Author: James Wallace, Dave Raven / Codes: CMP3, HMP3 / Published: 22/05/2018
Adult priority call, 3 minutes. You read the ambulance hand over, and tut to yourself. 90-year old lady, fallen down the stairs, normal observations. You wonder why they’re bothering to pre-alert you, after all… her observations are normal. You read down, and your SHO peers over your shoulder. “Ooooh, silver trauma” they say. You realise, maybe, you should not put out that priority call; maybe you need a trauma call instead.
The world’s population is getting older, more dependent on healthcare and is presenting in greater numbers to our emergency departments with complex medical, social and traumatic complaints. Trauma training and triage have traditionally been based upon the mechanism and injury patterns, with outcomes of operative intervention, massive transfusion and mortality.
Mechanisms for serious injury and trauma outcomes differ subtly compared to the younger trauma patient, and our older trauma patients may still receive injury-based care, rather than holistic patient-centred care – if their injuries actually get recognised and treated.
For example the 90-year old lady that trips in the garden and sustains a fractured neck of femur will be placed on a well-recognised pathway that will eventually have ortho-geriatric input. However, there may not be any early review of the postural hypotension that caused the fall, the delirium causing her to take the bins out at 0300 on a February morning, or that she’s mistakenly taken too much warfarin the night before because her main carer/husband has just been admitted to respite care.
Care of the older trauma patient should be patient centred, not injury centred.
What is an older patient?
Older age has always been sociologically defined as 65 or retirement age. The International Consortium on Health Outcome Measures defines older age as the last ten years of life before regional life expectancy. So a patient in parts of central London would be defined as older at 80, but a patient in parts of the North of England would be older at 70.
Frailty is also another description that is commonly and sometimes incorrectly associated with older patients. It is quite possible to be aged 20 and frail, but also aged 90 and not be frail. There are many studies looking at whether frailty is a better predictor for outcome than age in older trauma patients.
Physiology and outcome
Most prehospital and in-hospital trauma triage are based upon mechanism, injuries sustained and some physiological parameters, with various outcomes such as need for surgical intervention and mortality. Our older patients have not only a different pattern of injury and more occult injuries but the physiology of ageing may not have the traditional parameters to trigger major trauma pathways.
Older patients may have underlying hypertension, are less able to respond to hypoperfusion and are more likely to have heart rate controlling medication. Therefore, higher systolic blood pressures and lower heart rates may be a sign of hypoperfusion which, combined with reduced elasticity of blood vessels and organs leads to increased potential for occult and devastating haemorrhage.
For those patients who are in the last few years of life, increased mortality may not be the most appropriate outcome measure but perhaps quality of life, length of inpatient stay, risk of iatrogenic injury, need for permanent care and permanent disability would be applicable.
What has changed
The most recent TARN report on older persons’ trauma showed that we under triage both pre and in-hospital, do not place as many trauma team activations, have less senior reviews of older trauma patients and that the commonest mechanism for an ISS >15 was a fall from own height, with the head and thorax being the commonest body areas injured.
Several international centres have looked at different models for older persons trauma triage, using different physiological parameters and mechanisms to trigger a more senior review or trauma team activation. They essentially reduce the mechanism to trigger a trauma transfer or activation, incorporate other past medical factors such as lung/cardiac disease and anticoagulation as well as changing the abnormal parameter threshold for trauma team activation.
The Midlands Silver Trauma Group has proposed a Silver Safety Net, to try and improve the prehospital pre-alerts for older people with traumatic injuries. This is designed to assist identifying the most appropriate method of conveyance to an MTC or trauma unit, with a silver trauma pre-alert to highlight the potential need for early intervention and/or imaging but who would not need a formal full trauma team response. The group run a very informative course on Elderly Trauma and ongoing recovery at multiple sites across the country.
The care of an older trauma patient doesn’t stop in the ED- it begins there and should continue in a multidisciplinary manner throughout their stay. Whilst EM physicians may not be trained in the use of comprehensive geriatric assessments, we do begin the process during our clerking of medically unwell patients and there’s a plethora of simple tools available from our physio/occupational therapy/pharmacist colleagues that can be used as part of the initial trauma clerking to assist getting older patients back on their feet, prevent iatrogenic injury and reduce length of stay.
Delirium is very commonly missed in older trauma patients, and commonly presents in hyperactive or hypoactive states. Multiple medications, especially analgesics can contribute to delirium and other trauma induced positional complications such as atelectasis with chest wall injury, constipation and pressure sores from dehydration. The STOPP START toolkit is very useful for reviewing medication in older patients, as well as early involvement of pharmacists for polypharmacy reviews.
- There are more older patients sustaining trauma and EM physicians are in the perfect place to get their care right from the outset
- Falls from own height and head injuries are the commonest causes for high ISS and mortality
- Older patients have reduced physiological reserve to respond to traumatic insult, but their observational parameters may not show it
- Patient-centred care is more important than injury-based car
- Have a lower threshold for senior review and activation of a silver trauma team
- Older trauma patients need an MDT approach earlier in their stay
- The CGA and discharge planning can start at triage
- Beware polypharmacy and delirium
Further interesting reading:
- Geriatric Trauma RCEM Conference Podcast
- Trauma – mention of silver trauma
- TARN Major Trauma in Older People – 2017 report
- British Geriatrics Society Silver Book – Quality care for older people with urgent & emergency care needs
- STOPP START Toolkit. Screening Tool of Older People’s potentially inappropriate Prescriptions and Screening Tool to Alert doctors to Right Treatments.
- Superiority of frailty over age in predicting outcomes among geriatric trauma patients: a prospective analysis. Joseph, B. et al. JAMA Surg. 2014 Aug;149(8)
- Predicting hospital discharge disposition in geriatric trauma patients: is frailty the answer? Joseph. B, et al. J Trauma Acute Care Surg. 2014 Jan;76(1):196-200
- Predictors of mortality in geriatric trauma patients: a systematic review and meta-analysis. Hashmi, A. et al. J Trauma Acute Care Surg. 2014 Mar;76(3):894-901