GERIATRIC TRAUMA

Presented by Cathrine Diana

PG trainee IIOral and maxillofacial surgery

CONTENT

• Introduction• Epidemiology• Demographic content• Pathophysiology • Incidence of trauma• Various Types of fracture &management• Summary

INTRODUCTIONAgeing:• The normal predictable and irreversible changes of various

organ system over the passage of time which ultimately leads to death

WHAT IS GERIATRIC?

• Dictionaries define 'geriatric' as 'pertaining to old people'

• The World Health Organization (1963) has defined 'middle-

age' as being 45-59 years, 'elderly' as being 60-74 years and

the 'aged' as over 75 years of age

• Most developed countries have accepted the chronological

age of 65 years as a definition of 'elderly' or older person

DEMOGRAPHIC DATA

• India’s older population will increase dramatically over the

next four decades. India’s 60 and older population is expected

to encompass 323 million people, a number greater than the

total U.S. population.

• Today’s issue on ageing issue 25, march 2012

• Bloom (2011a) calls the share of India’s population ages 50 and

older relatively small at 16 %, but notes that India will

experience rapid growth among this age group.

• The United Nations Population Division projects that India’s

population ages 50 and older will reach 34 % by 2050 (UN

2011)

• Today’s issue on ageing issue 25, march 2012

>65 years old > 80 years

• 2010 5% 1%

• 2050 14 % 3%

• life expectancy

• In 1774 - 35 years,

2010 - 74 years

2050 - still more

Today’s issue on ageing issue 25, march 2012

EPIDEMIOLOGY

• Increased life expectancy due to • Improved health• Better nutrition• Social support• Improved technology• Improved medical facilities and awareness

GERIATRIC TRAUMA

• A study by Ferrera et al in 2000, 94% of the reported

mechanism of injury (MOI) in the geriatric population

was due to falls, motor vehicle crashes and pedestrian

related accidents

• 55% of the hospitalizations for trauma were due to low-

mechanism falls (LMFs)

• Traditionally the geriatric patients with trauma have been triaged in a similar fashion and by the same guidelines as our adult population. However, several studies have revealed that these two populations have different survival rates from similar trauma.

• The most common fractures in elderly population

• rib,

• distal radius,

• pelvic ring, (25%),

• facial bones, 10.1%

• Proximal femur (25%)

• proximal humerus,

• clavicle, (24%),

• ankle, and sacrum.

• The injuries associated with the highest mortality rates were

fractures of the cervical spine with neurological deficit (47%),

at the C2 level (44%),

PATHOPHYSIOLOGY IN ELDERLY

• 13% -disability that affects at least one activity of daily

living.

• > 1/4th are underweight and

• 1/3rd undiagnosed hyper tension.

PRE EXISTING CONDITION

• PECs with the strongest effect on mortality• hepatic disease - 5.1,• renal disease - 3.1 • Cancer - 1.8.• Chronic steroid use increased the odds of death after trauma

PULMONARY SYSTEM

• functional capacity & lung elasticity.

• breathing effort is mainly depend on diaphragm • This negatively impacts tidal volume• chronic obstructive pulmonary disease (COPD) and the

patient's ability to compensate during stress can be severely impaired. • Micro aspiration is more common in old age group.• Therefore, seemingly minor injuries, can cause significant

respiratory compromise.

Cardiovascular system

• Impaired cardiac output • Lower heart rate and stroke volume

• Decreased catecholamine responsiveness • Decrease circulating blood volume (diuretics) • Diastolic dysfunction/hypertension • Lower myocardial cell mass SBP < 100 mm of Hg consider as a state of shock – one of the cause for morbidity in elderly injured patients.

CENTRAL NERVOUS SYSTEM Cerebral atrophy shrinkage of the brain

tension on the cerebral veins tear more easily

subdural hematomas.

• Due to cerebral atrophy, there is gap between skill box and

the brain, so even a blunt injury , may not cause skull bone

fracture, but cause significant brain damage.

Impairment :

• cognitive function,

• memory,

• hearing and vision,

• perception.

