**3.6. Spine injury**

elderly, due to alterations with aging, anticoagulant usage may increase the chance of profuse bleeding during the catheter procedure. Special care should be taken during this procedure.

Secondary survey includes head-to-toe evaluation, reassessment of all vital signs, diagnostic tests and expanded history of the geriatric trauma patients. A detailed description of the secondary survey is provided separately; special circumstances in geriatric trauma patients are discussed here. Clinicians should focus on identifying and treating injuries which were not discovered during the primary survey. Geriatric trauma patients often present with significant occult injury mostly caused by minor mechanism such as ground-level falls. It is demonstrated that the elderly with blunt head trauma are more likely to present in occult fashion than youngsters, even if they have significant intracranial injury. Moreover, persistent vomiting and headache were less likely to occur in elderly with any intracranial injury [28]. Also, initially stable geriatric trauma patients may deteriorate rapidly and without warning. During the secondary survey it is essential to assess the alterations in mental status, especially compared to presentation.

The risk of complications increases with the severity of the *trauma*; however, even minor traumas such as ground-level falls or slipping while walking off a curb may seem relatively

Traumatic brain injury (TBI) is a significant problem among the elderly. For the age of 65 years and older, falls are the primary mechanisms of TBI-related ED visits (81.8%) and TBI-related deaths (54.4%) [30]. In the review of the literature, it is recognized that older adults with moderate–severe TBI have poor outcomes with high rates of significant disability and mortality. Two major factors put geriatric trauma patients at a greater risk for increased incidence of TBI: age-related structural changes and preinjury anticoagulant-antiplatelet usage. First, with aging, parasagittal bridging veins stretch and make the elderly more susceptible to traumatic tears. Thus, the elderly have a higher incidence of subdural hematoma. Also, cerebral atrophy leads to a significant amount of blood accumulating in subdural area before clinical signs manifest. Rapid neurologic decline should be considered in these patients. Second, an increased incidence of the anticoagulant and antiplatelet therapy in the elderly may have detrimental consequences. It is suggested that taking anticoagulant therapy at the time of the injury increases the risk of intracranial hemorrhage [31] and is related with worse outcomes [32, 33]. One of the most frequently prescribed anticoagulant medications is warfarin. Also, Franko et al. concluded that warfarin use at the time of injury also makes mortality significantly higher after the age 70 [32]. Thus, immediate noncontrast head computed tomography (CT) is recommended for the elderly patients who take anticoagulant or antiplatelet therapy, even if their trauma seems minor. Additionally, rapid screening for anticoagulant use, INR value and subsequent correction with blood component therapy may improve outcomes.

harmless in elderly patients, they can lead to severe injury and death [29].

**3.3. Secondary survey**

122 Trauma Surgery

**3.4. High-risk injuries**

**3.5. Head injury**

**Cervical spine** injuries are more common in the elderly and the incidence appears to be increasing [34, 35]. The most commonly seen injury site is upper cervical spine (UCS) especially the odontoid process [36] and caused by falls. The UCS injuries are associated with a high rate of mortality and morbidity. Elderly patients tend to sustain more C-spine fracture following simple falls such as ground-level falls [37]. It is attributed to increased frequency of preexisting cervical spine pathology such as osteoporosis and osteoarthritis [36]. It may also result in occult presentation, delayed diagnosis, increased risk for spinal cord injuries and difficulty in interpreting plain radiographs. Moreover, mild extension injuries followed by fall or rear-end motor vehicle crushes may cause central cord syndrome in the presence of preexisting spinal canal stenosis [37].

**Thoracolumbar spine** fractures in the elderly are usually associated with osteoporosis. Osteoporosis affects almost 50% of these individuals and contributes to the occurrence of spontaneous vertebral compression fractures. The majority of the osteoporotic vertebral fractures are situated in thoracolumbar spine, and the anterior wedge compression fractures are the most common site.

