Good afternoon and welcome to our Trauma University session, our first session. My name is Tim Murphy and I'm the chair of the Education Committee here at TCAA. And it's my distinct pleasure to introduce to you our first moderator, Dr. Britt Christmas. Dr. Christmas is a co-chair of our Education Committee, as well as a member of our Board of Directors. So welcome, Dr. Christmas. Great. Thank you, Tim. I'm glad to be here today. I know I've participated in the Trauma University since its inception and want to thank everybody for attending today. So presenters for today will be Kim Berry, Gail Gieson, Stephen Johnson, Maggie Devon, Laura Gamino, and me as your moderator. This year we chose to do something a little different and try and take a case from beginning to end to really look at several of the considerations in this year's Trauma University. So objectives today will be to discuss the role of injury prevention in geriatric falls, to discuss reversal strategies for common anticoagulants, and to discuss the role of geriatrics in the management of comorbidities, medications, and goals of care. I think we all realize that geriatrics, and especially geriatric falls, are rising throughout our country and all of our nation's trauma centers. So we start with this case presentation. This is a patient that was found down in a nursing home post-fall, striking her head with a small pool of blood noted. The history that we get from EMS is a history of hypertension and a DVT in the right lower extremity. They report that the patient was on Xeralto, Aspirin, Atenolol, Gabapentin, and Torsamide, and then an age of 88 years. So pre-hospital treatment so far, they've got a report of decreased movement in her bilateral upper extremities. She's in a C-collar and is receiving oxygen by a simple mask with sats of 100%. Airway is intact. Patient's verbal, responsive, bilateral breath sounds. Skim is warm, palpable central pulses, bilateral radial and femoral pulses, and palpable distal pulses bilaterally. GCS is reported as 15. She's appropriate, answering all your questions. And there's a small abrasion to the right upper extremity with a wound to the right side of her occiput. Of note, the patient reports no spinal tenderness, step-offs, and no gross bony abnormalities. So we get a chest X-ray in the trauma room, and this is what we see. If you look, you can see several rib fractures on the patient's right side. And the thing from a physician's standpoint, I'm going to cue you into kind of what's going through my head when I see these patients. This patient has three rib fractures identified. So for me, right off the bat, I know that this is a geriatric patient, and they have increased mortality from rib fractures in all geriatric patients over 65 years. So this increased likelihood of death also gets higher with a greater number of rib fractures, with an onto ratio of two, over two and a half. And then it's also a high likelihood of needing chest tube drainage. And if a patient has greater than or equal to four rib fractures, when it does come time to discharge them, they're more likely to go to a facility rather than being able to be reintegrated back home. So as we're moving through, we get a CT scan of the patient's head. And as you can see here, the patient has a small subdural hematoma that we pick up on. Well, once again, what's going through my head? Well, I'm looking and going already, this patient's going to get admitted, they already had, you know, three rib fractures, but now I'm looking at a traumatic brain injury in the setting of an anticoagulant. So you look at the chronological age and TBI severity alone, they're really inadequate prognostic markers. You know, when I'm speaking to a family, I can't tell them exactly what to expect from this patient over the next several days or even weeks, months. And there's a lot that can evolve in the next 24 to 48 hours, even. The outcomes following moderate to severe TBI in older adults are poor. They're just not as good as with younger patients. And we recognize that. And they have high rates of significant disability and mortality. And we have a growing number of patients that are on anticoagulant and antiplatelet agents. And this number continues to increase. And it seems like there's a new one almost every six months. So for example, this patient came in and I heard Xeralta. Well, first, I'm getting a trade name from EMS. And then I have to figure out what is its mechanism? What's its mode of inhibition? Is there anything I can do to reverse it? And do I need to reverse it right now? And pre-injury anticoagulation with intracranial injuries exhibits a four to five hold higher mortality risk than the non-anticoagulated patient. So this patient came in with bilateral upper extremity weakness. And for shortness sake, I'll say we had a negative CT of the C-spine. However, knowing that the patient has a neurological deficit, we proceed forward and the patient gets an MRI. And this is not uncommon to see in our geriatric patients. And if you look at this, you can definitely see cord compression, not uncommon as these patients tend to fall and lead with their face, if you will. And this leads to an extension injury in our older patients, especially with pre-existing spinal canal stenosis. So a younger patient that may not have this, that would have fallen, doesn't suffer the extension injury. But in this elderly patient, we're now looking at rib fractures, a subdural hematoma and central cord syndrome. So you can see the constellation of injuries is quickly adding up for what was just a simple fall. And the reality is central cord syndrome accounts for about 9% of all spinal cord injuries in these patients. And it presents as in this patient, bilateral upper extremity weakness and paralysis. And the most common way to diagnose this is MRI. And most of the time, you're not going to see abnormalities on that initial CT scan. Well, then this gets us into how are we going to manage this? And we have Steven Johnson on today that'll be discussing some of the considerations from neurosurgery standpoint. Is this an early fixation, a delayed surgery? And do we have some blood pressure goals, given that we had a neurological deficit? And then what are our EMS criteria for trauma center transfer? Geriatric patients are often under triaged and not transferred appropriately to higher levels of care. But what are those transfer criteria and to what level trauma center or do we go all the way up to a level one trauma center? And what are the standards for resuscitation? What warrants an ICU admission when I, as a physician, am standing there in the emergency department trying to figure out the disposition for this patient? And even then, when I get them to the ICU, what level of monitoring is it going to entail? And what am I going to be able to do to immediately fix that? And I'll just show you this from our medical center is something we've developed over the last several years called the geriatric trauma triage score for disposition for these patients as soon as they come in. And as you can see, it goes by age, injuries, and we have a scoring system so that anybody that scores above a six at least goes to the ICU for an overnight admission or a single 24-hour period, so that we don't have these patients out on the floor and we know they are able to decompensate so quickly. So that's a high-level overview of kind of the what's going through my head as a physician when I see these patients. And next up, we'll have Kim discussing some of the emergency department considerations. Thank you. Thanks, Dr. Christmas. So let's go to the emergency department and walk through how we would evaluate this patient. We'll start with the polling question. So let's give everybody the opportunity to participate. At your trauma center, what level of activation with this patient actually end up coming in at? Would it be your highest level? Would it be your second tier? Do you have something that's geriatric specific? Or would it not be a trauma activation at all? We'll go ahead and give everybody the chance to weigh in. All right, a little bit longer. All right. There you go. All right, so you can, thank you for the feedback, and you can see here that there still remains some variation across the hospitals across the country. At my facility, this would be a second-tier activation, probably using age as a discretionary criteria for trauma activation. So let's go ahead and evaluate her. All right, so we know pre-hospital, she fell, she sustained a laceration, oop, can we back up the slide? All right, sorry about that. All right, so they applied a dry sterile dressing in the field to her, to her head. So we're going to want to see if it's actively bleeding or whether that has sort of staunched the blood flow. They put a C collar on her. We're going to want to make sure that it actually fits her well. We don't know about any IV access, so we're going to have to address that. The report that was patched in, sort of starting to shift the story a little bit, her GCS is sort of 14 to 15 at this point and her vital signs, her heart rate is 70, respiratory rate is 16, blood pressure is 106 on 70. Well, I don't know about you, but for me, this is not enough information to be able to effectively evaluate the patient and sort of inform our trauma care. One of the first things I want to know is just this baseline GCS. So as we all know, some of the documentation is going to be a little bit sketchy. So what EMS reports and what we find in facility information may be a little bit different. And so, you know, somewhere documented is that this lady has some level possibly of dementia. So we don't really know what her level of function is. So I'm going to want to know is how is she presenting? Is that actually baseline for her? Also, these are great vital signs if you are 30 and don't have any comorbid conditions, but we know that's not the case for this particular woman. And so we're going to want to know what her baseline vitals would be. And we're probably also going to want to start triggering that we know she may be in distress and these vital signs are not actually reflecting that. Her heart rate is blunted by her beta blocker use, and this is