The Role of the Emergency Physician for Injured Geriatric Patient Care in the ED

  • Dave Milzman
  • Sarada Rao


The rapidly aging population is now shifting the focus of healthcare. As the population lives longer, a greater percentage of individuals are living longer, more active, and subsequently at more of a risk to suffer from a traumatic injury. This means that more older persons are at risk to fall down and fracture a hip and suffer from a subdural hematoma and more at risk to be struck in a crosswalk and suffer from multiple trauma. Injuries in the geriatric population presenting to the emergency department (ED) are undergoing a change in presentations and complexity. Geriatric trauma is increasing both in absolute number and proportion of annual trauma admissions, with admissions in level I and II trauma centers up from 23% in 2003 to 30% in 2009 [1]. The geriatric trauma patient is three to five times more likely to die from trauma than a younger patient who sustains a similar mechanism of injury [2, 3].


  1. 1.
    Carpenter CR, Platts-Mills TF. Evolving prehospital, emergency department, and “inpatient” management models for geriatric emergencies. Clin Geriatr Med. 2013;29(1):31–47.CrossRefPubMedGoogle Scholar
  2. 2.
    Taylor MD, Tracy JK, Meyer W, Pasquale M, Napolitano LM. Trauma in the elderly: intensive care unit resource use and outcome. J Trauma. 2002;53(3):407–14.CrossRefPubMedGoogle Scholar
  3. 3.
    JM K, Sciadini MF, Sinclair E, O’Toole RV. Geriatric trauma: demographics, injuries, and mortality. J Orthop Trauma. 2012;26(9):e161–5.CrossRefGoogle Scholar
  4. 4.
    Centers for Disease Control and Prevention. The state of aging and health in America 2013. Atlanta, GA: Centers for Disease Control and Prevention, US Department of Health and Human Services; 2013.Google Scholar
  5. 5.
    Meldon SW, Reilly M, Drew BL, et al. Trauma in the very elderly: a community-based study of outcomes at trauma and nontrauma centers. J Trauma. 2002;52:79Y84.Google Scholar
  6. 6.
    Sanders AB, Witzke DB, Jones JS, Richmond K, Kidd P. Principles of care and application of the geriatric emergency care model. In: Sanders AB, editor. Emergency care of the elder person. St. Louis, MO: Beverly-Cracom Publications; 1996. p. 59–93.Google Scholar
  7. 7.
    Mohan D, Barnato AE, Rosengart MR, et al. Trauma triage in the emergency departments of nontrauma centers: an analysis of individual physician caseload on triage patterns. J Trauma Acute Care Surg. 2013;74(6):1541–7.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Sasser SM, Hunt RC, Faul M, et al. Centers for Disease Control and Prevention. Guidelines for elder triage of injured patients: recommendations of the National Expert Panel on Field Triage, 2011. MMWR Recomm Rep. 2012;61(RR-1):1–20.PubMedGoogle Scholar
  9. 9.
    Committee on Trauma, American College of Surgeons. Collaborative clinical services. In: Rotondo M, Cribari C, Smith S, editors. Resources for optimal care of the injured patient. Chicago: American College of Surgeons; 2014. p. 76–87.Google Scholar
  10. 10.
    Kohn MA, Hammel JM, Bretz SW, Stangby A. Trauma team activation criteria as predictors of patient disposition from the emergency department. Acad Emerg Med. 2004;11(1):1–9.CrossRefPubMedGoogle Scholar
  11. 11.
    A H, Ibrahim-Zada I, Rhee P, Aziz H, Fain MJ, Friese RS, Joseph B. Predictors of mortality in geriatric trauma patients: a systematic review and meta-analysis. J Trauma Acute Care Surg. 2014;76(3):894–901.CrossRefGoogle Scholar
  12. 12.
    Phillips S, Rond PC 3rd, 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(2):278–83.CrossRefPubMedGoogle Scholar
  13. 13.
    Gage AM, Traven N, Rivara FP, Jurkovich GJ, Arbabi S. Compliance with Centers for Disease Control and Prevention elder triage guidelines in an established trauma system. J Am Coll Surg. 2012;215(1):148–54.CrossRefPubMedGoogle Scholar
