In response to my post yesterday, Chris Nickson wrote:
“Is it possible there were physiologically young but chronologically old patients with isolated rib #s that were sent home from ED that were not included in the study?
I suspect that there are patients over 65 years old with isolated rib #s that can be safely discharged if follow up is bullet proof and pain well controlled.
However, I agree with your over riding message to not underestimate the elderly rib fracture!”
Very few authors do anything but stratify the elderly by age when they write research papers. They do not look at frailness, even though there are scoring systems to do just that. Plus, the retrospective nature of most of the literature (including this paper) preclude the use of such a scale.
Most of the elderly patients that we all see in the ED are selected out to be frail. The healthy ones stay at home and tough out a single rib fracture or even two. But the ones who are brought in are most likely having issues with pain or breathing, thus prompting the visit.
Bottom line: I agree that some elderly patients (the younger and healthier ones) could potentially be sent home from the ED with some pain medication. But the trauma professional needs to make sure that they are comfortable and can move about with well controlled discomfort. They also need good discharge instructions regarding returning to their primary physician or ED promptly if they start to have pain control or respiratory problems. If there is any doubt, bring them in to the hospital for a brief visit for pain control and pulmonary management.
Just like children are not small adults, elderly patients are not just old adults. As I mentioned yesterday, mortality increases significantly as we get older such that the same injury is much more likely to kill an elder.
Rib fractures are no exception. A 10 year retrospective cohort study looked at the management and mortality of this problem in patients 65 and older at Harborview in Seattle. When comparing young and old patients with the same number of fractures and injury severity, death and pneumonia were twice as likely in the elderly (22% vs 10% mortality, 31% vs 17% pneumonia). Ventilator days and hospital/ICU length of stay was significantly longer, too. Mortality increased by 19% and pneumonia increased by 27% for each additional rib fracture in the elderly.
Here are some practical tips for management of rib fractures in the elderly:
- Admit any older patient with even a single rib fracture for pain management and pulmonary toilet
- Treat their pain well, but watch the narcotics! Consider an epidural if indicated, but monitor carefully.
- Keep your patient out of bed as much as possible. Chairs are good, walking is better.
- Encourage coughing and other pulmonary toilet techniques
- Do not discharge until they pass the “eyeball” test. This means that they have to look well enough to go home and participate in their usual activities. They should be walking around at their usual speed and agility. It does no good to discharge and lay in bed or on the couch. They’ll be back dying of pneumonia before you know it.
- A general rule of thumb: Length of stay is generally n+1 days, where n is the number of rib fractures (isolated injury). Be wary of trying to send someone home sooner than this.
Reference: Rib fractures in the elderly. J Trauma 48(6):1040-1046, 2000.
Thanks to Scott Weingart, author of the EMCrit Blog (www.emcrit.org) for suggesting this topic!
I’ve had several requests for a piece on geriatric trauma. We know that elderly patients (officially age > 55) have worse outcomes for the same degree of injury. And as they get older, mortality rises rapidly. Here are some practical tips for trauma professionals.
- For EMS: As I mentioned yesterday, heed the CDC trauma triage guidelines. Older patients have better outcomes at trauma centers, so take advantage of it.
- In the ED: Ask immediately about anticoagulation. This can cause life threatening situations, especially in the face of intracranial hemorrhage. If your patient is taking anything that interferes with clotting, treat them like a STEMI or stroke patient. Time is of the essence. Draw coags and get rapid access to the CT scanner. Refer to the guidelines I previously published on reversing the usual culprits.
- Most elderly patients with any degree of head trauma need a head CT. They can hide bleeding well, until it’s too late to save them.
- Once admitted, treat them very carefully. Even minor errors (too much fluid, unneeded IV contrast) can cause significant complications.
- Use as little narcotic as possible. Acetominophen and ibuprofen work great. Lidocaine patches may be helpful in may cases. Steer away from narcotics and muscle relaxants as much as possible to avoid altering mental status.