probably not a baseline blood pressure for her. We're also going to, we know that she takes some medications. We're also going to want to know at that point when she last took those meds. So we put her in our resuscitation bay and we take a set of vitals and her temp is 97.6, her pulse is 72, respiratory rate is 22, blood pressure is for us 109 on 72. So she does have a little bit of, you know, shift in her grip strength and she looks stable at the moment. So we're going to take her to CT scan real quick. And these are her vitals when she gets back. You can see her pulse is 77, respiratory rate is 25 and her blood pressure is like 100 on 68 now. And so as Dr. Christmas went through, we know that she has these three right displaced rib fractures. And so our nursing considerations are that she's, we know she's going to be at risk for pulmonary compromise. So we're going to make sure that we invest in some pain assessment and multimodal pain management. And perhaps your facility has geriatric pain management pathways like ours does, and we try and stay away from, you know, those opioids positioning. If she's able to participate in, in centrospirometry, that would be something down the road that we would definitely make sure that we follow it up on. Her CT scan, as Dr. Christmas said, she has a subdural hemorrhage. So we know we're going to be watching her neural status. And at this point, we're having that conversation about how we are going to manage a reversal of those meds that she takes. So we do know that she, when she gets back from CT scan, that her vitals are a little soft. We do a quick survey again, a primary survey, to a disability, and we noticed that she's really struggling with those hand grasps. So in addition to making sure we're doing blood pressure management, that we're talking about reversing those meds, now we're going to be talking about trying to just determine what is going on with her strength. So we get an MRI and you can see she already has degenerative changes. She's got moderate to severe narrowing in her C-spine. On top of that, she has all of this edema. She has intraspinous edema. She's got, you know, some facet joint effusion. So while she doesn't have overt fractures, she already has sort of impingement of her spinal canal from just degenerative processes. And as Dr. Christmas said, you know, this is sort of your secondary injury from the fall that wouldn't ordinarily happen in somebody who's younger. So basically we are now anticipating ICU admission or for facilities that don't offer some of the neurosurgical services or levels of care. We're talking about, you know, the possibility of transfer. So we'd want to be getting that. And some of the key things that we know is that when we are handing off, this is where we put our patients at risk. It is known that this is a problem. So what are the key components of this patient's picture that really has to be communicated to either the ICU team or to the receiving facility? So some of the things that, you know, you're going to hit is just through your standard mechanism of injury. You're going to go through their past medical history. It's important to know their history and their meds. Yes, definitely all of your imaging findings, the fact that they have, that we know she has rib fractures, that she has a separal, that she had an MRI, the results of that MRI. And when we're talking about her neurostatus, we want to know, is this baseline for her? Have you seen any acute changes from when she actually presented to you? Her grip strength is in the setting of this central cord syndrome. Are we seeing any deterioration? Are we just monitoring it sort of routinely at this point? Positioning requirements. Have you changed out that C collar? Is it a good fit? Are you sure that it's immobilized her C spine? And does her spinal anatomy pose any issues? We all know that some of these older patients, they get kyphotic and their positions are different and you have to sort of work with what their body naturally is doing to make sure that they're positioned correctly. Cardiovascular, going to go through their vital signs. Absolutely. So are there blood pressure parameters that have been set that you need to treat? And have you had to treat them? You're going to need to know about IV access. Have you added anything? Have you changed anything? Do you now have central access? Have you optimized her lab work? What was her H and H? Are her electrolytes normal? Just sort of, just trying to tune the patient up with anticipation that other things might need to happen. From a pulmonary standpoint, we know she has rib fractures. Has she had pain? Have you had to give her anything? Is she short of breath? Has she had O2 requirements? What are her O2 stats? Knowing that there is a possibility that she's, you know, may go to surgery, depending on what serial CTs of her head look like, you know, is she NPO? And do we know when the last time she ate was? Also, does she have a Foley? It's really in these geriatric patients, it's so important to sort of balance the need for that script intake and output monitoring against risk of infection. And something to definitely consider is if you have elements of court syndrome, you know, they're at risk for having neurogenic bladder. So you're going to want to definitely, you know, pay attention to all of that. So I think that predominantly covers, you know, the things that we need to report off to the team to make sure that we've provided the best continuity of care for this patient. So while we're waiting for the patient to head to ICU, let's talk about some of the administrative trauma PI pieces. So when you're looking at trauma triage and level of activation, we know these injuries are probably going to code out to an injury severity score of more than 15. And so where would that lie in your triage criteria? And would it be under triage? And how would you address that? We're also going to talk about your level of activation. So we'll talk about trauma triage. We'll talk about surgeon arrival, neurosurgeon arrival. How do you evaluate compliance with your care pathways? For us, it would be something like monitoring time to CT scan. It would be intracranial hemorrhage management. It would be reversal of the anticoagulants in the setting of intracranial hemorrhage. So these would be all the things that you would be looking at. Also, some of the things is if you're looking at the specificity of your impression in your imaging results, because that really will affect your registry team's ability to accurately code your injuries. And that will, you know, affect your ISS and how you report out. So just some of the things to consider. While your patient is waiting from an administrative standpoint with PI. And now that we've packed the patient up and we are sending them off to either ICU or our receiving facility, I am going to pass off to Gail, who's now going to discuss the pharmacology associated with this patient's care. Gail. Thank you, Kim. My name is Gail Gieson. I'm a critical care pharmacist at Atrium Health. And I will be focusing on the use of pharmacologic agents for the reversal of oral anticoagulants. I don't have any conflicts of interest to disclose, but I will be discussing the off-label use of two of the four-factor PCCs, including Kcentra and Feva. The oral anticoagulant agents that I'll be covering today include the vitamin K antagonist, Warfarin, the factor Xa inhibitors, including apixaban, rivaroxaban, and adoxaban, as well as the direct thrombin inhibitor, the bigotran. In respect to reversal agents, I'll be covering two PCCs, Kcentra and Feva, as well as the targeted agents. These include andexanet, alpha, and idariosuzumab. The prothrombin complex concentrates can be classified as either non-activated or activated. Kcentra is a four-factor non-activated PCC. It contains factors two, seven, nine, and 10, and it is FDA-approved for vitamin K antagonist reversal, specifically in patients that either have an acute major bleed, or they're not necessarily bleeding, but they're anticoagulated with Warfarin, and they require an urgent surgery or an invasive procedure. Feva is an activated PCC. It also contains four factors, two, seven, nine, and 10. However, it is the factor seven component that is activated. It is labeled for use for hemophilia-related bleeding. However, it is used in an off-label fashion for major bleeding associated with the direct oral anticoagulants. Beginning with Warfarin reversal, I'll focus on Kcentra. Its mechanism of action is fairly simplistic. It works to replete the vitamin K-dependent clotting factors. Dosing is based on both the patient's weight as well as the pre-dose INR, and if you refer to the chart at the bottom of the slide, you can see, for example, if a patient presents with an INR of 2 to 3.9, the dose would be 25 units per kilo. Dosing is capped at 100 kilos, so the maximum dose for that category is 2,500 units, and you can see the corresponding doses and maximum doses for higher INRs. It is important to remember that vitamin K should be administered concurrently. Although it has a slower onset of action, it will provide a durable reversal of the INR, and in this situation, repeat dosing is not recommended. We'll move next to reversal of the Factor Xa inhibitors and discuss both the PCCs as well as indexin-alpha. The PCCs work in this scenario to increase thrombin generation, so they are not specific or targeted reversal agents. There are a variety of considerations that go into dosing the PCCs for the purposes of this presentation. I'll focus on dosing in the setting of intracranial hemorrhage. I think the two best resources that we have to guide dosing come from a guideline published in 2016 jointly by the Neurocritical Care Society and Society of Critical Care Medicine, where a 50-unit-per-kilo dose is recommended for both the non-activated four-factor PCCs as well as activated PCC. If it's being given within three to five half-lives of Factor Xa inhibitor exposure or in the context of liver failure. More recently, in 2020, the FIX-ICH study was published. This was also an effort through the Neurocritical Care Society, and patients receiving either apixaban or riboroxaban who presented