**3.1. Prehospital management and triage**

The triage decision can be made through "field triage decision scheme" which was published by the American College of Surgeons Committee on Trauma (ACS-COT) to provide a guidance for the field triage process (**Figure 2**). Under triage, inaccurate triage which results in an assignment of lower triage level is more common among the elderly patients [24]. In order to avoid high under-triage rates in elderly, two important statements were added to Step Four of the scheme:


Furthermore, we recommend that the injured elderly who met Step Four criteria should be transported to the trauma center [25]. Moreover, elderly seem to benefit more from triage to trauma center with improved outcomes [26]. Also, it is important that the transferring and receiving facilities develop transfer agreements in advance.

### **3.2. Primary survey**

Primary survey of geriatric trauma patients includes rapid and efficient assessment of vital functions, assessment of the ABCDs, and identification and therapeutic intervention of lifethreatening conditions as those for adults. Establishing and maintaining a patent airway to provide adequate oxygenation within-line cervical stabilization is the first objective. Avoiding excessive movement of the neck is crucial to prevent spinal cord injury. Because geriatric patients have limited respiratory reserve, early administration of supplemental oxygen is crucial. Early intubation should be considered if geriatric trauma patients present shock or chest wall injury/altered level of consciousness. For geriatric trauma patients, it is more challenging to recognize the early symptoms of shock. The aging process diminishes the physiologic reserve and chronic diseases can impair their ability to respond to injury; a tachycardic response may be absent or blunted. Also, medications such as β-blockers may mask tachycardia. Blood pressures are also misleading in the elderly patients. Due to increased incidence of underlying hypertension, the clinician must use a higher cutoff for hypotension than in younger patients [27]. In addition, frequently repeated measurement and interpreting the results according to baseline and previous ones may help the clinicians. Early and close monitoring must be instituted. Resuscitation of the elderly warrants special attention. Fluid

resuscitation is often challenging in geriatric trauma patients because of underlying cardiac dysfunction and concerns about precipitating heart failure. Primary survey also includes urinary and gastric catheters, arterial blood gas levels and X-rays (e.g., chest and pelvis). In the

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**Figure 2.** Guidelines for field triage of injured patients-United States, 2011 [65].

**Figure 2.** Guidelines for field triage of injured patients-United States, 2011 [65].

mortality was 4% in all age groups and 17% in seniors [23]. Moreover, for seniors there is a greater increase in mortality risk for every 1% increase in burn size and 1-year increase in age

The management of injured elderly requires the rapid assessment and rapid intervention of life-threatening situations. The assessment sequence should be same as in adults and pediat-

The triage decision can be made through "field triage decision scheme" which was published by the American College of Surgeons Committee on Trauma (ACS-COT) to provide a guidance for the field triage process (**Figure 2**). Under triage, inaccurate triage which results in an assignment of lower triage level is more common among the elderly patients [24]. In order to avoid high under-triage rates in elderly, two important statements were added to Step Four of the scheme:

Furthermore, we recommend that the injured elderly who met Step Four criteria should be transported to the trauma center [25]. Moreover, elderly seem to benefit more from triage to trauma center with improved outcomes [26]. Also, it is important that the transferring and

Primary survey of geriatric trauma patients includes rapid and efficient assessment of vital functions, assessment of the ABCDs, and identification and therapeutic intervention of lifethreatening conditions as those for adults. Establishing and maintaining a patent airway to provide adequate oxygenation within-line cervical stabilization is the first objective. Avoiding excessive movement of the neck is crucial to prevent spinal cord injury. Because geriatric patients have limited respiratory reserve, early administration of supplemental oxygen is crucial. Early intubation should be considered if geriatric trauma patients present shock or chest wall injury/altered level of consciousness. For geriatric trauma patients, it is more challenging to recognize the early symptoms of shock. The aging process diminishes the physiologic reserve and chronic diseases can impair their ability to respond to injury; a tachycardic response may be absent or blunted. Also, medications such as β-blockers may mask tachycardia. Blood pressures are also misleading in the elderly patients. Due to increased incidence of underlying hypertension, the clinician must use a higher cutoff for hypotension than in younger patients [27]. In addition, frequently repeated measurement and interpreting the results according to baseline and previous ones may help the clinicians. Early and close monitoring must be instituted. Resuscitation of the elderly warrants special attention. Fluid

• Low impact mechanisms (e.g., ground-level falls) might result in severe injury.

**3. Clinical features and the management of injured elderly patients**

than among adults [23].

120 Trauma Surgery

**3.2. Primary survey**

ric population and includes the following elements:

**3.1. Prehospital management and triage**

• SBP <110 might represent shock after age 65.

receiving facilities develop transfer agreements in advance.

resuscitation is often challenging in geriatric trauma patients because of underlying cardiac dysfunction and concerns about precipitating heart failure. Primary survey also includes urinary and gastric catheters, arterial blood gas levels and X-rays (e.g., chest and pelvis). In the 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.

**3.6. Spine injury**

preexisting spinal canal stenosis [37].

the most common site.

**3.7. Chest trauma**

**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

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**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

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

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

patients aged ≥65 years from being considered low risk for cervical spine injury.

### **3.3. Secondary survey**

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.

### **3.4. High-risk injuries**

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