Geriatric trauma patients face higher risks than younger adults due to age-related frailty and medical comorbidities. Ground-level falls are a leading cause of injury in older adults and can result in significant morbidity even from seemingly minor falls. Pre-existing conditions like osteoporosis, anticoagulant use, and cardiovascular disease increase complications. Rib fractures and cervical spine injuries pose particular dangers. Mortality is influenced more by injury severity, comorbidities, and medications than age alone. Proper management requires awareness of geriatric needs and tailoring care to address specific risks.

1. Geriatric Trauma
Aisling Wadden
07/09/2017

3. Geriatric Trauma
• Trauma – any presentation due to or involving
an injury or with potential to have an injury…
• Geriatric - .........>/= 65 !!

4. Be wary of the old frail faller
• Majority of trauma in elderly is ground level
falls/GLF (fall from standing height, fall off
bed, fall off chair) – in younger people this
mechanism is considered low risk/trivial
• Elderly patients high risk for significant
morbidity/mortality due to “trivial” falls etc

5. Falls
• The risk of falling is increased by
impaired eyesight due to any cause (e.g. glaucoma, macular
degeneration, incorrect glasses/lens prescription)
balance disorder
movement disorders (e.g. Parkinson's disease)
 dementia
sarcopenia (age-related loss of skeletal muscle).
• Collapse/syncope leads to a significant risk of falls/injury;
causes may include cardiac arrhythmias vasovagal syncope,
orthostatic hypotension and seizures.

6. Injuries
• Intracranial bleed
• C-Spine fractures
• Hip Fractures
• Rib Fracture
• Wrist fractures
• Internal injuries

7. Complications
• Sepsis
• Wound infection
• Delerium
• Pneumonia
• Death

9. Is being old really that dangerous?
• Age itself is not an independent risk factor?
• Mechanism of injury
• Injury severity score (ISS)
• Pre-existing conditions
• Anticoagulation use

10. “Older Age, Comorbid Illnesses, and Injury Severity Affect Immediate
Outcome in Elderly Trauma Patients” J Emerg Trauma Shock. 2017 Jul-Sep;
10(3): 146–150.
• Currently, traumatic injuries are the fifth leading cause of
death in elderly patients.
• 1027 patients aged ≥65 years who were admitted to Level I
Trauma Centre following blunt trauma*. Patients’ charts were
reviewed for demographics, ISS, mechanism of injury, pre-
existing comorbidities, Intensive Care Unit and hospital length
of stay, complications, and in-hospital mortality.

11. “Older Age, Comorbid Illnesses, and Injury Severity Affect Immediate
Outcome in Elderly Trauma Patients” J Emerg Trauma Shock. 2017 Jul-Sep;
10(3): 146–150.
• The mean age of injured patients was 78.8 ± 8.3 years (range 65–109).
• The majority of patients had mild injury severity (ISS 9–14, 66.8%)
• Falls (all low energy) was a main MOI (907, 88%) followed by motor
vehicle crush and pedestrian injury (119, 11.6%).
• Orthopaedic trauma followed by head trauma (or combined) was the
reason for hospital stay in majority of the cases (68 and 28%, respectively).
• 10% of patients had chest trauma (often ribs fractures).

12. “Older Age, Comorbid Illnesses, and Injury Severity Affect Immediate
Outcome in Elderly Trauma Patients” J Emerg Trauma Shock. 2017 Jul-Sep;
10(3): 146–150.
• Multiple comorbidities (≥3) were found in 233 patients (22.7%).
Hypertension, diabetes mellitus, and coronary artery disease (CAD) were
the most frequent comorbidities in the study group
• Chronic anticoagulation treatment was recorded in 13% of patients
• The addition of a single comorbidity increased the odds of wound
infection to 1.29 and sepsis to 1.25.