with intracranial hemorrhage were dosed with PCC, and you can see the doses here for the non-activated PCC. Just under 50 units per kilo was the initial dose. For activated PCC, in this case, it was a little bit lower, just over 25 units per kilo, and these dosing regimens did achieve hemostatic efficacy in the majority of patients, over 80%. Another option for Factor Xa inhibitor reversal is indexinet-alpha. It's a newer agent. It is considered to be a Factor Xa decoy molecule, so to understand the pharmacology of this agent, it is helpful to first review the structure of Factor Xa itself. Factor Xa molecule contains a GLA domain, and it contains a serine residue that the Factor Xa inhibitor is bind to. The modifications to indexinet-alpha include removal of the GLA domain, so it can't form the prothrombinase complex, and then the serine site is replaced with an alanine, and Factor Xa inhibitors bind to that, but with this substitution, indexinet-alpha, in and of itself, cannot generate thrombin. In respect to indications, it is only indicated for patients treated with rivaroxaban or apixaban. It has been studied with other Factor Xa inhibitors, but the numbers were fairly low in the Annexa IV trial, and therefore, it did not gain an indication. Also, it is indicated only for patients that have a life-threatening bleed or uncontrolled bleeding, so at this time, at least, it does not hold an indication for reversal prior to an emergent procedure. Also, it's important to remember that the pharmacodynamic half-life of this drug is quite short. It's only one hour. The dosing strategies include either a low-dose or a high-dose regimen. Both of them consist of a bolus and then a follow-up infusion, and that infusion should be started immediately after the bolus. In order to determine the appropriate regimen, it should be the patient's Factor Xa inhibitor that they were on should be identified, so we need to know if it's rivaroxaban or apixaban. We ideally would like to know what dose they're on, and then we also need to know the time since the last dose, so for the patient in this case who is taking rivaroxaban, 20 milligrams daily, would receive a high-dose regimen if she presented less than eight hours or the low-dose regimen if she presented eight hours and beyond. Kcentra, Feba, and Indexanet all do have boxed warnings for arterial and venous thromboembolic events, so it is very important that a risk-benefit assessment be made prior to reversal. Kcentra and Feba also are contraindicated in patients who have disseminated intravascular coagulation, and because Kcentra is formulated with heparin, it also is contraindicated in patients who have heparin-induced thrombocytopenia. Okay, and lastly, we'll discuss dabigatran reversal with idariosuzumab. Idariosuzumab is indicated only for reversal of dabigatran. It won't work for other direct thrombin inhibitors such as argatroban or bivalorudin. In patients that have a life-threatening bleed or if they require an urgent surgery. The mechanism is different from the rest. It is a monoclonal antibody. Again, it's specific to binding dabigatran and its metabolites, and it will neutralize the anticoagulant effect. Its onset is within minutes, and its duration is 24 hours, possibly longer. And the dosing is fairly straightforward. It's a five-gram dose. The only complexity is that two separate 2.5-gram doses need to be administered within 15 minutes of each other. Okay, so that brings us to our polling question. For the patient in this case, as a reminder, she was taking rivaroxaban 20 milligrams a day. She presented with intracranial hemorrhage. If a decision is made to reverse, what is the most appropriate drug and dose? And you were able to confirm that the patient's last rivaroxaban dose was 12 hours ago. So is it K-centra, 50 units per kilo, FEBA, 100 units per kilo, and dexanet, the high-dose regimen, or idariosuzumab for a total dose of five grams? Okay, so it looks like the majority chose and dexanet. We'll just go through these answers. So K-centra, 50 units per kilo, is an appropriate choice. That dosing strategy is supported by the Neurocritical Care and SCCM guidelines, as well as the recently published FIX-ICH study. FEBA would be an appropriate agent. However, the 100 unit per kilo dose is too high. That's more consistent with hemophilia-related bleeding. So a more appropriate dose would be 25 units per kilo. And dexanet, again, could be an appropriate choice. However, since the patient had her dose of rivaroxaban greater than eight hours ago, she would qualify for the low-dose regimen. And another consideration is, remember that this drug is not approved at this time for reversal prior to an emergent procedure. So although she has a life-threatening bleed, if she does require surgery, that could introduce a gray area. And then, Idariosuzumab is incorrect because that would be indicated only for dabigatran reversal. All right, and with that, I will pass it off to our next speaker, Dr. Johnson. All right, thank you very much for having me. I really appreciate the opportunity to talk neurotrauma, especially in a multidisciplinary setting. So just before I start, I want you to know the goals of my talk are primarily to explain why neurosurgeons do what they do and why we're thinking what we're thinking. Because I'm pretty sure everybody in this conference has had an experience with a neurosurgeon in a trauma patient where the resident comes down to the trauma bay, leaves a note in the chart, probably size 36 bold font, saying no neurosurgical intervention is indicated, we'll sign off. And then there's probably another experience where the resident comes down screaming and brings a patient up to the operating room instantly. So I want to provide a little bit of a 30,000 foot view of what causes us to diverge in those two different directions and what we're thinking. And then we'll try to circle back with some of that rationale to the specific case report that we have today. So the first thing I want to show are the different compartments because traumatic intracranial hemorrhage, they're not all created equally. And each different compartment can create a different deficit, a different problem, and subsequently can be managed differently. So here we're looking at the epidural component. So that is sitting on top of the brain and pushing down on. Subarachnoid, it actually infiltrates the arachnoid layer, which covers the brain almost like a skin. A contusion is intraparenchymal. So that's actually inside the brain. And then subdural can be confused with epidural because they're both on top of the brain and pushing on. And I'll give you a few CAT scan examples here. So this is an intraparenchymal contusion. It's within the brain. And the same types of traumatic mechanisms can cause any one of these different bleeding patterns. But in this case, again, the blood is inside the brain. So this is something that's a lot trickier to evacuate if you do enter a crisis of intracranial pressure. Subarachnoid bleeding is something that usually has the least amount of mass effect. This typically will not cause intracranial pressure problems. And what you see here is hyperdense or bright blood, and it's just following the patterns of a sulcus or a gyrus of the brain. Diffuse axonal injury, and we're gonna get to subdural and epidural in a second, but diffuse axonal injury is a little different in that it actually occurs at the cellular level. So it's shearing of the axons of individual neurons. So you have very fine punctate bleeding. This is something you usually can't find on a CAT scan. So in a trauma patient with a severe TBI, if you get an MRI a couple of days after their trauma, on the right sequence of MRI, you see these black dots, and that's very small amounts of blood that's collecting around the junctions of neurons. So this type of bleeding pattern can be devastating. It causes very severe problems. However, there's no surgical fix for it. There's no mass effect to it. This here is an epidural. So it almost has the shape of a lens. So it's epidural means it's above the dura, and there are sutures that connect the dura to the inner table of the skull. So an epidural cannot permeate beyond those sutures. That's why you see the bleeding as a well-defined endpoint above and a well-defined endpoint below. With a subdural, you're below those sutures. So the bleeding can run along the entire convexity of the skull. And this, again, is pushing down directly on the brain. In an elderly population with ground-level falls, the two most common bleeding patterns that you will see are subdural and traumatic subarachnoid. That's what you will most often see. In this particular case, you see that the subdural bleeding is pushing the contents of the skull and shifting them over to the opposite side. This is also very important for a subdural hematoma and especially important in the geriatric population. When a subdural starts, it is acute. So the day of the fall, there is acute subdural bleeding. This blood has the consistency of jelly. So surgically, if I'm going to do something about it, I need a large exposure because I can't create one small hole and have all the jelly roll out. I need direct exposure of all of the bleeding so that I can actually peel it off of the surface of the brain. The way that looks on a CAT scan is that this is very bright. You can tell that the blood is brighter than the brain. So that's an acute subdural. And of course the patient's history is helpful as well. If they had a fall today, you know you're dealing with an acute subdural. What is also very common in the elderly population is dealing with a chronic subdural. So as the blood turns chronic over the course of one to three weeks, it thins out and becomes more watery. It has the consistency of motor oil. That is good because it's easier to fix. If you drill a small hole in the skull, you can actually get all of that bleeding to rush out and that relieves the mass effect. However, it's bad because if you're trying not to operate on a patient, you're trying to avoid surgery, as the blood transitions from acute to chronic, it expands. So the mass effect on the brain can get worse. The patient's symptoms can get worse. However, the