• Dementia affects 20% of the elderly above 80 years of age. • Alzheimer’s diseases, • depression related cognitive dysfunction

RENAL SYSTEM

• Decreased renal function can impact the patient's ability to survive a protracted recovery period.• Impaired concentrating ability • creatinine clearance

Loss of nephrons 40- 50% Reduction in GFR

responsiveness to renin-angiotensin-aldosterone

renal blood flow due to changes in vessels (50%)

loss of muscle mass leads to low creatinine level

• Immune response• Production of T-cells, B-cells risk for infection• Changes in endocrine system • leads to osteoporosis, diabetes, hypertension

Poly pharmacy:

• ability to physiologically compensate for the stress of trauma is also compromised by the medications • Some key medications to be concerned about include the

blood thinner Coumadin (warfarin) and • the antiplatelet agents, such as aspirin and Plavix (clopidogrel),

which can lead to significant bleeding complications.• OHG• Anti hypertensive drugs- Beta-blockers and calcium-channel

blockers • diuretics

• Drug PT/INR aPTT TT

• Warfarin • Dabigatran mild • Rivaroxaban mild mild

SUB OPTIMAL NUTRITION

• Elderly population are mostly in sub optimal nourished

state, due to inaccessibility/ unavailability of nutrients,

age related changes influencing glucose intolerance,

renal clearance, and decreased serum growth hormone

level.

• 45 % – lack of access to “an improved water source.”

• 60% -live in dwellings lacking access to an improved

sewer system

INCIDENCE OF TRAUMA IN OLD AGE

Elderly people are the most rapidly growing demographic in

developed nations. Although they sustain traumatic injury less

commonly than children and young adults, the mortality rate for

trauma in the elderly is higher than in younger people

• Trauma is 7th leading cause of death in geriatric patients

• Trauma has 3-fold higher mortality

• – Older patients with pre existing medical conditions = 9.2%

• – Younger patients without pre existing medical conditions =

3.2%

1.FALL (25%)

• Most common injury involves trauma to head, pelvis and lower extremity. • Account for 40% of deaths .• Impaired vision• hearing and memory, • postural sway, • impaired neurosensory coordination

• Indian J Dent Res, 19(2),

motor vehicle collision 79.4%• Most common cause of trauma in developing countries.• slower reflexes• error in perception• impairment of vision and hearing, • the elderly are more liable to get involved in accidents

3.PEDESTRIAN TRAUMA• – slow pause, gait imbalance• ,impaired auditory and visual sense.• Mortality rate > 25%

• Burns• violence• occupational accidents• neglect & suicide

Geriatric Trauma Triage Guidelines:

• The American College of Surgeons Committee on

Trauma(ACS-COT)- patients older than the age 55 should

be “considered” for direct transport to a trauma centre,

apparently without regard to the severity of injury

• Glasgow Coma Score < 15 with suspected traumatic brain

injury (TBI);

• Falls with evidence of traumatic brain injury (even from a

standing position);

• Systolic blood pressure < 100 mmHg;

• Geriatric pedestrian struck by motor vehicle;

• Known or suspected proximal long-bone fracture sustained in

a motor vehicle crash (MVC); and

• Multiple body regions injured

APPROACHES TO GERIATRIC TRAUMA

PRE-HOSPITAL CARE

• Evaluate the past medical history and the event leads to

trauma

• Determine baseline functional status

• Monitor the vitals, elderly patients may go to

decompensating state without warning

EVALUATION/MANAGEMENT

ABBREVIATED INJURY SCALE ( AIS)

• An anatomically based, consensus derived, global severity

scoring system that classifies each injury by body region

according to its relative importance on a 6-point ordinal

scale (1=minor and 6=maximal).

• AAAM's Abbreviated Injury Scale". Association for the Advancement of

Automotive Medicine. Retrieved 2014-03-27

Abbreviated injury Score

AIS-Code Injury Example AIS % prob. of death

1 Minor superficial laceration 0

2 Moderate fractured sternum 1 – 2

3 Serious open fracture of humerus 8 – 10

4 Severe perforated trachea 5 – 50

5 Critical ruptured liver with tissue loss 5 - 50

6 Maximum total severance of aorta 100

9 Not further specified (NFS)

Initial Care - Airway

• Consider anatomy

• Dentition (dentures), nasopharyngeal fragility,

microstomia, cervical arthritis

• Consider early intubation –

• Decreased cardiopulmonary reserve

• Shock, chest injury, altered LOC

• EAST Practice Management Guidelines Work GroupJ Trauma. 2003;54:391

–Breathing/Ventilation

• Decreased vital capacity/respiratory reserve

• Chest injuries (rib fractures, pulmonary contusion,

pneumothorax, hemothorax)