Treatment of diagnosed vertebral fractures in these individuals is still controversial. Two options are avaliable: conservative therapy and surgery. Unstable fractures, flexion distraction injuries and severe burst fractures causing neurologic deficit mostly indicate surgical intervention. However, in the patient who is neurologically intact, conservative treatment including bad-rest and bracing seems a more viable option depending on the type of fracture [38]. Consequently, we recommended that apparently low-energy level injuries should be considered as a high-risk for spine injury and investigated elaborately. CT scan is the preferred initial modality for assessing the geriatric cervical spine because The Canadian Cervical-Spine Rule, but not the National Emergency X-Radiography Utilization Study criteria, excludes patients aged ≥65 years from being considered low risk for cervical spine injury.

### **3.7. Chest trauma**

Chest traumas account for ∼796,000 emergency department (ED) visits annually in the USA [39]. For blunt chest trauma, the most prominent factors in etiology are falls and motor vehicle collisions. The elderly are more prone to incur chest injuries following blunt chest trauma, and this is associated with a high risk of mortality and morbidity [40]. Rib fractures and pulmonary contusions are more common in this population due to preexisting osteoporosis, loss of muscle mass and comorbidities [41]. The mortality and risk for pneumonia following blunt chest trauma significantly increase after 65 years [40, 41] and it is correlated with the increased number of rib fractures [40, 42]. In the presence of pulmonary contusion, clinicians should consider early ventilatory support because these patients are highly vulnerable to respiratory compromise. Given these risks, detailed physical examination, close observation and early administration of supplemental oxygen with adequate pain medication are highly recommended for elderly patients with even one rib fracture. Also, advanced imaging is warranted in older patients with multiple rib fractures. CT may be necessary to assess the extent of injuries that might not be seen on plain radiographs. Simple pneumothorax and hemothorax are poorly tolerated by elderly patients. Thus, geriatric patients with life-threatening chest trauma should be considered for intensive care unit (ICU) observation.

for diagnose is plain radiographs. However, it is estimated that 2–9% of fractures may be radiographically occult [49], and further imaging such as CT and MRI is required to make a definitive diagnosis. MRI has higher sensitivity than CT for detecting occult hip fractures. Additionally, nuclear medicine scintigraphy may be another choice for diagnosis due to high sensitivity. However, access to the scintigraphy usually is difficult and, it has limited capabil-

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Elderly individuals are more likely to have preexisting comorbidities. The presence of a preexisting medical condition was associated with increase in mortality of elderly patients who sustained low or moderate severity trauma [50]. The most frequent preinjury comorbidities are hypertension (HT), diabetes mellitus (DM), coronary artery disease (CAD) and use of anticoagulants/antiplatelets [51]. Preinjury medical conditions usually make the management of geriatric trauma patients challenging; preexisting HT can hide the early signs of shock and cause delay or under-treatment and the presence of heart failure may cause volume overload and pulmonary edema during IV fluid therapy. ET intubation also would be challenging in the patient who has cervical or temporomandibular arthritis. Thus, early detection of preexisting medical conditions, appropriate treatment and follow-up care may improve outcomes

As the population ages, increasing numbers of elderly are being prescribed a medication for chronic medical conditions. It was shown that medications (especially sedatives and hypnotics, antidepressants, and benzodiazepines [52]) are particularly complex risk factors for falls and the risk of falling increases with the number of medications taken [18]. Also, polypharmacy is associated with occurrence of drug–drug interactions and adverse drug reactions which are frequently encountered in the elderly [53]. B-adrenergic blocking agents may limit the tachycardia response which can result in undesirable decreased cardiac output and reduced tissue perfusion. Calcium-channel blockers may prevent peripheral vasoconstriction and contribute to produce hypotension. Chronic diuretic use may lead to elderly patients being chronically hypovolemic, hyponatremic and hypokalemic. Additionally, declines in renal and hepatic function may alter the metabolism and clearance of these drugs. The side effects, drug interactions should always be considered and potentially nephrotoxic drugs

In the elderly population, both age-related structural changes and usage of some chronic medications may increase the risk of bleeding. Chronic anticoagulant therapy can increase the risk of hemorrhage, especially intracranial hemorrhage (ICH) [31]. The usage of warfarin at the time of injury also makes mortality significantly higher after the age 70 [32]. Recent

must be given in adjusted doses based on calculated creatinine clearance.

ity to delineate the full nature of the fracture.

**4. Special circumstances**

following trauma in elderly.

**4.3. Risk of bleeding**

**4.2. Pre-injury medication usage**

**4.1. Preexisting medical conditions**
