Silver Trauma
When you think of major trauma, most of us probably think about young guys in mangled suberus and 40 something horse riders who have performed an unscheduled dismount, onto some rather hard ground. However there is another patient group that you would be forgiven for not thinking of. 75 year olds who have tripped over a slipper.
Silver trauma is the term used to describe trauma in older patients but generally refers to those patients that fall into the major trauma criteria. Over 60’s already represent 50% of the major trauma patients that are seen in the UK, this is only set to increase as our population increases in age. Lack of early identification means that initial treatment is more likely to be in a Trauma Unit or standard ED. The evidence suggests there is an increase in time to important interventions such as CT scans and that assessment is more likely to be lead by a more junior doctor. Older patients are much less likely to be transferred to specialist care and have longer times to both investigation and intervention [1]
Moreover a significant amount of time, money and effort is spent toward injury reduction of the kind of trauma killing and affecting young people. Speed awareness etc. However, silver trauma often occurs through mechanisms that are less impressive and less obvious! Conceivably this could become the most common type of trauma we see In the future.
It’s important this is at the forefront of our minds. Although Elderly are more likely to die from major trauma, Of those that survive it, they are more likely to go back to a lifestyle free of disability. So this is absolutely not a lost cause. [2]
Major trauma is classed an injury severity score (ISS) over 15. So when we consider major trauma in older patients this would be a patient over the age of 65 with an ISS of 15 or more [TARN - The Injury Severity Score (ISS)].
What TARN data shows us in a report published in 2017 is that silver trauma is steadily on the rise. There is a multitude of potential reasons that may suggest why this is including; people living longer and an ageing population being a more dominant proportion of the the population, improved quality of life meaning more people are active and exposed to increased risk of trauma but also could be just related to improved recognition and collection of data due to improvements in the recognition of silver trauma as an entity in its own right. Traditional thinking considered patients being affected by major trauma as having high mechanism of injury (MOI) e.g. major RTCs, falls from heights, stabbings etc. However evidence shows us that major trauma in older patients can have significantly lower MOI, the most common mechanism being a fall from standing height. Again this is represented in the TARN data and may also add to the reason why people overlooked these silver trauma patients as major trauma in the past.
Another interesting factor is the location of silver trauma patients. TARN also identified a change in outdoor to indoor trauma occurring between the 60-69 and 70-79 with a rapidly increasing move to indoors from 80+. This makes sense in relation to a combination of factors that may include retirement and less occupational exposure to injury risk, decreased number or older people driving when compared to other generations, increasingly more time in their place of residence and increasingly frailty. So again when compared against traditional teaching for pre-hospital clinicians on major trauma, it isn’t unreasonable to suggest that pre-hospital clinicians may not consider major trauma in these older patients due to the combination of traditional teachings around higher MOI vs lower MOI in older persons, the perceived perception of lower risk environment unconsciously influencing decision making when a fall in the home is compared for example to someone hit by a car lying at the side of the road.
With this in mind its is therefore easy to see why TARN also demonstrate that with increasing age triage using the pre-hospital major trauma bypass tool, major trauma pre-alert and in-hospital trauma team activations as a percentage of confirmed major trauma patients all decrease with age. We have to therefore consider the reasons why this is occurring and identify ways to improve this. Firstly by educating ourselves around silver trauma, secondly by identifying our bias towards assessment of older persons who have experienced trauma and understanding a lower MOI in this demographic can still result in significant injury and major trauma and finally by understanding that older persons do not always present in the same way as our traditional teaching of trauma and therefore we need to be wary of tools such as pre-hospital major trauma bypass decision tools and have a lower threshold in our clinical acumen when considering variation in anatomy and physiology and response to trauma and when to bypass to an MTC.
Physiological Changes in ageing
Every system in the body is affected by ageing. Everything has a decline in function over time,
Skin – as we age the skin becomes thinner, drier and less elastic. This is most obvious as wrinkling – the most visible sign of aging. But reduction in the amount of elastin and collagen in the skin makes it more fragile and liable to tears.
When we are younger our skin is more taught, meaning any bleeding is able to tampanade easily, forming small bruises. However, older people with their more lax skin, larger dermal layers and small subcutaneous layer of fat means very little pressure is required to start bleeding under the skin, and small slow bleeds can often go unnoticed, going on to produce large haematomas under the skin.
Osteoporosis - bone reabsorption exceeds new bone production and = loss of bone mass.
Joints Stiffen - Stiffening of joints and ligaments. Less flex and more rigid. – particularly notable in the cervical spine. 2/3 older patients show some signs of kyphosis.
Airway - The musculature of the upper airway weakens with age. This means that when patients become obtunded or unresponsive, their tongue and soft tissue of the oropharynx are more likely to cause obstruction or restriction of airflow.
- Dentures – can cause airway obstruction if not noticed. If removed, they often lose a lot of hard structure to the face, which we rely on to use a BVM / loss of teeth / hard structure to provide rigidity towards OPA.
Respiratory System – Loss of flexibility and compliance in the chest, loss of muscle mass in inspiratory muscles leads to as much as a 50% decrease in vital capacity by age 75.
