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.
Time for some philosophy again. A paper in Neurology released ahead of print confirms something I’m seeing more and more often. Specifically, hospitals can be bad for you, particularly if you are elderly.
The trauma population that we all see is aging with the overall population. Being older predisposes one to injuries that are more likely to require hospitalization. And unfortunately, being in the hospital can have adverse effects. I’m not just talking about the usual culprits such as medical errors or exposure to resistant bacteria.
The Chicago Health and Aging Project has been tracking a group of elders as they age, and has been making a number of interesting observations. Most recently, they have released information on a correlation between cognitive decline and hospitalization. They tracked nearly 1900 people, of whom 1335 ending up in the hospital for one reason or another (not just trauma). They found that there is a baseline rate of global cognitive decline with age (surprise!). Unfortunately, this rate of decline accelerated 2.4 times in the hospitalized group. Episodic memory scores declined 3.3 times faster, and executive function declined 1.7 times faster. And declines tended to be more pronounced in patients who had more severe illness, longer hospital stay, or advanced age.
There are some issues with the study. It is large, but it is a correlation study nonetheless. Are the effects due to something that happens in the hospital, or are they caused by something not evaluated by the study? It’s also not clear to me whether the declines noted are clinically significant in the daily lives of the people studied, or are just a number on some scale.
Bottom line: Some of the “benign” things that we do to patients in the hospital can have a big impact on their functional outcome. Always remember that they are more fragile than the young trauma patients we take care of. That extra fluid bolus, or dose of morphine, exposure to IV contrast, or noisy neighbor that keeps them from sleeping can make a real difference in how they do. Always consider that everything you do to them might kill them. Then seriously reconsider whether you really, really need to order it at all.
Reference: Cognitive decline after hospitalization in a community population of older persons. Neurology, epub ahead of print, March 21, 2012.
Yesterday I talked about using a medical orthopaedic trauma service to provide better care to elderly patients with fractures. Many of these patients have multiple pre-existing diseases and are quite fragile. A recent paper from the Rhode Island Hospital shows just how fragile these patients may be.
Urinary tract infection (UTI) is one of the most common nosocomial infections, accounting for about 40% of all such infections. The vast majority are related to indwelling bladder catheters. It is so much of a problem that, in order to decrease federal spending in the US, Medicare now denies payment for care related to these infections.
This study looked at the relationship between UTI and bladder catheters and how this infection relates to overall mortality in older trauma patients. It was a retrospective review of 6 years of data from a single institution. After excluding patients who entered the hospital with a UTI, they found that 12% of their patients developed this infection and 72% were indeed related to catheters. Males had a significantly increasing risk of UTI with increasing age. And the risk of death from UTI increased about 7% per year after age 55.
Bottom line: Urinary tract infections are especially bad for the elderly. As part of your daily rounds on any patient, look at every tube and line and ask yourself “is that really needed any more?” If not, get rid of it before it kills your patient!
Reference: The development of a urinary tract infection is associated with increased mortality in trauma patients. J Trauma ePub ahead of print, doi: 10.1097/TA.0b013e31821e2b8f, July 2011.