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.
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.
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.
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.
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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