• Increased mortality

• High risk of atelectasis, pulmonary edema, pneumonia, and

acute respiratory failure

In patients 65 years of age and older, an admission respiratory

rate < 10 is associated with a 100% mortality

EAST Practice Management Guidelines Work GroupJ Trauma. 2003;54:391

• Liberal use of supplemental oxygen

• CXR and ABG

• Analgesia

• Tidal Volume status

• Pulmonary toilet

• Maintain SPo2 > 90 %

• EAST Practice Management Guidelines Work GroupJ Trauma. 2003;54:391

• Head CT – in case of LOC, neurologic deficit, dementia, head and

neck injury, multisystem injury, h/o anticoagulant therapy

• Less force is enough to cause cervical spine fracture (C2) • Need rigid collar/halo while transportation

• EAST Practice Management Guidelines Work GroupJ Trauma. 2003;54:391

Circulation:

• Criteria were developed to select patients for invasive

hemodynamic monitoring.

• These criteria included

• pedestrian–motor vehicle mechanism,

• initial blood pressure < 100 mm Hg,

• acidosis,

• multiple fractures,

• and head injury

• Patients were moved to the intensive care unit as quickly as possible. • Pulmonary artery catheters and arterial lines were inserted in

all patients. • Volume infusion and inotropes were used to augment

hemodynamic parameters.• Attempts were made to optimize patients to a cardiac index >

4 L/min/m2 or an oxygen consumption index of 170 mL/min/m2.

ICU RECOMMENDATION:• Pelvic fracture

• hemoperitonium - significant mortality rate.

• Geriatric patients with a TS <15

• AIS > 3

• Shock

• Chronic cardio vascular or renal disease are at high risk for complications

and should be admitted to the ICU and treated aggressively.

EAST Practice Management Guidelines Work GroupJ Trauma. 2003;54:391

Prescribing guidelines (Beers Criteria ACS 2012)

• Discontinue nonessential medications

• Continue medications with withdrawal potential (, beta

blockers, clonidine, statins, corticosteroids)

• Adjust doses for renal function (GFR)

• Monitor narcotic use closely

• Consider non narcotic alternatives

• Plasma, FFP or cryoprecipitate can be given to reverse the

anticoagulant effects of warfarin and admitted to ICU for close

neurologic monitoring and pulmonary care

• Enteral feeding is the clear choice for most effective

physiologic route for providing nutrition.

• other consideration for enteral route feeding site is decrease

in septic complication and improvement of nitrogen balance,

and maintenance of gut mucosa.

DISTRIBUTION OF INJURIES IN ED POPULATION

• In elderly population trauma involves more than one fracture

• Brain injury - (63.0)

• Cervical spine - (5.3)

• Other spinal injury - (20.9)

• Upper extremity - (43.4)

• Lower extremity (33.0)

• Thoracic injury - (31.0)

• Abdominal injury - (15.0)

• J Oral Maxillofac Surg 72:352-361, 2014

• soft tissue injuries - 46%

• maxillary fractures- 30%

• mandibular fractures-18%

• zygomaticomaxillary complex fractures, 30%

• nasal bone fractures - 43.2%

• orbital floor – 27%

• dentoalveolar fractures, and cranial bone fractures. 5%

• Appropriate radiographic imaging should be performed for final diagnosis

• J Oral Maxillofac Surg 72:352-361, 2014

HEAD INJURIES

• Traumatic insult to the head that may result in injury to soft

tissue, bony structures, and/or brain injury

• Blunt Trauma

• Penetrating Trauma

• Scalp laceration or avulsion -Most common injury

• Vascularity = diffuse bleeding

• Skull fracture – linear or depressed

Signs

• Hemotympanum or bloody ear discharge• Rhinorrhea or otorrhea• Battle’s sign • Raccoon’s eyes• Cranial nerve palsies

Sub Dural hematoma

• common in elderly trauma population- Between Dura

mater and arachnoid.

• Usually venous Bridging veins between cortex and Dura.

Causes increased intracranial pressure.

