropriate for patients over the age of 65 with an injury from blunt chest trauma (even a single rib or clavicle fracture), blunt abdominal trauma associated with any symptoms or findings, head trauma with any alteration in mental status or other sign of injury (eg, hemotympanum, retroauricular ecchymosis), extremity trauma that limits the patient's ability to perform activities of daily living, or concerning symptoms such as pain that is not easily controlled or shortness of breath. Transfer to a trauma center should not be delayed in order to complete imaging studies. Special care should be taken with older patients who have significant underlying comorbidities such as cardiopulmonary disease, as such conditions dramatically increase the risk for adverse outcomes following trauma. (See 'Age-related risk factors' above.)

In addition to the general guidelines above, we suggest admission to an intensive care setting in a trauma center whenever possible for older adult patients with significant injury to one or more organ systems, two or more rib fractures, a serum lactate concentration ≥2.4 mmol/L, or concerning vital sign trends (eg, increasing heart or respiratory rate), even if the absolute measurements are not grossly abnormal.

Potential causes of trauma in older adults include cardiac syncope, myocardial infarction, infection, and stroke. Therefore, determining the cause of trauma is another potential reason for admitting the older adult patient to the hospital. Advanced age is not an absolute predictor of poor outcome following trauma and should not be used as the sole criterion for denying or limiting care [80]. The Geriatric Trauma Outcome Score (GTOS) is a useful tool for assessing in-hospital mortality risk in the injured older adult patient [114-116].

Older adults found to have only minor injuries from trauma, no concerning underlying medical cause, and appropriate social supports and medical follow-up may be discharged. The importance of follow-up cannot be overemphasized. Among older adults who are discharged appropriately from the emergency department following minor injury, a substantial number experience functional decline following the incident. As an example, in a prospective, multicenter study of nearly 3000 adults over the age of 65 discharged home following minor trauma, 17 percent (95% CI 12.5-23 percent) experienced a significant functional decline over the subsequent six months [117]. Thus, it is important to ensure that appropriate follow-up is arranged. This may include assessments by primary care, physical therapy, visiting nursing, and social services. (See "Comprehensive geriatric assessment".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: General issues of trauma management in adults".)

SUMMARY AND RECOMMENDATIONS

●Definitions and epidemiology – There is no clear definition of geriatric trauma; we consider patients 65 and older to be geriatric. Geriatric patients have greater morbidity and mortality for virtually all traumatic injuries and mechanisms. Even apparently benign mechanisms (eg, fall from standing) can cause significant injury. With proper care and appreciation for the differences in injured older adults, a return to baseline functional status is a reasonable expectation for many patients, including those with major injuries. (See 'Definition' above and 'Epidemiology and mechanisms of injury' above.)

●Anatomy and physiology – Multiple anatomic and physiologic changes that accompany aging place the geriatric trauma patient at greater risk of injury and death, and impair their capacity to respond to the stress of injury (table 1). In addition, older patients frequently have pre-existing conditions that diminish physiologic reserve and take medications that mask signs of injury. Clinicians must remain vigilant, even in the setting of "normal" vital signs and "minor" mechanisms. (See 'Clinical anatomy and pathophysiology' above and 'Age-related risk factors' above.)

●Under-triage – Geriatric trauma patients are chronically under-triaged, increasing their risk for morbidity and death. We suggest that trauma patients over the age of 70 be evaluated at a trauma center with trauma team activation whenever possible, regardless of the mechanism. In addition, we suggest that any patient 65 or older with a systolic blood pressure <110 mmHg be transported directly to a trauma center for evaluation, and that a heart rate of 90 be used as the threshold for tachycardia in patients in this age group. (See 'Problem of under-triage' above.)

●History – In addition to the standard trauma history, the following questions are important to address with geriatric trauma:

•What happened immediately before the trauma (eg, altered consciousness, difficulty breathing, change in vision)?

•What medications is the patient taking (eg, anticoagulant, antiplatelet, beta blocker, calcium channel blocker)?

•What underlying illnesses does the patient have (eg, hypertension, cardiovascular or renal disease, diabetes)?

•What was the patient's baseline level of motor and cognitive function prior to the traumatic event?

•Does the patient have a written advanced directive or a health care proxy that may be useful for determining the goals of care?

●Airway and breathing – Blunted responses to hypoxia, hypercarbia, and acidosis can delay clinical signs of distress in older adult trauma patients. Serious injuries are likely to be present even when concerning clinical findings are not apparent initially. Diminished respiratory reserve often prevents patients from compensating adequately for chest injuries. Early aggressive airway management may be necessary and may include tracheal intubation or noninvasive positive pressure ventilation. (See 'Overview' above and 'Airway and breathing' above.)

●Circulation – "Normal" vital signs in geriatric trauma patients may be substantially different from their younger counterparts; recognizing early shock is more difficult. Baseline hypertension is common and can cause relative hypotension to be misinterpreted as a blood pressure in the "normal" range. The effect of medications (eg, beta blocker) can obscure the meaning of vital sign measurements. Trends of vital signs are often more useful than any individual measurement. (See 'Circulation' above.)

Aggressive resuscitation is appropriate for the initial treatment of older adult trauma patients with hypotension or signs of hypoperfusion. One reasonable approach is to rapidly infuse a bolus of 500 mL, assess the patient's response, and repeat the bolus if needed. However, preexisting conditions such as ischemic heart disease, heart failure, or renal dysfunction can cause older adults to decompensate from excessive fluid administration or blood loss. Therefore, it is reasonable to begin transfusing packed red blood cells if hypotension or signs of hypoperfusion persist after just 1 or 2 L of crystalloid are infused. (See 'Circulation' above.)

●Monitoring – As older trauma patients may not manifest obvious signs of injury, close monitoring is essential. Monitoring should include serial examinations, including vital signs, mental status, and reassessment of any areas of concern. In addition to a cardiac monitor and pulse oximeter, we suggest using an end-tidal CO2 monitor for any older patient with the potential for respiratory problems. (See 'Monitoring' above.)

●Diagnostic testing – We obtain basic laboratory studies in older adult trauma patients with known or at significant risk for major injuries. These studies are listed in the text. Lactate concentrations and base deficit measurements can be helpful in the management of geriatric patients with multi-system trauma, who are at increased risk of occult injury. (See 'Diagnostic testing' above.)

●Secondary survey – A thorough systematic secondary survey is necessary for all older adult trauma patients. Important and common injuries to keep in mind include: head (eg, intracranial) injury, cervical spine injury, major burns, clavicle and rib fractures, hip fracture, and pelvic fracture. (See 'Secondary survey' above and 'Common and high-risk injuries' above.)

●Intracranial hemorrhage and cervical spine injury – Older age is an independent risk factor for morbidity and mortality from head trauma. Thus, in nearly all cases of head trauma in geriatric patients, it is prudent to obtain a computed tomography (CT) scan of the head. The management of patients taking anticoagulants is described in the text. High cervical fractures (eg, odontoid) are more common in older adult patients. (See 'Head injury' above and 'Cervical spine injury' above.)

●Abdominal trauma – Diminished pain sensation and increased laxity of abdominal wall musculature make the abdominal examination less reliable in geriatric patients. Early evaluation to detect intraperitoneal hemorrhage (eg, using ultrasound) is important. In stable patients, it is best to obtain a CT scan if intra-abdominal injury is suspected. The risk of contrast-induced nephropathy is higher in older adult patients and preventative measures should be taken. (See 'Abdominal trauma' above.)