13. “Older Age, Comorbid Illnesses, and Injury Severity Affect Immediate
Outcome in Elderly Trauma Patients” J Emerg Trauma Shock. 2017 Jul-Sep;
10(3): 146–150.
• In-hospital complications were recorded in 209 (21%)
survivors (n = 991).
• Sepsis and pneumonia were the most common complications
(69 patients, 7% and 67, 6.7%, respectively).
• Any surgical site infections were found in 49 patients (4.9%).
Venous thromboembolic events were detected in 24 patients
(2.4%)

14. Mortality
• All study group mortality was noticed in 35 cases (3.4%).
• 22 patients (63%) died from severe head trauma on median post-trauma day 8 (range 1–11).
• 7 (20%) patients died from sepsis and multi-organ failure; others from severe multi-trauma and
haemorrhagic shock and high spinal injury
• Mortality increased with age - of 35 deceased, 18 (51%) were above 86 years old.
• In the group of patients who passed away during their hospital stay, a statistically significant
association was found between death and existence of certain comorbidities (CAD, renal failure,
dementia, and warfarin use; P < 0.05).
• In 29 mortality cases (83%), at least a single comorbidity was noticed versus no co-morbidities in
705 survivors (71%).
• Both age and ISS increased the odds of death as −1.08 and −2.47, respectively.

15. “Older Age, Comorbid Illnesses, and Injury Severity Affect Immediate
Outcome in Elderly Trauma Patients” J Emerg Trauma Shock. 2017 Jul-Sep;
10(3): 146–150.
• *Any types of blunt trauma mechanism were included: falls
and car accidents including both inside car injured and
pedestrian.
• Conclusion: age alone in elderly trauma population is not a
robust measure of outcome, and more valuable predictors
such as injury severity, pre-existing comorbidities, and
medications are accounted for adverse outcome. Trauma care
in this population with special considerations should be
tailored to meet their specific needs.

16. “Differences in Mortality between Elderly and Younger Adult Trauma Patients: Geriatric Status
Increases Risk of Delayed Death”
Perdue, Philip W. MD, MPH; Watts, Dorraine D. RN, PhD; Kaufmann, Christoph R. MD, MPH; Trask,
Arthur L. MD
Journal of Trauma-Injury Infection & Critical Care: October 1998 - Volume 45 - Issue
• Records from 5,139 adult patients from a Level I trauma centre were
retrospectively reviewed. Injury Severity Score (ISS), Revised Trauma Score
(RTS), early mortality (<24 hours), and late mortality (>24 hours) were
determined for elderly (>or=to65 years) and younger (16-64 years) patients.
• Mortality in elderly patients was twice that in younger patients despite
equivalent injury severity (p < 0.001), and elderly patients were more likely to
suffer later death than younger patients (p < 0.005).
• The prevalence of pre-existing disease was greater in the elderly, as was the
incidence of complications. Using logistic regression, ISS, RTS, pre-existing
cardiovascular or liver disease, the development of cardiac, renal, or infectious
complications, and geriatric status were all independently predictive of late
mortality (p < 0.05).

17. Scghed.com

18. • Cervical Spine injury

19. J Clin Med Res. 2013 Apr; 5(2): 75–83.
“Geriatric Trauma Patients With Cervical Spine Fractures due to Ground
Level Fall: Five Years Experience in a Level One Trauma Center”
Hao Wang,a,c et al.
• From 2006 - 2010, a total of 12,805 trauma patients were included
in trauma registry, of which 726 (5.67%) had sustained C-spine
fracture(s).
• Among all C-spine fracture patients, 19.15% (139/726) were
geriatric patients.
• Of these geriatric patients 27.34% (38/139) and 53.96% (75/139)
had C1 and C2 fractures compared with 13.63% (80/587) and
21.98% (129/587) in young trauma patients (P < 0.001).
• Of geriatric trauma patients 13.67% (19/139) and 18.71% (26/139)
had C6 and C7 fractures compared with 32.03% (188/587) and
41.40% (243/587) in younger ones separately (P < 0.001).
• Furthermore, 53.96% (75/139) geriatric patients had sustained C-
spine fractures due to GLF with more upper C-spine fractures (C1
and C2).

20. J Clin Med Res. 2013 Apr; 5(2): 75–83.
“Geriatric Trauma Patients With Cervical Spine Fractures due to Ground
Level Fall: Five Years Experience in a Level One Trauma Center”
Hao Wang,a,c et al.
• ICP associated with C-spine fractures were only found in geriatric patients
in this study. Seven different clinical variables could potentially be
independent risk factors associated with C-spine fractures and ICP in
trauma patients due to GLF or less. The results of our multivariate
regression showed only age (OR 1.17) and male gender (OR 91.57) were
two independent risk factors.