fix is easier. And the reason that's important is if you have an 88 year old patient, they may not be able to tolerate the surgery for an acute subdural. But if they are able to basically maintain brain function, avoid large deficits, if you then do the surgery two weeks later, you're talking about an incision that's this big, a single hole in the skull, the blood rushes out and they can do very well. So acute versus chronic are a very important distinction. Another thing that is extremely important that was mentioned for this patient in this case report is the GCS. The GCS is universal language that conveys the severity of a traumatic brain injury. So when you have low numbers without looking at a scan, without examining the patient yourself, you know you're dealing with something serious. When a patient is a GCS 15, you often know that you have some time. So I won't run through every single point in this scale, but basically from what the eyes are doing, which is something that is extremely underrated in the neurological exam. If I could only know one aspect of the GCS, I would pick the eyes. If someone's eyes are open, that means they're awake, they're not that sick. If someone's eyes will not open, regardless of the stimulation you deliver, then you know their level of neurological function is extremely poor. So conveying what the eyes are doing is, in my opinion, the most important part of the GCS. There's a reason it's listed first. So you can see here at the bottom, minor brain injury, moderate brain injury, and severe. There is a movement within the neuro trauma, the leadership in the neuro trauma field to change this. Some people feel that this is sort of a quick and dirty way to lump in different levels of TBI, but for now, this is the best we have. So moderate, severe, and minor, depending on the GCS on arrival. So this is from the perspective of the neurosurgeon, because people often joke that the brain is a black box to other healthcare practitioners, and to neurosurgeons, the rest of the body is a black box. So I want to just lay out, from the perspective of a neurosurgeon, the way a traumatic brain injury works and the workflow. So of course, initially, TBI or otherwise, any trauma patient comes in, the trauma survey takes place, that takes precedent. So ABCs and airway security are the priority. Eventually in the trauma survey, there is a neurological exam where the GCS is established. Obviously, a GCS will be presented to you from the EMS team as well, but that's reestablished in the trauma bed because that number is often fluctuating. Once the survey is complete and the patient is deemed stable for imaging, in addition to a chest, abdomen, and pelvis, the patient's going to get a non-contrast head CT. The second the hemorrhage is confirmed on that head CT, that's when neurosurgery should be consulted. At that point, we're investigating the patient's history to see, are they on Xarelto? Are they on Coumadin? What type of bleeding diathesis might they have? And then a strategy is established for reversal. The plug that I do want to circle back to the last talk, when I was a resident, and I don't like to think I'm that old, but I'm old enough that when I was a resident, if a patient was on a blood thinner, it was usually Coumadin, and the primary option was FFP. Now you need a pharmacologist. You need a pharmacist who is ready to go to talk about dosing and reversal strategy, because there is a new agent seemingly every month. And really only a pharmacist has the expertise for how to reverse these days. It's not as simple as it used to be. Once the patient reaches the ICU, under the assumption that they're not going straight to surgery, these are some of the parameters that neurosurgeons are going to check in on. So we want to maintain parameters for sodium. Every surgeon wants different restrictions on sodium, and the evidence is something that is evolving and varying. But the bottom line is that you do not want hyponatremia. If you have hyponatremia that increases intracranial pressures, it increases fluid in the extravascular space in the brain. So edema is worse if the sodium is run down. So there needs to be a multidisciplinary plan between nursing, the ICU team, trauma, and neurosurgery for what we want our goal sodium to be and how often we want to check and what we're going to do about it when we get too low. If there is a bleed in the brain, we want to hold DDT prophylaxis. So that means no heparin shots, no Lovenox. And again, this is a multidisciplinary problem. So we should establish a plan for when these patients are going to get back on it because I've seen so many times neurosurgical patients in a trauma ICU, DDT prophylaxis is held, and it's never resumed because nobody had a specific conversation about it. And these are sick patients who are very high risk for DDT and PE. For all traumatic head bleeds, the best evidence at this time for seizure prophylaxis is seven days of an antiepileptic. It used to always be Dilantin, but now we're shifting to Keppra because the side effect profile is a little bit softer and a little bit better tolerated. And the other thing that is the gold standard, a crucial step for anybody with an intracranial hemorrhage in the setting of trauma, no matter how big or how small, is that a bleed is not stable until it's proven with a serial scan. And the question of when to order that scan depends on how concerned you are. So for this particular patient, 88 years old, with a subdural based on the imaging we have now that is not surgical, but they're on an anticoagulant and an antiplatelet agent, this is a patient who is exceptionally high risk to bleed. That bleed is going to get bigger on the next CAT scan. So this is someone where I would not order a CAT scan for 24 hours from now. You order that CAT scan for four to six hours from now to see how this is changing. So in this case, if you're worried, you get a short interval scan. If it's a 20 year old who is neurologically intact with a tiny traumatic subarachnoid, then you can get a scan tomorrow morning. But this patient needs a very short interval scan. There we go, okay. So one of the keys for neurosurgical management in trauma patients is understanding what the intracranial pressure is, and then having an algorithm for what to do about it. If the patient has a GCS between nine and 15, that means you can monitor their neurological exam. And that's a pretty good surrogate for intracranial pressure. Once the GCS dips below eight, that's when you really need invasive monitoring because you can't trust your exam. A GCS could dip below eight because of another injury that may require sedation, because of drugs or alcohol that are on board. So there's a lot of reasons just besides a neurological injury that may lower the GCS. But the bottom line is once you hit eight, you can't trust your neuro exam anymore. So you need some sort of monitoring to know what's going on. So the terms you may have heard, a bolt, a Lycox, a Camino, or an external ventricular drain, this is intracranial pressure sensitive monitoring that tells us exactly what the pressure is so that we're not relying on other factors. With ICP management, we start with the most basic bedside interventions, which escalates all the way to the operating room. So the first things that we can do are elevate the head, that makes a difference. You clear a cervical collar, which is especially relevant in this patient because we're talking about a central cord syndrome and the patient needs to be in a hard cervical collar. However, if you're struggling with intracranial pressure and you have a patient with a tight cervical collar, that decreases venous return and that can substantially increase intracranial pressure. So that's another multidisciplinary conversation about getting that collar off if it's safe. Hyperosmolar therapy is another medical intervention that can help. So we talked about sodium goals. When you really start to have trouble with intracranial pressures, that's when we can get more aggressive in driving the sodium up, which can help in reducing ICP. Manitol is a diuretic that can be very helpful with ICPs, but only as a bridge because the effects of Manitol are transient. So if you know a patient is going to the operating room, you can push Manitol, which will reduce the amount of brain damage the patient sustains as we wait to achieve the decompression. But that's not something you would really give a patient that has been deemed to be non-operative because it is just a very temporary band-aid. And then last is hyperventilation. So if you drive the end-tidal CO2 down on an intubated patient, then you are reducing their intracranial pressures. So these are the most basic things that can be done at the bedside. Once we're in the ICU and we're dealing with some more complex medical management, again, we can work on pain control. I saw in the chat somewhere, somebody mentioned that pain control is very important. Pain control is very important. That can make a big difference on whether somebody tips over the edge into an ICP range that they can't tolerate. So general sedation is helpful. And once we reach into areas where we are struggling with ICP crisis, paralytic agents, which can be delivered in conjunction with anesthesia and the critical care team in the ICU, that will reduce ICPs. A pentobarbital coma. So if these patients are on EEG and we're basically achieving a complete flatline of neurological function on EEG, this will also help with ICP reduction. Then the first invasive option for reducing intracranial pressure is an external ventricular drain. This can help in certain patients, but again, it's incomplete. So I would say there are not very many patients that I have encountered in my career where the ICP was bad enough that we could not control it medically, but manageable enough that an EVD got the job done. Usually once you exhaust medical options for ICP control, you need to do a surgical decompression and an external ventricular drain is inadequate at that point. The way an external ventricular drain works is at the bedside, a very small burr hole is drilled into the skull, which is anterior to the motor strip because you would have weakness