Alveolar collapse, increased likelihood of Respiratory pathology i.e. COPD, reduced alveolar surface area = decreased FRC
Chemoreceptors in the aortic arch, responsible for sensing changes in CO2 and O2 become less sensitive as we age. As a result, we have worse central responses to Hypoxia and Hypercapnia, less able to compensate.
Vasculature - Atherosclerosis risk increases with age – partial or complete occlusion of vessels. Organs are less able to cope with stress.
Myocardium – Myocytes are replaced by collagen and fat cells. Less contractile walls are less stiff and less able to stretch. Less ability to respond to increased requirements for blood flow.
Change in baroreceptors, less sensitive to change in circulatory volume. Less able to pick up changes and respond to them as in the respiratory system.
Arrhythmias - SA node = 90% decrease in number of cells by age 75 – hence the risk of AF. AF = loss of atrial kick and thus 20-30% of stroke volume.
AV node sees a decrease in cells. Fibrosis and fatty deposits along electrical pathways = increased risk of aberrant conduction, particularly in cases of stress.
Stiffening of valves in the heart = reliant on higher pressures to overcome this. As a result, small drops in blood pressure can result in marked reductions in cardiac filling and output.
Central Nervous System - Both motor and sensory neuronal networks slow = slower reaction time, less ability to protect oneself, I.E. no FOOSH. Less able to move out of the way.
Brains shrink as we age with an actual decline in neuronal volume. Loss of approx 10-20% of its mass by age 80.
Older brains = more space from atrophy, bridging veins, which return blood from the brain to duramater/ between surface of brain + skull are under greater tension, themselves less elastic and more rigid. Higher risk of tearing = EDH
Less volume in an elderly head, so hard neurologoical signs from EDH may take some time to present. Classic waxing/waining GCS / LOC but now concious
GI – Gastric motility slows, will be worse in trauma, consider parental medications over enteral where appropriate.
Co-morbidities in trauma:
Diabetes
Age vs frailty – outwardly young inwardly old. Pg 8 HECTOR
Parkinsons – hypertonia – lack of flexion in neck
Medications affecting Trauma
Poly pharmacy is common in older populations given increasing co morbidities. The more medicines a patient takes the more they are likely to interact both with each other and on the physiological response to trauma and the pathophysiological effects of traumatic injuries.
Anti- coagulants – Warfarin and novel/direct oral anticoagulants (NOACs/DOACs) are commonly prescribed in the elderly to manage the risk of clotting e.g. ischemic stroke. An unfortunate complication of this is then unwanted increased bleeding in those who suffer with trauma. Any patient on anticoagulant medications can have occult bleeding even in relatively minor trauma. Warfarin inhibits vitamin K dependant synthesis of some clotting factors and can be revered using IV vitamin K, FFP and prothrombin complex concentrate such as Octaplex. In hospital management of older persons trauma will often try to target a patients INR to <1.5 when active bleeding is identified. However in relation to DOACs this reversal is not as simple. DOACs such as Rivaroxaban are direct factor Xa inhibitors. Reversal is becoming increasingly possible with various medications but these vary depending on the DOAC the patient is on. One of the most common risks that will be familiar to pre hospital clinicians is the increased risk of ICH in patient who have sustained head injuries, hence why CT head scanning is indicated in those who have suffered from even relatively minor head trauma as when we combine the factors we discussed earlier in physiology that increases risk of bleeding along with medication that increases bleeding we can see how this heightens risk [www.nice.org.uk/Guidance/CG176]. As well as head trauma our primary survey and subsequent imaging should help us to identify other bleeding areas that can lead to hypovolemic shock including chest trauma, abdomen and pelvic injuries as well as long bone fractures where haemorrhage risk is amplified by those on anticoagulants.
Beta blockers – commonly used in older patients for a variety of reasons e.g hypertension, angina, arrhythmia management. Their B1 effects lead to a reduced heart rate which in can both restrict compensatory mechanisms of tachycardia and therefore response to shock but also in the same token mask tachycardia in relation to hypovolemia making heart rate an unreliable indicator of shock. Careful assessment for occult injury is needed in patients who take beta blocking medications and a low threshold for trauma teams for pan trauma CT is warranted
Steriods – another common medication for elderly patients may be the use of steroids for anti inflammatory/ immunosuppressive benefits. However steroids can also further supress the body's response to both illness and injury. A further adverse side effect of steroids when taken long term is skin thinning and the development of osteoporosis. Skin thinning can occur as part of ageing but is worsened by steroid use still further, leaving the skin more vulnerable than younger individuals to traumatic injuries, delays healing and can result in infection developing. Pressure sores should be considered when immobilising a older trauma patient as even relatively short durations of immobilisation on hard surfaces can cause these, so be mindful of immobilisation techniques, vacuum mattress is a better approach than scope if it can be safely applied in a timely fashion.
HRT – is used as osteoporosis prevention in post-menopausal women.