- Watch sleep patterns. Sleeping meds are bad, but reducing interruptions in the middle of the night is good (do they really need vital signs taken at 2AM?).
- Look at the patient’s baseline status. Are they a spry 90 year old, or a demented 70 year old who falls all the time? Have realistic expectations and communicate them with the family if major procedures or intubation are considered. Sure, we have the technology to fix many things, but at what cost to the patient? The family needs to understand the real likelihood of ICU, tracheostomy, and prolonged or permanent debilitation. Don’t make them as miserable as you can make the patient.
One of the major components of any trauma system is the prehospital piece. These providers extricate, begin medical treatment, and decide where to take the patient. The choice of hospital can make a big difference, and the number of deaths can potentially be reduced by up to 25% by making the right decision. Where to take the patient is not necessarily clear cut, even though CDC guidelines exist to help. Geographic and weather factors can be a factor, as well as patient choice at times (unfortunately), local medical control, or even time of day (traffic).
Harborview and the University of Washington conducted a large retrospective review of the transport patterns for nearly 12,000 injured patients over a 5 year period. They specifically looked at whether CDC guidelines for field triage were being followed. About half were transported to Harborview, the only Level I center in the state. The remainder were transported to the 7 remaining trauma centers, levels III to V. There were a number of interesting findings:
- Patients transported directly to the Level I center were more likely to be young, male, injured by a penetrating mechanism, have worse vital signs and GCS and higher injury severity
- Older patients were less likely to be transported from scene to a Level I center
- The oldest patients were 89% less likely to be transported to the Level I center, either directly or after initial management at a lower level center
Bottom line: For reasons that are not clear, elderly patients were far less likely to be transported to a Level I trauma center by prehospital providers in Washington state. In fact, the guidelines were obeyed only about 50% of the time! Does this happen in other states or countries? We don’t know. Is this a problem? Unfortunately, we also don’t know how much lower the mortality in these patients is when treated at higher level centers. It seems to be, especially in the more severely injured patients. What we do know is that if the guidelines exist, adhere to them unless you have good reason not to. Their life may depend on it!
Reference: Compliance with Centers for Disease Control and Prevention field triage guidelines in an established trauma system. J Amer Col Surg 215(1):148-156, 2012.
Time for the answer! There were lots of well thought out guesses, and a few correct answers.
Here’s the story. This is a young male who presented in the trauma room with a small penetrating injury on the lateral aspect of his right arm, and another one just medial to the top of the scapula. If you look at first image last Wednesday, you can see an obvious humeral fracture, a not so obvious lack of lung markings, and a few tiny metallic foreign bodies (bullet fragments picked up by Canuck ER MD, injuries surmised by Kurt Rubach, paramedic). I provided a zoomed in view on Thursday to make them a little more obvious.
What I didn’t tell you (besides the fact that there were bullet holes) was that there were no pulses in the arm. The patient was hemodynamically stable, so after evaluation in the ED and insertion of a chest tube, he was taken to angio to evaluate the injury location. Unlike many penetrating injuries where the location is obvious, this was a deep mediastinal hit possibly involving Zone I of the neck (thanks Traumahst). Angio was selected because this was in the days before chest CT.
This shows a cutoff of the right subclavian artery. The patient was taken to the OR for sternotomy with a right neck extension and resection of the medial third of the clavicle (see Friday’s xray). The injury was successfully repaired with good return of function, and some residual hemothorax. He was discharged home in a week.
Bottom line: This one was tough because I didn’t give you much of what trauma professionals really need: clinical context. An isolated xray without a clinical history is not enough. It’s very easy to see things that really aren’t there and end up on a wild goose chase. Keep that in mind the next time you expect your radiology colleagues to come up with miracle diagnoses while sitting in a darkened room. Give them the whole story, or have them pop over to the ED to see for themselves.