if we drilled too far behind. And you can see these little blue chambers in the brain, which are the ventricles. So they contain fluid. So this catheter goes into these fluid spaces and then drains fluid. In removing that fluid, it reduces the pressure inside the skull. It can also monitor the pressure as well. So it's both diagnostic and therapeutic. And then finally, we get to the last option, which is surgical decompression. This animation here shows you that this is a morbid operation. So we are turning a flap and basically removing half of the patient's skull. And once that's done, we're accomplishing two things. One, we're giving the brain room to swell and two, we're directly removing the blood that is layering over the brain. But this is not a small operation. It causes a lot of pain and it has a lot of morbidity. So this is something that we do not take lightly when somebody is over 70 years old. Can they tolerate this operation? If they're on blood thinners, they need to be completely reversed. Otherwise the blood we remove will be completely replaced by new blood at the end of the operation. So circling back to our specific case, when do we do surgery? When do we decompress? When can we just stick with medical management? So sometimes medical management can fail in a delayed fashion because swelling does get worse over time. Peak swelling can be two or three days after the actual trauma. So if we see that ICPs are trending up and there's nothing we can do to stem that, then we can do a delayed surgery. Other times it's more urgent at the time of the trauma. Also, a patient needs to be salvageable. So their neurological exam needs to show hope that they can have some sort of a meaningful recovery. And they also need to have a scan, so a CAT scan of their brain that does not show damage that is so widespread that there's nothing that can be done. Age needs to be taken into account. So the best data in the neurotrauma literature right now show that there's a cutoff around 65 in how functional patients can be after this operation. That's not to say that we do not do this operation in older patients. It's just to say that's where the most noticeable drop-off is in Kronofsky score and performance status after this surgery. But again, the goal of this surgery is intracranial pressure. We're trying to reduce that. So this graphic here is basically all of neurosurgical management of traumatic brain injury in a nutshell. On the left, you have patients that are appropriate for medical management. These patients are going to do well without surgery, without neurosurgeons, they're going to recover. Then in the red area, you have patients where we don't offer surgery because they either are too old, they do not have the physiologic reserve for this operation, and we just cannot help them. And then that narrow sweet spot in between is where medical management has failed, but we really have hope that we can help the patient. This is why multidisciplinary communication is so important and is so critical because sometimes neurosurgeons do not share this thought process with the trauma team, with the ICU team. And every neurosurgeon, this graphic is a little different. For some, that green area is huge. For others, the green area is almost non-existent. It varies despite all of the best algorithms and protocols that exist nationwide. And with that lack of consistency, there's always going to be variation in medical practice, but that's why communication is so important, that we explain why we're thinking what we're thinking, why we're doing what we're doing. So for this particular patient that came in, if they came in on my watch, the first thing I would tell my resident and the trauma team is that this bleed will get bigger. They are on an anticoagulant, they are on an antiplatelet agent. Even if we reverse them instantly, this bleed is going to get bigger. And it's very important to have a conversation with these patients during their lucid interval. If this gets worse, what would you want? So have a plan, because if this patient's bleed were to get much bigger to the point that they are comatose, we need to have an instantaneous plan in place already. Either we're not doing anything or we're going right to the operating room. So if you have a lucid patient who's a GCS 15 that you're worried their bleed is going to expand, have the conversation now, so that we're not scrambling at 2 a.m. trying to reach a second cousin to make a decision on whether or not we're going to surgery. Let's have a plan in place so we know if we're going, we know that we're going to be moving in more of a palliative direction. The other thing that's very important from the neurosurgical perspective, sometimes we forget that we're doctors as well, and we only think about the head bleed. So if somebody is on aspirin, we'll push platelets aggressively so the bleed doesn't get worse, and then we'll shut down somebody's cardiac stents. It's very important to have a multidisciplinary conversation, explain to the trauma team exactly how worried we are about bleed progression, and then come up with a reversal strategy that makes sense. Because there is risk, there are thrombotic complications, if we give every octogenarian on aspirin two units of platelets when they come in with a head bleed. There is a lot of morbidity associated with that. This is a patient where I would push for the platelets, I would push for the reversal because they're going to get into trouble if we don't do it. But there are times whereas the neurosurgeons, we need to take a back seat and not push for reversal. So now just to quickly transition to spinal cord injury, which also applies to this patient. Central cord syndrome is one of the most common types of spinal cord injury, and is specifically common in the geriatric population. So you can get this type of injury from lower mechanism traumas, ground level falls, doesn't have to be a 100 mile an hour car accident or an ATV rollover. So this is common with smaller mechanism trauma and older patients. The big thing here that misleads people often is the CAT scan is negative. So these patients come in with other traumatic injuries and complex trauma problems. They have a negative CT of their cervical spine, and then we often forget about the possibility of a central cord syndrome. So if a patient has grip strength weakness, that's always something that should be running through your mind. Could they have central cord? So it's always something to look out for because you're not gonna see an obvious fracture on the CAT scan. The hand weakness is usually worse than leg weakness, but that's not always the case. So in a severe central cord, the legs can be very weak as well. It's also not always a hyperextension injury. The patients don't always read those textbooks. It usually is, but there's a lot of different injury, interesting, different traumas that can cause a central cord. So some of the medical management for this, these patients should wear a C collar at all times. This is an interesting problem for our patient right now because they also are gonna be running into ICP problems that the C collar may be exacerbating. In this case, if we're doing okay with ICPs, I'd leave the C collar on. An arterial line is very important because if we drive up the mean arterial pressures, that helps the spinal cord to heal and prevents worsening injury. So if the spinal cord is going to swell, basically you hurt your knee, your knee can swell. The same thing can happen with the spinal cord. As the spinal cord swells, blood flow shuts down. So driving up the pressures maintains blood flow and prevents progression of the injury. So once you suspect a central cord injury, even with negative imaging, you consult the spine team. At that point, we're gonna get an MRI, but again, these are trauma patients. So we need to get the MRI when it's safe. If they're going up for a decompressive hemicrania or an X-LAT for other problems, the MRI unfortunately can wait and has to wait. But as soon as it's safe, we put them in the MRI. The reason to keep this in mind is the MRI is a tube. You're not examining the patient, your vital signs are less reliable, and they're in that tube for a half hour at least. So you've got to make sure they're stable before we get that MRI. The last part is the real variable. So what do we do about this once they have a central cord injury? And the evidence can be a little erratic here, but my general philosophy is see how severe the deficit is. So if a patient's hands are not working at all, no strength, hands are out, and the legs are very weak, that's an urgency. We wanna get them decompressed pretty quickly. If the deficit is more subtle, so the legs are working fine, one hand is very weak, the arms are a little weak, that's a more subtle deficit. And especially if they have other traumatic injuries, do serial neurological exams. Surgery is traumatic as well. So manipulating the spinal cord with surgery can make their trauma worse. They can wake up even weaker than they went into surgery. So if their motor exam is improving, I will usually tell my residents, let me know when they stop improving. So if they're getting better and better and better, let them. I don't wanna get in the way of that. But if their progress levels off and they're still weak, that's the time to intervene with the surgery. But as long as they're getting better, we can watch that and give them some time. For this particular patient, I would definitely not be considering any surgery because I'm more worried about their head injury than their spine. So we would have MAP goals in the ICU, but we would not be talking about an operation at this time. Then we can get to fractures, which this patient does not have, but this is a little bit easier because it's picked up on the initial trauma survey. You get a CAT scan of the spine and you detect a fracture. So the second the fracture is detected, you want to maintain strict CTL spine precautions. That just means you're immobilizing everything. Cervical collar, log roll the patient, minimal motion. Then you consult the spine service. They'll evaluate the fracture. They'll get a very detailed motor and sensory exam. And then at