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EAST Practice Guideline – Geriatric Trauma (2010 Update)

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The EAST Practice Management Guideline on management of geriatric trauma was updated early this year. This post gives the details of the proposed changes. Click here to open a copy of the existing PMG for comparison.

Prehospital Triage

  • Level II – Injured patients with advanced age (>=65) and pre-existing medical conditions (PECs) should lower the threshold for field triage directly to a designated/verified trauma center.

Triage Issues

  • Level II – With the exception of patients who are moribund on arrival, an initial aggressive approach should be pursued with the elderly patient.
  • Level III – Patients 70 years of age or greater should receive care under the structure of the highest level of trauma activation and receive liberal application of invasive monitoring.
  • Level III – Elderly patients with at least one body system with an AIS >= 3 should be treated in designated trauma centers, preferably in ICUs staffed by surgeon-intensivists.

Low GCS

  • Level III – In patients 65 years of age or older with a GCS < 8, if substantial improvement in GCS is not realized within 72 hours of injury, consideration should be given to limiting further aggressive therapeutic interventions.

Head injury and anticoagulation

  • Level III – All patients who receive daily therapeutic anticoagulation should have appropriate assessment of their coagulation profile as soon as possible after admission. Those with suspected head injury should be evaluated with head CT as soon as possible after admission. Patient receiving warfarin with post-traumatic intracranial hemorrhage should receive initiation of therapy to correct their INR to normal range within 2 hours of admission.

Base deficit for triage

  • Level III – Base deficit measurements may provide useful information in determining status of initial resuscitation and risk of mortality for geriatric patients. ICU admission should be considered for patients >=65 with an initial base deficit >= -6.

Deleted guidelines – the following have been recommended for deletion from the PMG.

  • Attempts should be made to optimize cardiac index > 4L/min/M2 and/or oxygen consumption index of 170 cc/min/M2.
  • Complications negatively impact survival. Specific therapies to reduce complications should lead to optimal outcomes.
  • Admission trauma score < 7 is associated with 100% mortality and aggressive therapeutic interventions should be limited. 
  • Admission respiratory rate < 10 is associated with 100% mortality and aggressive therapeutic interventions should be limited. 
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What Happens When An Axle Snaps

The Ford Windstar minivan is being recalled to deal with a design defect in the rear axle. Here is NHTSA analysis video of what happens when the axle separates. The read of the car begins to steer in random, different directions. This makes the steering wheel nearly useless. Note how the professional driver in this video is saved from a rollover by the attached stabilizer bars.

(Source: https://www.youtube.com/)
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Observation of Occult Pneumothorax

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An occult pneumothorax is one that is seen only on CT scan, but not on conventional chest x-ray. They are noted in somewhere between 2% and 10% of major blunt trauma patients. Although management is usually conservative, this has not been well studied.

A paper was presented at the AAST earlier this year based on a prospective, multicenter trial. The authors attempted to determine what factors were predictive of failure of observation. They were able to quantify the size of the pneumothorax by measuring a line from the largest collection to the chest wall.

Sixteen centers participated and enrolled 569 patients, who had 588 occult pneumothoraces. Of those, 21% had immediate chest tube drainage (no reasons were given). The remaining 448 patients were observed, and 27 of those patients failed. Failure was determined if they had progression of the pneumothorax, developed respiratory distress, or developed a hemothorax. 

Risk factors were found to be: positive pressure ventilation (14% of observed group failed), size > 7mm, respiratory distress. 

The authors recommend that patients with respiratory distress and those placed on positive pressure ventilation have a drainage system inserted. Those with pneumothoraces greater than 7mm bear close watching.

Our practice is to monitor any patient with an occult pneumothorax with a followup chest x-ray (one view only) performed after six hours. If the pneumo is still not visible, no further observation is done. If it becomes visible, serial 6 hour x-rays are obtained until it is stable or requires a chest tube.

Reference: Management of blunt traumatic occult pneumothorax: is observation harmful? Results of a prospective multicenter study. Forrest O Moore, et al. Paper #5 presented at 69th Annual AAST Meeting, September 22, 2010.