Geriatric Trauma Resuscitation

1
Geriatric Trauma Resuscitation

• Kevin L. Ferguson MD FACEP
• Clinical Assistant Professor of Emergency
  Medicine
• University of Florida
• Gainesville, Florida

2
Geriatric Population

• 12.5 of population age gt 65 (1990)
• 28 of all deaths by trauma
• Estimated at 35 Million in 1995
• Estimated to be 52 M by 2020
• Anticipated increased participation in activities
  likely to incur injury

3
Demographics

• Analysis of EMS dispatch activity of 1154
  patients, 70 year old, over one year in Tucson,
  AZ
• 65.1 women 34.9 men
• 53.1 70-79 39.3 80-89 7.6 90
• Involved in 21.9 of all 911 calls
• EMS use rate 83.8/1000 vs... 42/1000 for younger
  patients

Spaite DW, Criss EA, Valenzuela TD, et al Ann
Emerg Med Dec... 1990191418-1421
4
Mechanisms of Injury

• Fall 60.7 78.9 on level surface,10 med.
  etiol
• MVA 21.5 71.8 gt 2 vehicles
• Fight 2.4
• Acc. poison 2.3
• Choking 2.1
• Self inflicted inj 1.7 includes ingestions
• Assault 0.7
• Misc.. 8.6 Drowning, MCA, burns etc..

Spaite DW, Criss EA, Valenzuela TD, et al Ann
Emerg Med Dec.. 1990191418-1421
5
Patterns of Injury

• Head/Face 25.1
• Upper Extremity 17.2
• Hip 14.5
• Lower Extremity 13.8
• Spine 9.8 More in MVAs
• Chest/Abd 5.0

Spaite DW, Criss EA, Valenzuela TD, et al Ann
Emerg Med Dec.. 1990191418-1421
6
Pre-existing Co-morbid factors

• Age 70.5 yr. range 60-91
• Sex 58 male 42 female
• Prior Medical Illness
• Pulmonary 15
• Cardiac 46
• Renal 1
• Diabetes Mellitus 11
• Other 57

Shapiro, Bartlett et alAm Surgeon 60(9)695-8
Sept 1994
7
Case Control Study of Major Trauma in Geriatric
Patients

• Data from Major Trauma Outcome Study (MTOS) by
  ACS
• Analysis of 46,613 major trauma patients admitted
  to 120 Trauma Centers over 4 years
• included age, mechanism of injury, outcome,
  length of stay, complications vitals signs,
  Glasgow coma score, Trauma Score, AIS, and
  H-ICD-9CM codes
• Data used to establish age-dependent mortality
  rates

8
MTOS Methods

• More detailed analysis of Washington Hospital
  Center (WHC) n4,098
• included DRGs costs, charges
• autopsy records analyzed for unknown pre-existing
  disease
• Trauma research records
• Resuscitation chart reviews
• Hospital chart review

9
MTOS Results

• ...at any ISS level, survival is lower for the
  older than for younger patients
• older non-survivors had a mean TS 3 points higher
  that younger nonsurvivors
• ...older patients with a TS gt 13 had a
  mortality 10 times higher than the corresponding
  group of younger patients...(those) who appear to
  have a good prognosis are much more likely to
  die.

10
MTOS Results

• Older patients with a good TS derived prognosis
  may in fact have poor outcomes.
• 2/3 elderly nonsurvivors arrived with a SBP gt 90
  compared to only 28 of young nonsurvivors
• Autopsy revealed 30 with substantial coronary
  artery disease ( occult?)
• Average hospital stay was twice as long for
  elderly vs.. younger group

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MTOS Summary ConclusionsBeware the STABLE
elderly patient

• Overall mortality of older patients is 89
  greater than younger patients
• Mortality has a high incidence of associated head
  injury
• ISS, when adjusted for age, is a good predictor
  of mortality
• Apparently well older trauma patients with TS gt13
  or SBP gt90 has a significant chance of death

