Anesthesia for the Geriatric Trauma Patient

  • Walid AlrayashiEmail author


As healthcare continues to improve, the average life expectancy is increasing and hospitals are seeing a steady rise in the average age of their trauma patients. The elderly have unique physiology, pharmacokinetics, and anesthetic concerns that differ from their younger counterparts. This chapter focuses on the impact of geriatric trauma in hospitals, initial triaging and assessment, special pharmacologic and physiologic considerations, the most common injuries, and current anesthetic management strategies.

Key words

Geriatric physiology elderly trauma (anesthetic concerns) head injuries in the elderly orthopedic injuries in the elderly thoracic injuries in the elderly 


  1. 1.
    Center for Disease Control and Prevention National Center for Health Statistics. Life expectancy. Accessed June 20, 2013.
  2. 2.
    Federal Interagency Forum on Aging-Related Statistics. Older Americans 2010: key indicators of well-being. Washington, DC; 2010 July.
  3. 3.
    Campbell JW, et al. In harm’s way: moving the older trauma patient toward a better outcome. Geriatrics. 2009;64(1):8–13.PubMedGoogle Scholar
  4. 4.
    MacKenzie EJ, et al. Acute hospital costs of trauma in the United States: implications for regionalized systems of care. J Trauma. 1990;30(9):1096–101; discussion 101–3.PubMedCrossRefGoogle Scholar
  5. 5.
    American College of Surgeons Committee on Trauma. Geriatric trauma. In: ATLS: student course manual. 8th edition. Chicago: ACLS; 2008. pp. 247–57.Google Scholar
  6. 6.
    The Eastern Association for the Surgery of Trauma. Geriatric trauma (update). Accessed July 20, 2012.
  7. 7.
    Carpenter CR, DesPain B, Keeling TN, et al. The Six-Item Screener and AD8 patients. Ann Emerg Med. 2011;57(6):653–61.PubMedCentralPubMedCrossRefGoogle Scholar
  8. 8.
    Labib N, Nouh T, Winocour S, et al. Severely injured geriatric population: morbidity, mortality and risk factors. J Trauma. 2011;71:1908–14.PubMedCrossRefGoogle Scholar
  9. 9.
    Thompson HJ, McCormick WC, Kagan SH. Traumatic brain injury in older adults: epidemiology, outcomes, and future implications. J Am Geriatr Soc. 2006;54:1590–5.PubMedCentralPubMedCrossRefGoogle Scholar
  10. 10.
    Keller JM, Sciadini MF, Sincalir E, et al. Geriatric trauma: demographics, injuries and mortality. J Orthop Trauma. 2012;26(9):e161–5.PubMedCrossRefGoogle Scholar
  11. 11.
    Ganz DA, Bao Y, Shekelle PE, et al. Will my patient fall? JAMA. 2007;297:77–86.PubMedCrossRefGoogle Scholar
  12. 12.
    Roudsari BS, Ebel BE, Corso PS, et al. The acute medical care costs of fall-related injuries among the US older adults. Injury. 2005;36:1316–22.PubMedCrossRefGoogle Scholar
  13. 13.
    Linn BS. Age differences in the severity and outcome of burns. J Am Geriatr Soc. 1980;28:118–23.PubMedGoogle Scholar
  14. 14.
    Buckner RL. Memory and executive function in aging and AD: multiple factors that cause decline and reserve factors that compensate. Neuron. 2004;44:195–208.PubMedCrossRefGoogle Scholar
  15. 15.
    Lewis MC, Karim A, Paniagua M. Geriatric trauma: special considerations in the anesthetic management of the injured elderly patient. Anesthesiol Clin. 2007;25:75–90.PubMedCrossRefGoogle Scholar
  16. 16.
    Geokas MC, Lakatta EG, Makinodan T, et al. The aging process. Ann Intern Med. 1990;113:455466.CrossRefGoogle Scholar
  17. 17.
    Rooke GA. Autonomic and cardiovascular function in the geriatric patient. Anesthesiol Clin North America 2000;18:31,46, v-vi.Google Scholar
  18. 18.
    Raine JM, Bishop JM. A-a difference in O2 tension and physiologic dead space in normal man. J Appl Physiol. 1963;18:284.PubMedGoogle Scholar
  19. 19.
    Varon A, Smith C, et al. Anesthetic management of geriatric trauma patient. In: Essentials of trauma anesthesia. Cambridge: Cambridge University Press; 2012. p. 275–87.Google Scholar
  20. 20.
    Muravchick S. Anesthesia for the elderly. In: Miller RM, editor. Anesthesia. 5th ed. Philadelphia: Churchill Livingstone; 2000. p. 2140–5.Google Scholar
  21. 21.
    Small SA. Age-related memory decline: current concepts and future directions. Arch Neurol. 2001;58:360–4.PubMedCrossRefGoogle Scholar
  22. 22.