that point, the spine service will say this is a stable fracture, motion's okay, or they'll say this is unstable. And this is the segment of the spine that needs to be immobilized. But it's also, again, multidisciplinary conversation is very important because these are very sick patients and the smallest mismanagement can have a butterfly effect on their eventual outcome. So we don't want cervical collars on longer than they need to be. We don't want patients immobilized in bedrest longer than they need to be. So anytime we're immobilizing a patient, we need a plan for what we're doing about it and when we can mobilize them. All right, and that is all I have. So I will now pass the ball on to Dr. Devon. That was just one. While I have you guys, we don't need to go through this entire algorithm here, but this is called the TLIC scale. And this is determined by spine surgeons just to review if a fracture is indeed unstable, which requires surgical fixation, or if it's something that can be either immobilized or just observed over time. And it involves ligamentous injury, the extent of the fracture in the patient's neurological exam. Thank you, Dr. Johnson. Good afternoon, everybody. My name is Maggie Devon. I'm a geriatrician at Atrium Health in Charlotte, North Carolina. I'm going to talk to you guys today about the geriatric assessment of a geriatric trauma patient. Just as a small disclaimer, I'm going to hit some of the highlights today of the geriatric assessment. I could probably keep you guys here for an hour and a half on my own if I went through everything that we do as geriatricians. Part of our job is to spend a lot of time with our patients, so it's pretty complex, all the intricacies that we hit during our assessment, but I'm going to hit some of the highlights today, including delirium, frailty indexes, medication review, and advanced care planning. Let's start off with a question. The use of antipsychotics for the treatment of delirium has been shown to decrease the length of delirium, hospital length of stay, and severity of symptoms. True or false? Got a 50-50 shot here. It looks like 70 percent of you guys believe that this is false, and that is the correct answer. Unfortunately, we have systematic reviews and meta-analyses that show that antipsychotics do not actually decrease the severity, the length of delirium, or the hospital length of stay, and this is in both medical and surgical patients. On that note, delirium, why do we care about delirium? Not only do the geriatricians care about delirium, but I know that our surgeons do too. We know from studies in surgical patients that delirium is actually one of the most common surgical complications in older adults. Studies have showed that up to 50 percent of patients experience delirium after hip fracture repair and cardiovascular surgery. It's a very prevalent problem. Also, we know that about 15-25 percent of patients with major elective surgeries experience delirium. We know that delirium is associated with adverse outcomes in the long-term and the short-term, including death, institutionalization, increased length of stay, falls within the hospital, functional decline, and dementia. One figure that I think is pretty remarkable is that in a JAMA meta-analysis, there was actually an increased odds ratio of around 12 for the development of dementia in patients who experience delirium in the hospital. You guys can see that it really does impact patients once they leave the hospital as well. How do we detect delirium? We have a few instruments that we use. I'm going to go over a few of the more common instruments that we use in the hospital. For non-critically ill patients, we use a method called the confusion assessment method or the CAM. The figure on the right side of the screen outlines the CAM for you guys. I like to think of it as a pyramid with three levels. In order to meet criterion for delirium, the patient must have each criteria positive in the first two levels and one on the bottom level of the pyramid there. The patient has to have acute change in mental status with fluctuating course. This is usually gotten through the patient's family history, who's at bedside, or the nurse's history. She tells you when you're rounding on the patient, that the patient was calm and cooperative throughout the day, but around 5 PM, they got real agitated, they spit out their medicines, they were pulling off their Kelly, all those sorts of things. For inattention, there's some pretty easy ways to assess this at bedside. We do this on a daily basis on a geriatric service. Simple way is to ask the patient just to count backwards from 20 to the number 1. Another common way to assess for this is to ask the patient to state the days of the week backwards starting from an arbitrary starting point. If they can do either of those things, they are considered attentive. If they have trouble with them, they do have inattention present. Then lastly, they must either have disorganized thinking or altered level of consciousness to be delirious. The disorganized thinking, usually pretty easy to ascertain from your conversation with your patient. This is the patient, you ask them, how did you sleep last night? They go off in the left field talking about their uncle coming to stay with them, and things that just really make no sense. Altered level of consciousness, you're looking for a patient who's either hyper-alert or hypo-alert. Hyper-alert patients usually look like the ones who are trying to climb out of bed. You go in and they have a lap belt on from nursing and risk restraint where they're trying to pull off their IVs or their tele-leads. Then hyper-alert patients are the ones who are somnolent. You're having to shake them every five seconds to keep them alert and talking to you throughout the exam. For critically ill patients, obviously, the CAM is not exactly developed. There is a modified version called the CAM ICU that can be administered where patients do not have to be able to speak with you. For patients who are intubated, that way there's different ways to assess the tension that I won't go through, but just know that that does exist. At our institution, we use something called the ICD-SC, or Intensive Care Delirium Screening Checklist. This is an eight-item checklist that goes through all the same criteria. The nurses fill this out for us. They're looking for altered sleep-wake cycle, evidence of hallucinations, and needs like that with the patient. Just so you know, all of these instruments actually have relatively good sensitivity and specificity for the detection of delirium. But all of them are, unfortunately, less sensitive in detecting hypoalert delirium. That's the patient who's sleepy. We know that hypoalert delirium does have an increased risk for outcomes, and it's actually the more prevalent subtype. Although these instruments are useful, you still have to have a high index of suspicion, especially for patients that you believe may have hypoalert delirium even if your test is negative. When you think about delirium risk factors, we think of two main groups. We think of predisposing risk factors and precipitating risk factors. Predisposing risk factors are the ones that are going to be present on admission, and then the precipitating risk factors are basically what we do to them in the hospital or what happens to them in the hospital that puts them at risk for delirium. It's a pretty simple tipping point to think about. The more predisposing risk factors your patient has, they're going to require less precipitating factors in the hospital. It's good to identify someone who has a lot of predisposing risk factors. This is one of the things that your geriatrics consultant can do and alert everyone to the fact that this patient is very high risk for development delirium during their hospitalization. Some common predisposing risk factors that we see increase age, underlying dementia or mild cognitive impairment, patients who are functionally impaired at baseline and are requiring assistance with ADLs or IADLs, patients who have many conditions, patients who have visual or hearing impairment, patients who have chronic lab abnormalities like hypernatremia, and patients who use alcohol. Common precipitating risk factors are the medications that we give patients in the hospital, especially sedative, hypnotic drugs and anti-cholinergic agents, patients who undergo surgery or require anesthesia, patients who develop infections, patients who have uncontrolled pain. We also think about acute illnesses that develop in exacerbation of chronic illnesses as well, along with sleep deprivation and dehydration, which we know occur commonly in hospitalized patients. How do we prevent delirium? We mentioned briefly with the first polling question that antipsychotics don't really help treat delirium. Really, the most important part of our interventions is going to be trying to prevent the development of delirium in the first place. There's a program called the Hospital Elder Life Program or HELP that was developed in 1999 by geriatricians and it basically was a study that looked at multi-component interventions to help prevent delirium. This is basically where geriatricians get their information about what helps prevent delirium and how we have learned what multi-component interventions help prevent delirium. We look at risk factors for delirium, as you can see listed here in the left column of the chart, and then we do strategies to help prevent exacerbation of those risk factors. To help prevent cognitive impairment, we recommend frequent reorientation of our patients, allowing visitors and doing cognitive stimulating activities with our patients. Things like giving them newspapers to read, having them watch the news to keep them engaged, word searches, crossword puzzles, things like that to keep their brains active while they're in the hospital. For sleep deprivation, we know that non-pharmacologic sleep enhancement is first-line. Things like aromatherapy or making it a comfortable environment for your patient, and also making sure to limit nighttime awakenings as able. If you do have a stable patient who's just awaiting placement on your service, do they really need to be woken up in