History:
As always its important to take a comprehensive history. This will vary in the detail and appropriateness depending on how unwell the patient is, so we’re not going to focus too much on this. However, two things to consider. A detailed history of the mechanism of injury, may help to elucidate areas to focus assessment. Secondly, don’t forget to work the patient up for the potential of a Transient Loss of Consciousness or T-LOC. this must be a consideration in any cases where the patient has poor or absent recall of events. For more, check out Episode 4 of General BroadCAST all about T-LOC.
Modifying our Assessment
Because our older patients are a different co-hort by comparison to our younger trauma patients, they require us to do things slightly differently.
C- Spine
Any person over the age of 65 with head/ facial injury following a trauma must be considered as being at risk of having a cervical spine injury. In patients where communication is challenging such as reduced GCS due to head trauma or inability to communicate accurately the absence of neck pain e.g dementia, current delirium, stroke etc should be considered to have a neck injury until proven otherwise.
Indications for spinal imaging/ radiological clearance of the c-spine include fall from standing with new-onset neck pain, high MOI as per standard processes, injury above the clavicles in any patient with GCS< 15 or those with GCS of 15 but c/o neck pain, significant head trauma. Distracting injury or new focal neurology.
Osteoporosis and reduced bone mass mean older patients are more likely to sustain c spine fractures than younger trauma victims. In fact some evidence suggests that of older trauma patients who are identified to have cervical spine fractures approximately 50% of them will be unstable. [3]
Airway
May have fallse teeth which present a potential obstruction risk
Removing tentures or cachetic/sullen face may make BVM use more difficult
Breathing
See changes above.
This group of patients are markedly suceptable to multiple rib fractures. Due to an already reduced vital capacity, they may become compromised easily.
Circulation
Ultimately these patients can have the same injuries reference bleeding we all do. Important to consider the elderly response to trauma, it may not be as obvious they are in shock. As discussed above, they lack the ability to mount a tachycardia and support their blood pressure the way younger patients do, so they may not spike a tachycardia. Medications such as beta-blockers can also prevent this.
Lateral compression fractures are five times more common than antero-posterior compression fractures in the elderly population, a reversal of the normal pattern observed in younger patients. May not respond to pelvic splinting. Consider pain response and physiological changes post-application. [3]
Occult Hypoperfusion HR/BP unable to compensate - This can sometimes be revealed by a lactate in hospital.
Coagulation status – VitK – beriplex / octplex early consideration. Flag in ATMIST
Disability: As above, these patients are at risk of brain injury without typical neurology and of unrecognised spinal fractures.
Treatment:
Morphine and opiates – morphine acts on various receptors but has an affinity for u- receptors which provides the analgesic effect we want when managing pain in trauma patients. However they also have negative effects including respiratory depression, nausea and vomiting, reduced GI motility. In the trauma patient this can have consequences that need consideration; in relation to airway vomiting in a patient who has been led flat could lead to airway compromise especially when combined with reduced GI motility. In relation to breathing and chest wall injury, morphine can result in respiratory depression reducing an already struggling respiratory effort and result in worsening ventilation and as a result hypoxia. However in contrast relieving pain can also have the opposite beneficial effect and improve respiratory effort so requires some clinical judgement. When considering circulation in a patient who may already be hypotensive it can lower blood pressure further and disability can reduced conscious level and affect pupillary response making it challenging to differentiate neurological deterioration from conditions such ICH from that of morphine administration.
Safeguarding Considerations
Evidence suggests that 10% of older adults experience some form of abuse, and only a fraction of cases are actually reported or referred to social services agencies. Elder abuse is associated with significant morbidity and premature mortality.
Victims of abuse resulting in trauma have more severe injuries and are more likely to be admitted to an intensive care unit and have a higher risk of death when compared to accidental trauma patients.
Could be 2ndary to dementia – i.e. demented man gets abusive and aggressive with a primary carer, may not be seen as abuse by them. Still needs reporting.
One of the biggest threats to this age group is serious injury from seemingly insignificant MOI’s. Starting the ball rolling in looking for serious injury starts with the paramedic.
Every organ system of the older patient is more vulnerable to Trauma. They often have less protection from injury, are more brittle and have a reduced ability to compensate for that injury.
It might seem that a lot of the things that kill elderly people in silver trauma is occult, and only found on CT imaging and Blood work…. Theres a lot of truth to that. It would be easy then to conclude that, there isn’t anything for prehospitalists to do in this patient group and really the real improvements are to be done in hospital….that would be where you’re wrong.
Time and recognition are the key things in this group. That starts with the pre-hospitalist. The course you start this patient on will be the one that makes the difference
We need to recognise theses patients as high risk and ensure our assessment is as detailed as we can make it, to look for any signs of serious injury.
We need to remember that these patients often wont present to us as dramatically unwell, and need to remember that the text book picture of poorly trauma patinets is biased towards the young.
Much of the Major Trauma bypass tool thresholds to initiate bypass do not serve elderly patients well who get seriously hurt from small MOI’s, aren’t able to mount as significant response with HR and have mortality increases at higher thresholds of BP, 110 vs 90 in young
We need to have a lower threshold for pre-alerting these patients and activating the hospital teams to “look for injury”.
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