    Peters A. Structural changes that occur during normal aging of primate cerebral hemispheres. Neurosci Biobehav Rev. 2002;26:733–41.PubMedCrossRefGoogle Scholar
  23. 23.
    Shetty AK, Hattiangady B, Shetty GA. Stem/progenitor cell proliferation factors FGF-2, IGF-1, and VEGF exhibit early decline during the course of aging in the hippocampus: role of astrocytes. Glia. 2005;51:173–86.PubMedCrossRefGoogle Scholar
  24. 24.
    Steiner LA. Postoperative delirium. Part 1: pathophysiology and risk factors. Eur J Anesthesiol. 2011;28(9):628–36.CrossRefGoogle Scholar
  25. 25.
    Franko J, Kish KJ, O’Connell BG, et al. Advanced age and preinjury warfarin anticoagulation increase the risk of mortality after head trauma. J Trauma. 2006;61:107–10.PubMedCrossRefGoogle Scholar
  26. 26.
    Lavoie A, Ratte S, Clas D, et al. Preinjury warfarin use among elderly patients with closed head injuries in a trauma center. J Trauma. 2004;56:802–7.PubMedCrossRefGoogle Scholar
  27. 27.
    Neideen T, Lam M, Brasel KJ. Preinjury beta blockers are associated with increased mortality in geriatric trauma patients. J Trauma. 2008;65:1016–20.PubMedCrossRefGoogle Scholar
  28. 28.
    Lambert DA, Sattin RW. Death from falls, 1978-1984. MMWR CDC Surveill Summ. 1998;37:S21–6.Google Scholar
  29. 29.
    Finelli FC, Jonsson J, Champion HR, et al. A case control study for major trauma in geriatric patients. J Trauma. 1989;29:541–8.PubMedCrossRefGoogle Scholar
  30. 30.
    Phillips S, Rond PC, Kelly SM, et al. The failure of triage criteria to identify geriatric patients with trauma: results from the Florida Trauma Triage Study. J Trauma. 1996;40:278–83.PubMedCrossRefGoogle Scholar
  31. 31.
    Baker SP, O’Neill B, Haddon W, et al. The injury severity score: a method for describing patients with multiple injuries and valuating emergency care. J Trauma. 1974;14:187–96.PubMedCrossRefGoogle Scholar
  32. 32.
    Lomoschitz FM, Blackmore CC, Mirza SK, et al. Cervical spine injuries in patients 65 years old and older: epidemiologic analysis regarding the effects of age and injury mechanism on distribution, type, and stability of injuries. Am J Roentgenol. 2002;178:573–7.CrossRefGoogle Scholar
  33. 33.
    Arden JR, Holley FO, Stanski DR. Increased sensitivity to etomidate in the elderly: initial distribution versus altered brain response. Anesthesiology. 1986;65:9–27.CrossRefGoogle Scholar
  34. 34.
    Homer TD, Stanski DR. The effect of increasing age on thiopental disposition and anesthetic requirement. Anesthesiology. 1985;62:714–24.PubMedCrossRefGoogle Scholar
  35. 35.
    Reves JG, Fragen RJ, Vinik HR, et al. Midazolam: pharmacology and uses. Anesthesiology. 1985;62:310–24.PubMedCrossRefGoogle Scholar
  36. 36.
    Heffernan DS, Thakkar RK, Monaghan SF, et al. Normal presenting vital signs are unreliable in geriatric blunt trauma victims. J Trauma. 2010;69:813–20.PubMedCrossRefGoogle Scholar
  37. 37.
    Martin J, Alkhoury F, O’Connor J, et al. ‘Normal’ vital signs belie occult hypoperfusion in geriatric trauma patients. Am Surg. 2010;76:65–9.PubMedGoogle Scholar
  38. 38.
    Callaway DW, Shapiro NI, Donnino MW, et al. Serum lactate and base deficit as predictors of mortality in normotensive elderly blunt trauma patients. J Trauma. 2009;66:1040–4.PubMedCrossRefGoogle Scholar
  39. 39.
    Jacobs DG, Plaisier BR, Barie PS, et al. Practice management guidelines for geriatric trauma: the EAST practice management guidelines work group. J Trauma. 2003;54:391–416.PubMedCrossRefGoogle Scholar
  40. 40.
    Marik PE, Cavallazzi R, Vasu T, et al. Dynamic changes in arterial waveform derived variables and fluid responsiveness in mechanically ventilated patients: a systematic review of the literature. Crit Care Med. 2009;37:2642–7.PubMedCrossRefGoogle Scholar
  41. 41.
    Santora TA, Schinco MA, Trooskin SZ. Management of TRAUMA in the elderly patient. Surg Clin North Am. 1994;74:163–85.PubMedGoogle Scholar
  42. 42.
    Siegmeth AW, Gurusamy K, Parker MJ. Delay to surgery prolongs hospital stay in patients with fractures of the proximal femur. J Bone Joint Surg Br. 2005;87:1123–6.PubMedCrossRefGoogle Scholar
  43. 43.
    Zuckerman JD, Skovron ML, Koval KJ, et al. Postoperative complications and mortality associated with operative delay in older patients who have a fracture of the hip. J Bone Joint Surg Am. 1995;77:1551–6.PubMedGoogle Scholar