• Pressure exerted downward on brain, compress Cerebral

cortex -- Altered level of consciousness

Hypothalamus --- Vomiting

• Signs:

• Slower onset

• Increased ICP - Increased BP,Decreased pulse, Irregular

respiratory pattern (Cushing’s triad)

• Headache, decreased LOC, unequal pupils

• Hemiparesis, hemiplegia

Management:• Consider - Airway, breathing and circulation first, followed by

drug therapy

• IV diazepam 5mg in case of seizure, may mask signs LOC.

• IV mannitol 1g/kg - decrease cerebral edema

• IV lignocaine 1.5mg/kg – prevents increase in ICP

• IV glucose in case of hypoglycemia

• Traumatic Coma Databank, , defined severe brain injuries as

GCS score < 8. But other studies suggested that admission

GCS <11 associated with 100% mortality rate in elderly

population >80 yrs. of age

• Kotwica and Jakubowski, in a study of head-injured patients

70 years of age and older, noted a 90% mortality in patients

with a GCS score <9 when craniotomy was required and 76%

when craniotomy was not required. On the basis of this

finding in 136 patients, they recommend aggressive treatment

for 24 hours only for those patients without space occupying

lesions. Aggressive treatment, then, is continued only in those

patients who show “significant” improvement within this time

frame

• Consider with holding of primary treatment for craniofacial

injuries that will not result in substantial functional loss.

• In medically compromised cases, consider secondary repair of

facial injury.

CRANIOMAXILLARY FRACTURE

• Primary concerns• Airway compromise secondary to bleeding• FB aspiration secondary to broken or avulsed teeth• Management:• ABCs• Suction • Stabilize impaled object• Collect tissue: tongue or tooth

• In elderly population craniofacial fractures are usually managed by conservative methods

• In case of undisplaced fractures, it can be managed with closed reduction- MMF, suspension wirings, external pin fixations.

• If it is displaced or affect the functional status , ORIF can be

performed based on the medical condition of the patient.

• ORIF of cariniomaxillary fractures can be approached through

existing laceration, hemi coronal or bi coronal approach

Gunning splint:

• Gunning splint was initially fabricated by Thomas brain

gunning for the immobilization of edentulous ridges.

• In edentulous patient due to the absence of teeth it is difficult

to reduce and immobilize the fracture.

• A gunning splint resembles a mono block consists of two bite

block fixed to the maxilla by per alveolar wiring and to the

mandible by circumferential wiring. Then interconnecting the

both with wire loop and elastics

• Existing denture can also be used as splint

Fabrication of gunning splint

• Impression materials

1. Impression compound

2. Alginate hydrocolloids

Impression tray:

Preformed trays

Sectional trays

Cast fabrication – type 2 plaster or stone

• Challenges:

• bleeding

• Trismus

• pain

• Fractured / mobile teeth

• Disoriented occlusion

• Posterior occlusal gag

• Gag reflex

• Wax bite is fabricated with appropriate VD

• In case of any retaining firm teeth , that can be used to

maintain VD

• 3 hooks per quadrant has to be fixed followed by acrylization

• Reverse hooks has to be attached in molar region if

suspension wiring was planned

• Maxillary gunning splint - per alveolar wiring, circumpalatal wiring, • Mandibular splint – circummandibular wiring• MMF – elastics, tie wires• Suspension wires, external pin fixators can also be attached

with it

NASAL BONE FRACTURE

• Epistaxis• Anterior bleeding from septum- Usually venous• Posterior bleeding- Often drains to airway• May be associated with Sphenoid and/or ethmoid fractures

Basilar skull fracture• Direct pressure over septum• Upright position, leaning forward or in lateral recumbent

position• Anterior and/ posterior nasal pack • Fractured segments can be reduced either by closed or open

method• Immobilization can be done by external splints or internal

plate fixation

Atrophic mandibular fractures

• Long edentulous period leads to atrophy of mandible• The remaining bone is markedly diminished in height

and often width, and is frequently entirely cortical (and brittle) in nature. • The highest degree of atrophy is seen typically in the

lateral body of the mandible, an area without major muscle attachment. There is no effective endosteal blood supply

• Depends mainly on periosteal blood supply.

• Because of the risk of non-union resulting from interference

with periosteal blood supply, reduction should be

accomplished with minimal exposure.