  14. 14.
    Davis JW, Kaups KL. Base deficit in the elderly: a marker of severe injury and death. J Trauma. 1998;45:873–7.CrossRefPubMedGoogle Scholar
  15. 15.
    Sterling DA, O’Connor JA, Bonadies J. Geriatric falls: injury severity is high and disproportionate to mechanism. J Trauma. 2001;50:116Y119.CrossRefGoogle Scholar
  16. 16.
    JB B, Gestring ML, Forsythe RM, Stassen NA, Billiar TR, Peitzman AB, Sperry JL. Systolic blood pressure criteria in the National Trauma Triage Protocol for geriatric trauma: 110 is the new 90. J Trauma Acute Care Surg. 2015;78(2):352–9.CrossRefGoogle Scholar
  17. 17.
    Pandit V, Rhee P, Hashmi A, Kulvatunyou N, Tang A, Khalil M, O’Keeffe T, Green D, Friese RS, Joseph B. Shock index predicts mortality in geriatric trauma patients: an analysis of the National Trauma Data Bank. J Trauma Acute Care Surg. 2014;76(4):1111–5.CrossRefPubMedGoogle Scholar
  18. 18.
    JM C, Raubenolt A, Cudnik MT. Modification of Glasgow Coma Scale criteria for injured elders. Acad Emerg Med. 2011;18(10):1014–21.CrossRefGoogle Scholar
  19. 19.
    Yilmaz S, Karcioglu O, Sener S. The impact of associated diseases on the etiology, course and mortality in geriatric trauma patients. Eur J Emerg Med. 2006;13:295–8.CrossRefPubMedGoogle Scholar
  20. 20.
    Chang DC, Bass RR, Cornwell EE, et al. Undertriage of elderly trauma patients to state-designated trauma centers. Arch Surg. 2008;143:776–81. discussion 782CrossRefPubMedGoogle Scholar
  21. 21.
    Scheetz LJ. Effectiveness of prehospital trauma triage guidelines for the identification of major trauma in elderly motor vehicle crash victims. J Emerg Nurs. 2003;29:109.CrossRefPubMedGoogle Scholar
  22. 22.
    McMillian WD, Rogers FB. Management of prehospital antiplatelet and anticoagulant therapy in traumatic head injury: a review. J Trauma. 2009;66:94.CrossRefGoogle Scholar
  23. 23.
    Meldon SW, Reilly M, Drew BL, et al. Trauma in the very elderly: a community-based study of outcomes at trauma and nontrauma centers. J Trauma. 2002;52:79–84.PubMedGoogle Scholar
  24. 24.
    Bonne S, Schuerer DJE. Trauma in the older adult: epidemiology and evolving geriatric trauma principles. Clin Geriatr Med. 2013;29(1):137–50.CrossRefPubMedGoogle Scholar
  25. 25.
    Vidán M, Serra JA, Moreno C, Riquelme G, Ortiz J. Efficacy of a comprehensive geriatric intervention in older patients hospitalized for hip fracture: a randomized, controlled trial. J Am Geriatr Soc. 2005;53:1476–82.CrossRefPubMedGoogle Scholar
  26. 26.
    Fisher AA, Davis MW, Rubenach SE, Sivakumaran S, Smith PN. Outcomes for older patients with hip fractures: the impact of orthopedic and geriatric medicine cocare. J Orthop Trauma. 2006;20:172–80.CrossRefPubMedGoogle Scholar
  27. 27.
    Gowing R, Jain M. Injury patterns and outcomes associated with elderly trauma victims in Kingston, Ontario. Can J Surg. 2007;50(6):437–44.PubMedPubMedCentralGoogle Scholar
  28. 28.
    Calland J, Ingraham A, Martin N, et al. Evaluation and management of geriatric trauma: an Eastern Association for the Surgery of Trauma practice management guideline. J Traum Acute Care. 2012;73:S345–50.CrossRefGoogle Scholar
  29. 29.
    Sterling DA, O’Connor JA, Bonadies J. Geriatric falls: injury severity is high and disproportionate to mechanism. J Trauma. 2001;50(1):116–9.CrossRefPubMedGoogle Scholar
  30. 30.
    Cohn B, Keim S, Sanders A. Can anticoagulated patients be discharged home safely from the emergency department after minor head injury? J Emerg Med. 2014;46(3):410–7.CrossRefPubMedGoogle Scholar
  31. 31.
    Hodgkinson S, Pollit V, Sharpin C. Early management of head injury, summary of updated NICE guidance. BMJ. 2014;348:g104.CrossRefPubMedGoogle Scholar
  32. 32.
    Sadro C, Sandstrom C, Verma N, et al. Geriatric trauma: a radiologist’s guide to imaging trauma patients aged 65 years and older. Radiographics. 2015;35:1263–85.CrossRefPubMedGoogle Scholar