the middle of the night for their vital signs and medications or can we reschedule some of those things? Studies have also showed that having a unit that is quiet, which I know is nearly impossible most of the time, but less alarms, less pagers going off, things like that help patients sleep. To target immobility, we recommend that patients ambulate at least three times per day, and if they're unable to ambulate, then active range of motion of the extremities is important. We also recommend decreasing devices that limit mobility, so things like Foley catheters, telemetry wires, IVs, all those kinds of mobility limiting devices should be discontinued as soon as medically feasible. For visual and hearing impairment, we recommend that the patient's adaptive equipment is available and that they actually use them too. You guys probably do know how many times that patients are sitting in their room with their hearing aids and the batteries are dead or they're not turned on. We want to make sure that those devices are there and are actually working as well. Then for dehydration, patients are hospitalized. A lot of times they're in queue for procedures, they're put on some dysphagia diet that they don't like. We want to make sure that they're getting assistance with eating or drinking and encouraging good oral intake while they're hospitalized too. Just a little plus for myself too, we know through studies that proactive geriatrics consultation in high-risk patients helps decrease the risk or the incidence of delirium as well. They help institute or we help institute multi-component interventions in patients, and also we help reduce exposure to high-risk medication. I'll say that there specifically was a trial that looked at high-risk patients who had hip fractures, and there was a group that received geriatrics consultation and a group who did not receive geriatrics consultation. In the geriatrics group, there was a 36 percent lower incidence of development of delirium, which came out to a number needed to treat of 5.6 to prevent one case of delirium. We give a lot of medications, especially in primary care, that have a much higher number needed to treat than that. If you have geriatrics at your facility, it's definitely something good to think about if you have a high-risk patient. Now we get into the actual treatment of delirium. This chart is actually taken from a review article of the evaluation and management delirium from the New England Journal. I like it because it shows you there's not a simple answer. This is a large chart with a lot of different words on it, which is an accurate way to describe the treatment of delirium. Basically, the most important things that you can do are to figure out why they're delirious and try to work on reversing that call. The things we talked about already, but determine is it a medication that's causing delirium or maybe a lack of a medication. Are we giving them anticholinergic that are causing them to be delirious? Are they in pain and they need more pain medication, that's why they're delirious? Are we holding some agent that they've been on for many years and withdrawing from that agent and perhaps that's why they're delirious? You also want to look at their electrolytes and correct any problems there. Of course, always looking for infection. We're all well-versed in understanding that infections cause delirium. We want to make sure that they have their devices available for hearing impairment and visual impairment as well. Then as our patient in this case has the intracranial disorder, which are subdural, we want to make sure that those things are attended to appropriately by the surgeons involved in the case as well. Always want to look for urinary retention and constipation, as these can also lead to delirium and then underlying myocardial and pulmonary problems as well. It is important to remember though that if you have a patient who is agitated and has hyperactive delirium that you want to try behavioral interventions with the nurses or the staff before reaching for your antipsychotic drugs. Because as we mentioned, we know that they don't change the outcomes in delirium and obviously have a large amount of risk associated with their use. We only recommend using antipsychotics if absolutely necessary from a safety standpoint. Typically, we recommend a low dose of a high-potency antipsychotic for the shortest amount of time possible. The next question, moving on to frailty. Frailty has been associated with all the following except, increased risk of fracture after ground-level fall, increased use of hospice services at the end of life, increased risk of discharge to a facility, or increased risk of delirium. Good job, you guys. Forty-two percent chose the right answer. Frailty has not been associated with increased use of hospice services. It has been associated with the other options, so increased risk of fracture after ground-level fall, increased risk of discharge to a facility, and also increased risk of delirium. So, why do we care about frailty? We know from studies of surgical patients that frailty is associated with several adverse outcomes. Frailty is associated with increased length of stay and also increased risk of discharge to subacute rehab, delirium, one-year mortality, utilization of health care in the year following surgery, and fracture after ground-level fall. Specifically, fracture after ground-level fall was a study looking at trauma patients. It's important for us to identify patients who are frail because we know that they are at increased risk for these four outcomes. In those patients, we should consider targeted intervention through a comprehensive geriatric assessment. So, another plug for geriatric consultation, essentially. So, one of the difficult things about frailty is that there's no consensus on how we define frailty. There are many indexes out there to help define frailty or identify frailty, but there's really not any recommendation to use one over the other. I'm going to talk about a few of the more common indexes today, and I'll start with the frail scale. This is the one that we actually use at our institution on our initial geriatric consultation of our trauma patients. We do a frail scale on each patient so we can help kind of categorize them. Frail scale is easy. That's one of the reasons that it's nice. It's a mnemonic. So, each letter of frail stands for one part of the scale. So, for the frail scale, we want to identify if the patient has fatigue. We want to quantify their resistance abilities, so we ask the patient, are they able to climb a flight of stairs? We want to determine if they're able to ambulate a city block. We want to look at their list of comorbidities or illnesses, and we also want to look and see if they've had any weight loss over the prior year. Depending on how many of those criteria are present, they're categorized as either robust, pre-frail, or frail. Another nice frailty scale that I use commonly for geriatric assessments in the outpatient setting is the clinical frailty scale that you can see here on the right side of the slide. This is more of a phenotypic frailty scale, and I like it because it looks at the patient's functional status, which geriatricians, we live and die by a patient's functional status. So, are they able to do their own ADLs? Are they able to do their own IADLs? So, this scale looks at that and also how much exercise they're able to do. It basically categorizes patients from very fit all the way to terminally ill. There is actually a trauma-specific frailty index, and that's the name of the index, that's used more in research, less clinical because it's 15 items long. It encompasses a lot of the things that we've talked about, and it's actually almost like a little mini comprehensive geriatric assessment, but the length and the thoroughness of the scale kind of prohibits use as a bedside instrument, in my opinion, but it has been validated in geriatric trauma patients, so that is available. And then lastly, the Freed Frailty Tool, this was developed by a well-known geriatrician, and it also kind of looks at most of the same other factors, except it has some objective measures of frailty included as well, including grip strength and gait. All right, so segwaying into the BEERS criteria, if you guys have ever known a geriatrician, you've heard them harp on BEERS criteria many times to you, but my question is for y'all, is the BEERS criteria a collection of risk factors for delirium in older adults, a list of potentially inappropriate medication in older adults, are the qualities found in older adults that increase risk of institutionalization, or is there a rating scale for the severity of dementia? 