21. J Clin Med Res. 2013 Apr; 5(2): 75–83.
“Geriatric Trauma Patients With Cervical Spine Fractures due to Ground Level Fall:
Five Years Experience in a Level One Trauma Center”
Hao Wang,a,c et al.
• Conclusion:
• Geriatric patients tend to sustain more upper C-spine
fractures than non-geriatric patients regardless of the
mechanisms.
• GLF or less not only can cause isolated C-spine fracture(s)
but also lead to other significant injuries with ICP as the
most common one in geriatric patients.
•
• Advanced age and male are two risk factors that can
predict this co-injury pattern. In addition, it seems that
alcohol plays no role in the cause of GLF in geriatric trauma
patients.

24. Rib Fractures
• “Elderly Trauma Patients with Rib Fractures Are at Greater Risk of Death and
Pneumonia” Bergeron et al Journal of Trauma-Injury Infection & Critical Care:
March 2003
• Results: Among 4,325 blunt trauma admissions, there were 405 (9.4%)
patients with rib fractures; 113 were aged ≥ 65.
• Injuries were severe, with Injury Severity Score (ISS) ≥ 16 in 54.8% of cases, a
mean hospital stay of 26.8 ± 43.7 days, and 28.6% of patients requiring
mechanical ventilation.
• Mortality (19.5% vs. 9.3%;p < 0.05), presence of comorbidity (61.1% vs. 8.6%;p
< 0.0001), and falls (14.6% vs. 0.7%;p < 0.0001) were significantly higher in
patients aged ≥ 65 despite significantly lower ISS (p = 0.031), higher Glasgow
Coma Scale score (p = 0.0003), and higher Revised Trauma Score (p < 0.0001).
• After adjusting for severity (i.e., ISS and Revised Trauma Score), comorbidity,
and multiple rib fractures, patients aged ≥ 65 had five times the odds of dying
when compared with those < 65 years old.

25. Scghed.com
• “With regard to patients with chest injury, the earlier pain is controlled, the less likely patients will
suffer complications from inadequate pain control, splinting OR excessive narcotisation. This is
especially the important in elderly patients and patients with significant comorbidities. There is an
agreement at SCGH between Pain Service, Trauma Service and the ED, that any patient with the
following criteria should be referred to the Acute Pain Service:
• Criteria for urgent referral to acute pain team:
• > 65 years old
• OR
• significant comorbidities
• OR
• no enteral route available
• AND
• > 2 rib fractures.”

26. • Relevant pre-existing conditions:
• Frailty!
• Advanced age
• Osteopenia , osteoporosis, Degenerative joint
disease
• Anticoagulant use
• CAD/CKD/DM/COPD

27. Osteoporosis
• It is estimated that 200 million people worldwide have
osteoporosis.
• About 15% of caucasians in their 50s and 70% of those over 80 are
affected.
• It is more common in women than men.
• There are 8.9 million fractures worldwide per year due to
osteoporosis.
• Globally, 1 in 3 women and 1 in 5 men over the age of 50 will have
an osteoporotic fracture.

28. Osteoporosis – Risk Factors
• Non-modifiable:
Increasing age
Female sex
Oestrogen deficiency
(menopause/oopherecto
my)
Family History
Ethnicity – European and
Asian highest rates.
• Modifiable:
Excess alcohol
Smoking
Vitamin D deficiency
Malnutrition
?Soft drinks – displace
calcium
Immobilisation
Steroids/AEDs/Lithium/PP
Is/Anticoagulants/Thiazoli
dinediones/L-Thyroxine

29. Osteoporosis
• Treatment:
modify risk factors
Vitamin D/Calcium
Bisphosphonates – after first fracture

30. Osteoporosis
• Hip fractures  The most serious consequences of osteoporosis. A 50-
year-old caucasian female is estimated to have a 17.5% lifetime risk of
fracture of the proximal femur
• Vertebral fractures smaller impact on mortality, can lead to a severe
chronic pain of neurogenic origin, which can be hard to control, as well as
deformity.
• Wrist fractures  In the United States, 250,000 wrist fractures annually
are attributable to osteoporosis. Wrist fractures are the third most
common type of osteoporotic fractures. By the time women reach age 70,
about 20% have had at least one wrist fracture.
• Rib fractures Cause of significant morbidity in the elderly, secondary to
pain, secondary pneumonia, over-sedation from analgesia etc