12
MOI Frequency and Mortality
65 lt 65 rel freq.
/mortality rel freq./mortality

• Fall 40.6/11.7 11.0/6.0
• MVA 28.2/20.7 33.5/9.6
• Auto v Ped 10/32.6 7.9/13.5
• Stab Wound 2.6/17.3 11.9/4.7
• GSW 5.5/52.1 13.0/19.5
• MCA 0.4/11.8 7.7/11.9

Champion, Copes Buyer et al Am J Pub Health
1989791278-1282
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Elderly vs. Youth Mortality

• Young patient who die are more obviously sick at
  presentation

lt 65 65

• Emergent intubation 40 6
• Present in shock 88 41
• ISS 31 19.2
• TS 7.7 11.8

Osler, Hales, Baack et alAm J Surg 156537 Dec..
1988
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Elderly Death v Survival

• Prob. of fatal outcome increases linearly with
  age by 1 per year over 65
• Factors associated with poor prognosis
• Severe head injury-GCS
• Hypotension
• prolonged ventilation
• pneumonia
• Early, cardiac function limits survival in elderly

Osler, Hales, Baack et alAm J Surg 156537 Dec..
1988
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Hemodynamic MonitoringScalea, Simon, et al

• Compared survival rates in geriatric multiple
  trauma when resuscitation was monitored early vs.
  delayed by non-emergent testing.
• 1986 mean time to HD monitoring, 5.5 hours-
  Mortality 93
• 1987 mean time 2.2 hours-Mortality 47

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Hemodynamic MonitoringScalea, Simon, et al

• 1985- 60 patients mean age 72.3
• Risk Factors for death-Auto v Ped, diffuse
  trauma, initial SBP lt 130, Acidosis, Multiple
  long bone Fx, Head injury
• All 11 with multiple Fx all with acidosis died
• Overall mortality 27/60 44
• 17/27 died after 4 days most of MOF (MODS)
• Patients with any 1 Risk factor 85 mortality

17
Hemodynamic MonitoringScalea, Simon, et al

• 1986- Invasive monitoring patients w/ risk factor
• 15 patients divided by HD characteristics I II
• Group I (n8)-Q lt 3.5 L/min., no response to
  fluids, Tx with inotropes, all died of
  cardiogenic shock lt 24hrs. 3 had nl BP pulse
  just prior to arrest

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Hemodynamic MonitoringScalea, Simon, et al

• Group II (n7)- Q gt 3.5 mean 4.2L/m but 5/7 had
  SvO2 lt 60 5/7 required inotropes, all had
  increased Q, and SvO2
• Optimization occurred 12-18 hours post admission
• 1 SURVIVED ICU
• 6 died of MODS, mean LOS 24.6 days

19
Hemodynamic MonitoringScalea, Simon, et al

• 1987- 30 patients Tx with early HD monitoring.
  Non-emergent tests delayed
• C-spine, CXR, Pelvis,
• Airway management, IVs,NGT, foley, Chest tubes
• Delay CT head for H/O LOC but awake
• Splint possible Fxs if closed delay x-ray
• DPL in ICU while monitoring lines placed

20
Hemodynamic MonitoringScalea, Simon, et al

• Group A-(n13) Q lt 3.5L/m
• 3 non-responders all died of cardiogenic shock,
• 3 responded but died of MODS,
• 1 responded, went to OR for 10hrs, back to ICU
  w/ Q 3.5, responded again but developed MODS
  Died
• 6 augmented to mean Q of 6.9 L/m and ALL survived

21
Hemodynamic MonitoringScalea, Simon, et al

• Group B-(n8) Q 3.8 - 5.2 L/m but Sx
  hypoperfusion
• 2 responded to volume, 6 to inotropes with a mean
  Q 6.8 L/m, SvO2 corrected in all
• 3 patients with severe head injuries died _at_ 4-8
  wks
• 1 patient died of unknown cardiac arrest _at_ 3wks
• 4 survived to discharge

