Trauma is a hot topic in the emergency medicine field. It is very mechanic (energy there = injury here, there is a hole = repair the hole, etc.). But in the last decade, another component complicated these equations: age. The population of 65 years and older is the only age group who are experiencing an increased proportion number in trauma (now 37%!).
Here is the history of how geriatrician became an important part of geriatric trauma care.
Trauma centers were instituted in the 1900s for most province, including Ontario. When you look at numbers, it actually reduced mortality significantly, except for one age group: 65 years and older. The chief of trauma and the geriatrician at St-Michaels Hospital decided to join their effort and provide more individualized care to the geriatric trauma patients. A comprehensive geriatric assessment is done in the first 24-48 hours of the trauma admission to every 65 years and older patients.
They then did a before-after study (Lenartowicz, 2012) and discovered that they were able to decrease delirium by 10% absolute, and discharge to long-term care by 5%. There were also less consultation to internal medicine and psychiatry. In trauma, the most important outcome is always mortality. In this study, there were no difference. Any idea why? Geriatric principles are usually around quality of life and not quantity. They are not afraid of the goals of care discussion because they think (with very good reason) that death is probably not the worse outcome for older adults.
Other hospital in the US published on the subject with similar results (Min, 2014), (Olufajo, 2016).
But what they actually do? The magic of geriatric!
- Delirium assessment and prevention is an essential component. They assess risk (previous cognitive decline, delirium, stroke, medication, foley, glasses and hearing aids, etc).
- They control the pharmacology. No anti-cholinergic for geriatric. Adequate pain control.
- Assessment of falls (because it is the main mechanism of trauma in geriatric).
- Help with the discharge disposition
- Early mobilization, diet and adequate hydration
- Follow up after the acute episode
- Goals of care discussions, sometimes early in the process of trauma care.
These little interventions that seems so banal but have a major effect on quality of care and delirium outcomes. This is a must do if you are a trauma center!
As for the actual trauma management, another subject for another post!