G-65 Geriatric Trauma

Inclusion

• ≥ 65 years old
• Traumatic Injury
• Injury within 48 hours

Exclusion

• Hospice care
• Injury >48 hours
• Admission criteria is medical

All trauma patients admitted to trauma service over the age of 65 years should be admitted under “Trauma Geriatric”.

• Consults placed by the ED must be seen expeditiously
• Primary, secondary and tertiary surveys must be completed or confirmed by the trauma team
• Admit to Red / Blue / Green GERI service (do not admit to regular team color)
• Time to admission < 240 mins
• Need for operative intervention does NOT influence decision for Trauma Geri admission
• Hip and lower extremity fracture time to fixation < 24hrs
• Urinalysis should be obtained on all Geri fall patients. Antibiotics if positive.
• Cardiac and medical consultation is NOT required on all Geri patients. Assess baseline level of function, mobility and METS. ECHO is only indicated in selected patients: extensive cardiac history or presence of a murmur. Fellow or senior resident should confer with Anesthesia attending directly, whether ECHO is necessary prior to surgery.
• Always consider mechanism of injury and maintain high index of suspicion for elder abuse. A report must be filed ASAP, if there is any concern.

• Isolated orthopedic injuries include those injuries confined to the extremities that consist primarily of bone and joint involvement. This includes both operative and non-operative pathologies.
• Soft tissue injury associated to fracture or isolated ligament/tendon/cartilage does not preclude orthopedic admission.

• Ofirmiv will be first analgesic medication in Resus/ED
• Judicious use of opioids and sedatives utilizing narcotics only with gentle escalation, as necessary. Suggested starting doses for geriatric patients:
  • Oxycodone 2.5mg
  • Morphine 2 mg
  • Fentanyl 25 mcg
  • Dilaudid 0.5 mg
  • Tramadol 25 mg
  • * Gabapentin 100mg *. Controversial and group discordance about its use. Special circumstances only.
  • Olanzapine 2.5 mg
  • Melatonin 3 mg
• DVT ppx: Lovenox 30 mg BID or heparin 5000units TID, if renally impaired
• Sz ppx: Keppra 500mg BID
• Remember to dose medications for reduced GFR

• If rib fractures present, refer to Rib Fracture Protocol above plus Regional Anesthesia consult
• Med/Surg patients will be admitted to Trauma 4A
• Isolated TBI should be admitted to NRS
• Post-operative patients will be admitted to TICU for perioperative cardiac monitoring, unless deemed unnecessary by the Trauma Attending, ONLY.

• All Geri patients to be seen and assessed by PT/OT within 24hrs of admission
• Social Work assessment within 24hrs with projected disposition and identification of potential barriers to dispo.

• All patients over 65 years old will be evaluated in the ICU post operatively.
  • The level of care can be changed at any time once the Trauma attending decides they are appropriate for another level of care.
• If the TICU and SICU are full then the patient is to be placed in the PATU to be evaluated by the Trauma attending with the possibility of 3 pathways.

1. The patient is be determined safe for transfer to another level of care
2. The patient is determined to be critically ill and remains in place until a bed can be made in TICU or SICU
3. The patient requires ongoing monitoring but is determined to be safe to be transferred to an ICU bed on Trauma 3a

*Sign out from Trauma Team to Trauma 3a NP must occur before transfer.*

• • • Only in beds 392 and 394 with nursing ration of 1:2
    • Cared for by Trauma 3a NP with first call to Trauma team for escalation
  • * The goal is to send all patients to TICU on second floor but will use overflow if needed