The Changing Landscape of Trauma Care, Part 1

Introduction

There has been a fundamental change in the face of injury in the United States. Traditionally, injury was thought to be a disease of the young male population, with motor vehicle collision (MVC) being the most common mechanism of injury. Depending on the trauma center, blunt trauma would comprise up to 99% of patients admitted. This profile has fundamentally changed over the last 15 years. Trauma center performance is often benchmarked against local, regional, or national norms, and as all medical centers now measure quality as the primary endpoint, these changes in demographics can be very important.

Certainly, the most important change has been the “graying” of trauma patients. When I (TS) started working in Baltimore 20 years ago, patients over age 65 years comprised approximately 5% of our total trauma admissions. Last year, over 30% of our 7,000 primary admissions were patients over age 65 years who had sustained ground-level falls.

Injury patterns in the elderly differ compared to standard blunt trauma in which traumatic brain injury (TBI) is common. Extremity fractures, particularly hip fractures, are common, whereas torso injuries other than rib fractures are relatively uncommon. As this article points out, elderly trauma patients almost universally have significant medical problems. Cognitive deficits and balance issues may explain ground-level falls in this population. Syncope from a myriad of underlying medical conditions and/or medications may have contributed to their falls as well.

The evaluation process for elderly trauma patients must be directed not only at diagnosing injury but also at attempting to identify the reason for the injury. This may involve a number of diagnostic tests in the ED, in the outpatient setting, or even on an inpatient floor.

Unfortunately, elderly patients can succumb to relatively minor injuries, and those who survive such afflictions often have difficulty making a full recovery. Many elderly patients who were able to function preinjury were marginally compensated at home. Operative therapy, often needed to treat injuries such as a hip or extremity fracture, by itself represents physiological burden to an elderly patient. Likewise, full recovery after even a mild TBI can be quite difficult.

Admitting an elderly patient to the hospital can present several challenges. For example, elderly patients are often on a number of prescription and nonprescription medications, including over-the-counter nutritional and herbal supplements, many of which interact with the newly prescribed medications given to treat trauma (eg, analgesics, sedatives, antiseizure drugs). Moreover, elderly patients often become disoriented and agitated when they are out of their home environment. All too often, the therapy for these and other problems is another medication, and thus the cycle continues. Therefore, elderly patients are ultimately at increased risk for death from seemingly trivial injury, which in turn may create significant perceived quality issues for a medical center.

The use of systemic anticoagulation has become almost ubiquitous in older patients. Some days it seems like every patient I (TS) admit is taking an anticoagulant—at least aspirin. While primary care providers (PCPs) correctly realize the important role these anticoagulants have in treating chronic medical conditions, they often do not recognize the dangers associated with increased traumatic bleeding following an injury.

Frequently, we knowingly take patients with conditions such as rate-controlled atrial fibrillation (AF) off their prescribed anticoagulant, believing they are simply not candidates for anticoagulation because of their propensity to fall. Even though we attempt to communicate our concerns to the PCP, when these patients are readmitted, it is common to find that they have been placed back on an anticoagulant.

The advent of novel oral anticoagulants (NOACs) has made routine laboratory testing obsolete. One need only to turn on the television to see the many advertisements explaining why this agent or that agent is preferable to warfarin. While, fresh frozen plasma (FFP) and/or prothrombin complex concentrates (PCC) are quite effective at reversing the anticoagulant effect of warfarin, reversal of these newer agents is either extremely difficult or impossible.

Anticoagulant reversal can be more or less important, depending on the situation. For instance, while subcutaneous bleeding is concerning, it can be temporized by operative exploration and/or packing. When necessary, blood can be transfused to replace the blood lost. However, the same is not true for a patient with significant TBI, because even a small volume of ongoing hemorrhage can prove lethal. Cavitary hemorrhage in the chest and/or abdomen is also extremely difficult to treat if the anticoagulant effect cannot be reversed. Given the popularity of the new anticoagulants, I (TS) am afraid that this problem will be with us for years to come.

There has been a significant spike in interpersonal violence in the United States over the past few years. While the cause is often difficult to identify, its existence is impossible to ignore. The violence seems to be concentrated in a number of municipal areas, but violence can occur in any community. Certainly, even mass casualties have become part of our everyday life.

In 2016, homicides and nonfatal shootings increased dramatically relative to 2015. In 201 7 , we are tracking a 40% increase in homicides and a 30% increase in nonfatal shootings—particularly concerning when one considers that these numbers are being compared to the previously increased 2016 statistics.

Many community EDs are not accustomed to dealing with a significant volume of penetrating trauma, and thus they may not be as familiar with the newest means of resuscitation, evaluation, and treatment of these injuries. It will be important for every medical center to do what is necessary to be able to effectively triage and provide initial treatment for patients with penetrating trauma.

The victims of penetrating trauma are often young, and unfortunately, despite our best efforts, these patients often die in the ED. This creates a huge emotional burden on people who work in the ED, particularly those who are not used to seeing large volumes of gunshot wounds (GSWs) or stab wounds. Even those of us working in busy urban trauma centers feel the emotional burden of this new epidemic. Each of us will need to cope with these issues and help each other deal with them.

It is important to recognize the dramatic change in trauma demographics over the last few years, and make plans to care for the changing face of trauma to optimize results and save as many lives as possible. In part 1 of our 2-part, “The Changing Landscape of Trauma Care,” we focus on the specific issues and concerns encountered in elderly trauma patients, as well as victims of all ages presenting with penetrating trauma from stab and GSWs.