• many undisplaced fracture require no active treatment

• The most common site of fracture is bilateral body region

(bucket handle fracture)- which may compromise the airway

and mandibular angle

METHODS OF IMMOBILIZATION

• 1.intermaxillary fixation with gunning splints

• 2. indirect skeleton fixation :

• Pin fixation, bone clamps

• 3.direct osteosynthesis:

• Bone plates (mini plates)

• Trans osseous wiring,

• Trans fixation with K-wires

• Bone grafting

• Rigid internal fixation (RIF) has been more effective in these complex injuries

• Modern locking reconstruction plates anchored by at least three screws on either side of the fracture or defect allow for undisturbed healing

• If wound complications occur, the internal fixator stabilizes the segments during further debridement, grafting, etc, with the patient continuing to function in general

• A reconstruction plate (locking or nonlocking) with bicortical screw placement (mostly only possible in chin and angle region) must bear the functional load in an atrophic mandible

SOFT TISSUE INJURIES

• Age related immunological changes appear to play a critical

role in wound repair and healing.

• The inflammatory, proliferative response are decreased.

• There is a measurable change in fibroblast function, collagen

formation, migration and cross linkage

• This affects the patient’s ability to resists infections and

delayed wound healing

• Most of the soft tissue lacerations can go for primary closure,

also skin turgor, rhytids do not adversely contribute to

outcome.

SUMMARY

• Advanced patient age is not an absolute predictor of poor

outcomes following trauma and, therefore, should NOT be

used as the sole criterion for denying or limiting care in this

patient population

• An initial aggressive approach should be pursued for

management of the elderly patient unless in the judgment of

an experienced trauma surgeon it seems that the injury

burden is severe and the patient appears moribund

• The preponderance of available literature, however, suggests more favourable long-term outcomes, with up to 85% of survivors functioning independently at home at follow-up intervals as long as 6 years post injury

• Geriatric trauma care presents unique challenges

• •Aggressive care is generally warranted

• •Consider pre-existing conditions

• •Anticipate complications

• •Don’t minimize discharge planning

• Premorbid status has to be consider more than the chronological age

• Consider early transport to trauma centre

• Vital and urine output are not absolute values to consider

• Physical examination may underestimate the injury, use of

radiographic studies indicated

Reference:

1. Killey’s fractures of mandible 2. Rowe and williams3. Oral and maxillofacial trauma - fonseca4. Geriatric Trauma: Demographics, Injuries, and Mortality Journal of

Orthopaedic Trauma: September 2012 - Volume 26 - Issue 9 - p e161–e1655. State of Ohio State Board of Emergency Medical Services Trauma

Committee: "Geriatric Trauma Task Force Report and Recommendations." 6. A Simple Fall in the Elderly: Not So Simple7. Journal of Trauma-Injury Infection & Critical Care:

February 2006 - Volume 60 - Issue 2 - pp 268-2738. .AAAM's Abbreviated Injury Scale". Association for the Advancement of

Automotive Medicine. Retrieved 2014-03-279. .Maxillofacial intervention in trauma patients aged 60 years and older

Indian J Dent Res, 19(2), 2008Journal of Trauma-Injury Infection & Critical Care: February 2002 - Volume 52 - Issue 2 - pp 242-246

10. . ACS-TQIP gediatric trauma management guidelineToday’s issue on ageing issue 25, march 201211 AO Principles of Internal Fixation of the Craniomaxillofacial Skeleton12. Defining Predictable Patterns of Craniomaxillofacial Injury in the Elderly: Analysis of 1,047 Patients J Oral Maxillofac Surg 72:352-361, 201413. Practice Management Guidelines for Geriatric Trauma: TheEAST Practice Management Guidelines Work GroupJ Trauma. 2003;54:391–14.Two Piece Gunning Splint In Edentulous Patient With Fractured Maxilla Indian Journal of Dental SciencesSakshi Malhotra Kaura Jugraj Singh. October 2014 Supplementary Issue Issue:4, Vol.:615. Conservative Splint Therapy For Atrophic Edentulous Mandible Fracture In A Geriatric Patient M Rathee, M Goel, A Hooda, A Kumar, R KunduConservative Splint Therapy For Atrophic Edentulous Mandible Fracture In A Geriatric Patient M Rathee, M Goel, A Hooda, A Kumar, R Kundu