H. Russell Harvey, M.D.
Consultant Anesthesiologist and Intensivist
2702 Vigilante Trail
Billings, MT 59102
tamazyn@yahoo.com

Douglas B. Coursin, M.D. (corresponding author)
Professor of Anesthesiology and Internal Medicine
Associate Director of the Trauma and Life Support Center
B6/319 UW CSC
Madison, WI 53792-3272
dcoursin@facstaff.wisc.edu

Case: A 100kg, 5â8", 71 y/o male falls 10 feet from his deer hunting tree-stand and sustains multiple rib fractures, a left hemopneumothorax and contusion. He has a 20-pack-per-year smoking history, hypertension and type II diabetes. He had an angioplasty and stent two years prior to injury. He takes glypizide, enalapril and atenolol. After fluid resuscitation of 2 liters of normal saline, his BP is 140/90, respiratory rate 30, pulse 90 and Sa02 ö 90 percent on 50 percent. His Hct is 33, creatinine 1.5 mg/dL and K+ = 5.4meq/dL.

Discussion

Critical care of this elderly trauma patient is more complicated than care of his traumatized 18-year-old counterpart. Statistically, the 18-year-old is essentially healthy and the alteration to his physiology is almost entirely secondary to his injuries. The elderly patient, however, has suffered the varying toll of the vagaries of a long life as well as age-related diminution in end-organ function (see chapter on Critical Care of the Elderly Patient). So, first off, why did this occur? Bad luck, bad timing, hypoglycemia, cardiac dysrhythmia, CNS or CV ischemia, drug side effect, or other? The role of such underlying event(s) is much more common and greater for the elderly trauma victim.

Decline in Organ Function/Reserve

The physiologic substrate of the elderly is different than that of the 18-year-old. As mentioned in the previous article "Critical Care of the Elderly Patient," all people suffer a decline in organ function as they age, affecting autonomic responsiveness and the endocrine response to stress, as well as the more obvious major organ systems. Many maintain homeostasis perfectly well, some despite chronic disease. However, when they are traumatized they have a decreased ability to maintain homeostasis or to regain it if lost. Our patient is hypertensive, most likely from multiple etiologies including chronic CV disease, pain, marginal gas exchange and response to fluid resuscitation. He has decreased physiologic reserve and may not tolerate the increased work of breathing and increased [A-a O₂] gradient after his pulmonary trauma. He is at risk for progressive multiple-organ dysfunction from this and from ongoing systemic inflammatory response.

Greater Likelihood of Chronic Disease

The prevalence of chronic disease is much greater in the elderly and correlates with age. One study states that 30 percent of trauma patients over 55 have pre-existing disease. Many will have hypertension, diabetes, COPD or arteriosclerotic heart disease. In the setting of obligatory decrease in organ function simply because of age, the presence of one or more of these diseases should raise a red flag. An overweight, elderly deer hunter with significant coronary disease (recent coronary angioplasty, smoking history and diabetes) may already consume most of his "reserve" just to maintain his vital signs and a saturation of 90 percent, but his trauma could precipitate widespread decompensation.

Priorities

Treating our elderly man requires:

• An accurate history to determine the underlying cause of his injury. If it is just a simple fall (falls, by the way, are the most common cause of trauma in the elderly), so be it, but rule out myocardial ischemia, sudden death event, metabolic process or CNS event.
• Definitive therapy with an arterial catheter, CVP (with or without a PAC catheter), serial monitoring of adequate O₂ delivery, chest tube, pain management (consideration of an intrapleural catheter, thoracic epidural, PCA, etc., to control his pain), noninvasive (CPAP, BiPAP) or expeditious invasive ventilatory support with appropriate fluid resuscitation.
• Elderly patients will not tolerate failures or even ambiguities in resuscitation. Therefore, we must exclude a metabolic or ischemic etiology for his fall and evaluate his response to our fluids, pain management, and means to optimize gas exchange.
• Early admission to the ICU to allow timely invasive monitoring and optimization of O₂ delivery once surgery is excluded and the patient is stabilized. Additional non-life- threatening diagnostic tests should be deferred until the patient is stabilized and adequately monitored in the ICU.
• Adequacy of volume restoration. The choice of fluid for resuscitation is not felt to be key (colloid versus crystalloid).

References

1. Cicala RS. Anesthesia in the traumatized elderly patient. In: Geriatric anesthesiology. McCleskey CH, ed. Baltimore: Williams and Wilkins; 1997:473-485.
2. De Maria EJ. Evaluation and treatment of the elderly trauma victim. Clin Geriatr Med. 1993; 9:461-471.
3. Johnson CL, Margulies DR, Kearney TJ, et al. Trauma in the elderly: An analysis of outcome based on age. Am Surg. 1994;60(11):899-902
4. Shapiro MB, Occhert RE, Colwell C, et al. Geriatric trauma: Aggressive intensive care unit management is justified. Am Surg. 1994; 60(9):695-698.
5. Wilson, RF. Trauma in patients with pre-existing cardiac disease. Crit Care Clin. 1994; 10:491-506.
6. Scalea TM, Simon HM, Duncan AO, et al. Geriatric blunt multiple trauma: Improved survival with early invasive monitoring. J Trauma-Injury Infect Crit Care. 1990; 30:129-134.