  44. 44.
    Sexson SB, Lehner JT. Factors affecting hip fracture mortality. J Orthop Trauma. 1987;1:298–305.PubMedCrossRefGoogle Scholar
  45. 45.
    Vidan MT, Sanchez E, Gracia Y, et al. Causes and effects of surgical delay in patients with hip fracture: a cohort study. Ann Intern Med. 2011;155:226–33.PubMedCrossRefGoogle Scholar
  46. 46.
    Koval KJ, Aharonoff GB, Rosenberg AD, et al. Functional outcome after hip fracture: effect of general versus regional anesthesia. Clin Orthop Relat Res. 1998;348:37–41.PubMedGoogle Scholar
  47. 47.
    Gilbert TB, Hawkes WG, Hebel JR, et al. Spinal anesthesia versus general anesthesia for hip fracture repair: a longitudinal observation of 741 elderly patients during 2-year follow-up. Am J Orthop. 2000;29:25–35.PubMedGoogle Scholar
  48. 48.
    Valentin N, Lomholt B, Jensen JS, et al. Spinal or general anesthesia for surgery of the fractured hip? A prospective study of mortality in 578 patients. Br J Anaesth. 1986;58:284–91.PubMedCrossRefGoogle Scholar
  49. 49.
    Neuman MD, Silber JH, Elkassabany NM, et al. Comparative effectiveness of regional versus general anesthesia for hip fracture surgery in adults. Anesthesiology. 2012;117:72–92.PubMedCrossRefGoogle Scholar
  50. 50.
    Pentland B, Hutton LS, Jones PA. Late mortality after head injury. J Neurol Neurosurg Psychiatry. 2005;76:395–400.PubMedCentralPubMedCrossRefGoogle Scholar
  51. 51.
    Tornetta III P, Mostafavi H, Riina J, et al. Morbidity and mortality in elderly trauma patients. J Trauma. 1999;46:702–6.PubMedCrossRefGoogle Scholar
  52. 52.
    Utomo WK, Gabbe BJ, Simpson PM, et al. Predictors of in-hospital mortality and 6-month functional outcomes in older adults after moderate to severe traumatic brain injury. Injury. 2011;40:973–7.CrossRefGoogle Scholar
  53. 53.
    Irvine DH, Foster JB, Newell DJ. Prevalence of cervical spondylosis in a general practice. Lancet. 1965;22(14):1089–92.CrossRefGoogle Scholar
  54. 54.
    Donaldson 3rd WF, Towers JD, Doctor A, et al. A methodology to evaluate motion of the unstable spine during intubation techniques. Spine. 1993;18:2020–3.PubMedCrossRefGoogle Scholar
  55. 55.
    Unni VK, Johnston RA, Young HS, et al. Prevention of intracranial hypertension during laryngoscopy and endotracheal intubation. Br J Anaesth. 1984;56:1219–23.PubMedCrossRefGoogle Scholar
  56. 56.
    Bratton SL, Chestnut RM, Ghajar J, et al. Guidelines for the management of severe traumatic brain injury. IX. Cerebral perfusion thresholds. J Neurotrauma. 2007;24:S59–64.PubMedGoogle Scholar
  57. 57.
    Battle CE, Hutchings H, Evans PA. Risk factors that predict mortality in patients with blunt chest wall trauma: a systematic review and meta-analysis. Injury. 2012;43:8.PubMedCrossRefGoogle Scholar
  58. 58.
    Gowing G, Jain MK. Injury patterns and outcomes associated with elderly trauma victims in Kingston, Ontario. Can J Surg. 2007;50(6):437–44.PubMedCentralPubMedGoogle Scholar
  59. 59.
    Bulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib fractures in the elderly. J Trauma. 2000;48:1040.PubMedCrossRefGoogle Scholar
  60. 60.
    Cohn S. Pulmonary contusion: review of the clinical entity. J Trauma. 1997;42:973–9.PubMedCrossRefGoogle Scholar
  61. 61.
    Cordell-Smith JA, Roberts N, Peek GJ, Firmin RK. Traumatic lung injury treated by extracorporeal membrane oxygenation (ECMO). Injury. 2006;37:29–32.PubMedCrossRefGoogle Scholar
  62. 62.
    ARDSnet. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and acute respiratory distress syndrome. N Engl J Med. 2000;342:1301–8.CrossRefGoogle Scholar
  63. 63.
    Ullman DA, Wimpy RE, Fortune JB, et al. The treatment of patients with multiple rib fractures using continuous thoracic epidural narcotic infusions. Reg Anesth. 1989;14:43–7.PubMedGoogle Scholar
  64. 64.
    John AD, Sieber FE. Age associated issues: geriatrics. Anesthesiol Clin North America. 2004;22:45–58.PubMedCrossRefGoogle Scholar
  65. 65.
    Bickel H, Gradinger R, Kochs E, Forstl H. High risk of cognitive and functional decline after postoperative delirium. A three-year prospective study. Dement Geriatr Cogn Disord. 2008;26:26–31.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  1. 1.Department of AnesthesiologyNew York University Medical CenterNew YorkUSA

Personalised recommendations