31. Anticoagulation
• Warfarin: The commonest side effect of warfarin is bleeding. The risk of
severe bleeding is small but definite (a typically yearly rate of 1-3% has
been reported)
• This risk increases greatly once the INR exceeds 4.5(atraumatic bleed) and
INR of >1.5 (traumatic)
• Aspirin: Some studies show increased risk of traumatic IC bleeding but
overall risk is not increased. (?)
• Other antiplatelet agents, especially Clopidogrel associated with
significant increased risk of traumatic ICB
• NOACS -- Increased risk but not as much as Warfarin………….?

32. “Preinjury warfarin, but not antiplatelet medications, increases mortality in
elderly traumatic brain injury patients.” Grandhi R1, Harrison G, Voronovich Z,
Bauer J, Chen SH, Nicholas D, Alarcon LH, Okonkwo DO
• Preinjury use of warfarin, but not antiplatelet medications, influences
survival and need for neurosurgical intervention in elderly TBI patients
with intracranial haemorrhage; haemorrhage progression and morbidity
are not affected. The importance of antithrombotic therapy may lie in its
impact on initial injury severity.

33. “Antiplatelet therapy and the outcome of subjects with intracranial injury: the
Italian SIMEU study”
Andrea Fabbri et al Italiana di Medicina d'Emergenza Urgenza Study Group
• Conclusions: pre-injury antithrombotic therapy is associated with an
increased risk of short-term radiological worsening and six-month
unfavourable outcome in subjects with a positive head CT scan,
particularly in subjects treated by clopidogrel. The results should be
considered in predictive algorithms of future guidelines of diagnosis and
treatment of head injury.

36. References
• Scghed.com
• J Emerg Trauma Shock. 2017 Jul-Sep; 10(3): 146–150.”Older Age, Comorbid Illnesses, and
Injury Severity Affect Immediate Outcome in Elderly Trauma Patients”Dvora Kirshenbom, Zila
Ben-Zaken, Nehama Albilya, Eva Niyibizi, and Miklosh Bala
• “Antiplatelet therapy and the outcome of subjects with intracranial injury: the Italian SIMEU
study” Andrea Fabbri,corresponding author1 Franco Servadei,2 Giulio Marchesini,3 Carolina
Bronzoni,2 Danilo Montesi,4 and Luca Arietta4, of the Società Italiana di Medicina
d'Emergenza Urgenza Study Group
• J Clin Med Res. 2013 Apr; 5(2): 75–83. “Geriatric Trauma Patients With Cervical Spine
Fractures due to Ground Level Fall: Five Years Experience in a Level One Trauma Center” Hao
Wang,a,c Marco Coppola,a Richard D. Robinson,a James T. Scribner,a Veer Vithalani,a Carrie
E. de Moor,a Raj R. Gandhi,b Mandy Burton,a and Kathleen A. Delaneya
• “Elderly Trauma Patients with Rib Fractures Are at Greater Risk of Death and
Pneumonia”Bergeron, Eric MD; Lavoie, Andre PhD; Clas, David MD; Moore, Lynne MSc; Ratte,
Sebastien MD; Tetreault, Stephane MD; Lemaire, Jacques PhD; Martin, Marcel MD. Journal of
Trauma-Injury Infection & Critical Care: March 2003 - Volume 54 - Issue 3 - pp 478-485

37. References
• “Differences in Mortality between Elderly and Younger Adult Trauma
Patients: Geriatric Status Increases Risk of Delayed Death” Perdue, Philip
W. MD, MPH; Watts, Dorraine D. RN, PhD; Kaufmann, Christoph R. MD,
MPH; Trask, Arthur L. MD; Journal of Trauma-Injury Infection & Critical
Care: October 1998 - Volume 45 - Issue 4 - pp 805-810
• “Preinjury warfarin, but not antiplatelet medications, increases mortality
in elderly traumatic brain injury patients.” Grandhi R1, Harrison G,
Voronovich Z, Bauer J, Chen SH, Nicholas D, Alarcon LH, Okonkwo DO.