  33. 33.
    JA S, Wang J, Mills B, et al. The application of the CRASH-CT prognostic model for older adults with traumatic brain injury: a population-based observational cohort study. J Head Trauma Rehabil. 2016;31:E8–E14.CrossRefGoogle Scholar
  34. 34.
    Milzman DP, Boulanger BR, Rodriguez A, et al. Pre-existing disease in trauma patients: a predictor of fate independent of age and injury severity score. J Trauma. 1992;32(2):236–43.CrossRefPubMedGoogle Scholar
  35. 35.
    Ferraris VA, Ferraris SP, Saha SP. The relationship between mortality and preexisting cardiac disease in 5,971 trauma patients. J Trauma. 2010;69(3):645–52.PubMedGoogle Scholar
  36. 36.
    Scalea T, Holman M, Fuortes M, et al. Central venous blood oxygen saturation: an early accurate meansurement of volume during hemorrhage. J Trauma. 1988;28:725.CrossRefPubMedGoogle Scholar
  37. 37.
    Scalea T, Simon H, Duncan A, et al. Geriatric blunt multiple trauma: improved survivial with early invasive monitoring. J Trauma. 1990;30:129–36.CrossRefPubMedGoogle Scholar
  38. 38.
    Nguyen HB, Jaehne AK, Jayaprakash N, et al. Early goal-directed therapy in severe sepsis and septic shock: insights and comparisons to ProCESS, ProMISe, and ARISE. Crit Care. 2016;20(1):160–72.CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Process Investigators, Yealy DM, Kellum JA, Huang DT, Barnato AE, Weissfeld LA, et al. A randomized trial of protocol-based care for early septic shock. N Engl J Med. 2014;370(18):1683–93.CrossRefGoogle Scholar
  40. 40.
    ARISE Investigators, Anzics Clinical Trials Group, Peake SL, Delaney A, Bailey M, Bellomo R, Cameron PA, et al. Goal-directed resuscitation for patients with early septic shock. N Engl J Med. 2014;371(16):1496–506.CrossRefGoogle Scholar
  41. 41.
    Mouncey PR, Osborn TM, Power GS, Harrison DA, Sadique MZ, Grieve RD, et al. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med. 2015;372(14):1301–11.CrossRefPubMedGoogle Scholar
  42. 42.
    Angus DC, Barnato AE, Bell D, Bellomo R, Chong CR, Coats TJ, et al. A systematic review and meta-analysis of early goal-directed therapy for septic shock: the ARISE, ProCESS and ProMISe Investigators. Intensive Care Med. 2015;41(9):1549–60.CrossRefPubMedGoogle Scholar
  43. 43.
    VS MD, Thompson KA, Lewis PR, Sise CB, Sise MJ, Shackford SR. Frailty in trauma: a systematic review of the surgical literature for clinical assessment tools. J Trauma Acute Care Surg. 2016;80(5):824–34.CrossRefGoogle Scholar
  44. 44.
    Mangram AJ, Shifflette VK, Mitchell CD, et al. The creation of a geriatric trauma unit “G-60”. Am Surg. 2011;77(9):1144–6.PubMedGoogle Scholar
  45. 45.
    Smith JSJ, Martin LF, Young WW, Macioce DP. Do trauma centers improve outcome over non-trauma centers: the evaluation of regional trauma care using discharge abstract data and patient management categories. J Trauma. 1990;30:1533–8.CrossRefPubMedGoogle Scholar
  46. 46.
    Bouras T, Stranjalis G, Korfias S, et al. Head injury mortality in a geriatric population: differentiating an “edge” age group with better potential for benefit than older poor-prognosis patients. J Neurotrauma. 2007;24:1355–61.CrossRefPubMedGoogle Scholar
  47. 47.
    Fallon WF Jr, Rader E, Zyzanski S, et al. Geriatric outcomes are improved by a geriatric trauma consultation service. J Trauma. 2006;61(5):1040–6.CrossRefPubMedGoogle Scholar
  48. 48.
    State of Ohio, State Board of Emergency Medical Services, Trauma Committee. Geriatric Trauma Task Force Report and Recommendations.

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Georgetown University School of MedicineWashingtonUSA
  2. 2.Department of Emergency Medicine and Divison of TraumaWashington Hospital CenterWashingtonUSA
  3. 3.Study Center for Brain InjuryWashington Hospital CenterWashingtonUSA
  4. 4.Department of SurgeryEastern Virginia Residency ProgramNorfolkUSA

Personalised recommendations