22
Hemodynamic MonitoringScalea, Simon, et al

• Group C-(n9) Q gt5.8 no SvO2 de-saturation
• No inotropes,maintenance fluids, All survived
• 4 had no life threatening injury, 1 died
• note 4 patients without sig injuries died in 1986
• Overall survival 53 in 1987-88 vs.. 7 in 1986
  (p lt .001)
• Highly significant difference in optimized Q
  SVR in survivors vs.. non-survivors. (p.0001)

23
Hemodynamic MonitoringScalea, Simon, et al

• Vital signs are insensitive indicators of
  perfusion in geriatric trauma patients
• Improved survival is dependent on EARLY (1- 2
  hours) repayment of tissue oxygen debt
• Q lt 3.5 L/m or SvO2 lt 60 indicative of impaired
  VO2
• Most will require inotropes as well as volume to
  resuscitate
• Monitoring made the biggest difference in those
  who are clinically less severely injured

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Shock Defined by Oxygen Utility

• VO2 is normally dependent on metabolic demands,
  independent of DO2
• Shock State exists whenever VO2 is inadequate for
  tissue needs or when dependent on DO2
• Presence of normal vital signs DOES NOT exclude
  shock

25
Metabolic Response to Shock
Initially O2 extraction increases which decreases
CvO2. Arterial pH does not drop until late, due
to lactatic acid from anaerobic metabolism. Note
correlation between linear VO2/DO2 relationship
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Calculating DO2 VO2

• CaO2 the content of oxygen in arterial blood.
• CaO2 (Hgb x SaO2 x1.34) PaO2 x 0.003)
• Q Cardiac output
• VO2 C(a-v)O2 x Q Where C(a-v) is the difference
  between arterial and venous oxygen content
• At basal conditions VO2 250ml/min, DO2 1000
  ml/min, and O2 Extraction 25

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Resuscitation by Oxygen Delivery

• Goals of Resuscitation
• Identify the underlying etiology
• Hypoxemia
• Hypovolemia
• Pump failure
• Get VO2 independent of DO2
• Repay Tissue O2 Debt as rapidly as possible

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How can we accomplish this in ED

• Swan-Ganz
• Invasive
• Complications
• Time Consuming
• Non-continuous monitoring
• Trending not available
• Not an option in most EDs!

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Impedance Cardiography

• IQ Measures
• Impedance (Baseline)
• Heart-synchronous
• impedance changes

Continuous measurement of this resistance (called
impedance) enables the measurement, calculation,
and monitoring of the full cardiac cycle
including stroke volume, cardiac output,
contractility parameters, and total thoracic
fluid status.
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Origin of the Impedance Waveform

• Heart-Synchronous Variations in Impedance
• Changes in Volume and Velocity of Flow
• Flow-dependent Variation in Orientation of
  Disk-shaped Erythrocytes
• Volume of Electrically Participating Material
  (Blood)

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Flow-dependent Variation in Orientation of
Disk-shaped Erythrocytes
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Study Objective

• Determine the degree of correlation of Cardiac
  Index measurements using a Pulmonary Artery
  Catheter (PAC) and standard themodilution
  technique Vs. Impedance Cardiography.
• This would make using Fick equation feasible.

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Enrolled

• 62 Patients enrolled
• 60 Male
• 75 Post-operative heart
• 25 Mixed Medical-Surgical ICU

34
Impedance Cardiography vs. Thermodilution
Cardiac Index Correlation R 0.722
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Aggressive Care Justified?

• Low threshold for Mechanical ventilation
• HD monitoring and optimization
• Early tracheostomy
• Early nutritional support
• Early fracture fixation and ambulation
• Average 15 day LOS / 10 ICU days

Shapiro, Bartlett et alAm Surgeon 60(9)695-8
Sept 1994
36
Favorable outcome

• 78 overall survival, 100 of non-ICU, 68 ICU
  patients
• 53 Independent function at discharge
• Up to 28 require only short term rehabilitation
  and return to independent living

Shapiro, Bartlett et alAm Surgeon 60(9)695-8
Sept 1994
37
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