62% were correct, so the BEERS criteria is a list of potentially inappropriate medications in older adults. So let's talk a little bit about medication review and the role of a geriatrician for medication review in our geriatric trauma patients. In my opinion, the most important part of a medication review is the first step. It's reconciling the patient's medication. If you don't have a clear understanding of what the patient is or is not taking, it's really hard to give accurate advice about what should be continued or discontinued. So we have to do a little investigative work sometimes to help reconcile patients' medications. Many of our patients are not able to tell us clearly what they're taking, so we often find ourselves reaching out to family members, pharmacies, looking in electronic records for fill histories, and even calling nursing homes to get an accurate list of medications. Once you've gotten a good medication reconciliation, then we like to look through medication lists and consider the risks and the harms of the medication. So the way I like to do it is I look at medications individually, and then I also look at the medication list as a whole to look for drug-drug interactions and the potential risks of taking multiple medications together. I like to look at the list and decide what medications are important to make recommendations for continuing or discontinuing and consider the risks associated with both of these actions. So the BEERS criteria I previously referenced is a well-known list of medications that identifies ones that may be high-risk in older adults, and that can be used to review a patient's medication list. Specifically, it highlights a lot of anticholinergic agents, sedating medications, and medications that may be high-risk for drug-drug interactions. I also like to look at the medication list by classes of drugs, specifically drugs that we can get into trouble with with our geriatric patient or antihypertensive and diabetic medicines. I think we have to be realistic and understand that many patients are not able to be as compliant as their physicians may expect them or want them to be with their medications. So if you have an 88-year-old patient who weighs 90 pounds and they come in on five antihypertensive, you may want to reconsider whether you should start all those at the same time or not, or you're going to end up potentially precipitating some pretty bad hypertension. And the same thing with the diabetic medications. We want to avoid precipitating hyperglycemia at all costs during the hospitalization. We also look at the patient's renal and hepatic function when they come into the hospital and look at their medication in light of those variables to make recommendations if that, you know, that may change what medications should be stopped depending on how the medications are metabolized. I also like to look at their meds and consider harms of discontinuing medications. So we know that a lot of our patients, unfortunately, have been on their, you know, one milligram of Ativan at a time since they were in their 60s and they're still on it. So you have to be careful about stopping benzodiazepines in the hospital, which can precipitate withdrawal. You want to look at their chronic opiate requirements and think of their pain management in reference to that. Also antidepressants, you can have just continuation syndrome, some antihypertensive, and then also steroids. So patients who are on chronic steroids, you want to, you know, consider a continuation of some dose of steroids to help prevent withdrawal while they're inpatient. Lastly, we also review the inpatient medication list to look for any medications that put the patient at higher risk for development delirium, and then also discharge medications to make sure that adjustments have been made accordingly pending the patient's clinical course. So let's just take a quick look at our patient's medication list from the beginning of the case. She was on Xarelto, aspirin, Atenolol, Gabapentin, and Torsamide. So right off the bat from a geriatric point of view, independent of the fact that she had a fallen head sleeve, I noticed that she's on both the anticoagulant and aspirin. This highlights the importance of thinking about these medications and the patient's indication for the medications going forward. It appears to me that she was on aspirin likely for primary prevention of cardiovascular disease. And we know from a trial called the Asprey trial, which was published in the New England Journal in 2018, that aspirin did not actually lower cardiovascular event, and it actually led to an increased risk of bleeding in patients who are 70 or older. So I would argue that she probably should not be on the aspirin. As far as anticoagulant goes, you need to make sure you understand the indication for that. I believe hers is CBT-PE, and making sure that there's a clear duration for that medication going forward. She's also on a beta blocker and a diuretic for the history of hypertension. Neither of these agents are first-line for treatment, secondary, then on the diuretic, but not the loose diuretic. Not first-line for treatment of hypertension. And it also brings up the point that we need to think about the patient's blood pressure goals in reference to her age and comorbidities. So, you know, definitely if her blood pressure is overtreated we're putting her at increased risk for orthostasis, which may have contributed to her fall. She's also on gabapentin chronically. She is on a very low dose, only 100 milligrams daily, but it does carry an increased risk of sedation, constipation, confusion, and it's renally cleared. So it needs to be monitored carefully in the outpatient setting, and certainly may have contributed to her fall in polypharmacy. And lastly, she's on torcimide. So we know diuretics in older adults definitely increase risk of orthostasis, dehydration, and electrolyte derangement, all of which may have contributed to her fall as well. So that's basically the lens that I would view her medication through and make recommendations to the primary team in the hospital about consideration of what medication should be continued or discontinued. So lastly, we're gonna hit on one of the very important roles of the geriatrician. And a part of our assessment that we really enjoy being able to assist with, this is advanced care planning. So there are a lot of different ways to do advanced care planning discussions. And I really appreciate Dr. Johnson's comment earlier about the 2 a.m. phone call to the second cousin, because having a geriatrician involved, our number one goal is to prevent those things from happening for our patients and for you guys too, for the surgeons and the whole clinical team. So we want to, right up front on the patient's admission, be able to have this discussion with them. The first thing that we generally do when we talk to a patient is determine their decision-making capacity. So if they're not decisional at that time, it's still important to include them in these discussions because a lot of people will still be able to express their wishes, but they'll need some help from their family. But it's important to know that before you get too far into discussions with the patient, I think. We like to go ahead and identify a surrogate decision-maker up front as well, even if the patient does have decision-making capacity. We all know that things can change quickly with our patients. So we need to know if the patient can't make the decision, who do they want us to talk to? So I generally ask the patient, if you can't make your own decisions, who do you want the doctors to talk to? So let's say in our case, we have our lady. If she were to tell us that she was married, but then she told me that she wants me to talk to her daughter if she can't make her own decisions, that brings up an issue. So you want to determine between who they name as their surrogate in your state hierarchy laws, if there's congruency or any conflict. So by law in North Carolina, where I live, her husband would be her spouse, and that's pretty consistent across the country, would be her surrogate decision-maker. If she's named her daughter, however, and she hasn't filled that out in a healthcare power of attorney legally, her husband would still be her surrogate decision-maker. So this is one of the important roles of a geriatrician to kind of identify conflicts and help resolve those as well. I usually use that as an opportunity for education for my patients and about importance of completing healthcare power of attorney and living wills going forward. And of course, you want to evaluate to see if they've already completed that paperwork. There's no reason to start from scratch if you know they've already put their wishes on paper, and you can start from right there with that discussion. So I see you've already filled out a living will and these were your wishes, is that still the case? The next thing I like to do is I like to assess the patient's understanding, or if the patient's unable to speak for themselves, the family member's understanding of the patient's baseline health and chronic comorbidities. And then I also try to assess for their understanding of the current situation. You can kind of see how far you need to go depending on what they're able to tell you with education, and you can kind of frame your whole discussion based upon that. I also like to elicit the patient's fears and concerns about their health. This can often kind of lead into a natural flow of discussion about the patient's goals. So for instance, if you ask a patient, what are your worries or your concerns about your health? It is very common in geriatric patients that they'll tell you they're not worried. But sometimes another common thing we hear is that they're worried about what their family's going to have to go through or being a burden on their family. So that kind of patient generally is going to be more concerned with maintaining their function since they're not a burden on their family. Generally, we like to put our patients as much into one of these categories as possible, either their primary goal is longevity, maintaining their function, or comfort-focused goals, which is really hard because, you know, most people, they want a mix of all three of these. But what we're trying to do is kind of determine which category they fit into most completely so that we can help frame decisions with that outcome in mind. And one important thing that I'll say is that something that sometimes I forget myself, it's important to ask permission to discuss goals of care. This is something that our palliative care colleagues are very good about, but it's nice before you get into the nitty-gritty of these discussions with families or patients to kind of give them a heads-up and say, hey, you know, I do this with all my patients, but sometimes things don't go as planned. Are you okay if we have a discussion of what we would do next if things got more difficult? It's kind of a nice, we call it a warning shot or a heads-up so people can get their head in their very great plate before they discuss something that may be uncomfortable for them. All right, lastly, and then, so you can see here, the end of my advanced care planning discussion, we finally get to code status. There's a lot of groundwork that comes before that. So I usually just ask the patient, you know, if something were to happen and you got into trouble with your breathing and you needed to go on a breathing machine or if your heart stopped beating, would you want the doctors to put you on breathing machines or try to restart your heart? And then go from there. Generally, patients will be able to give you an answer pretty quickly in my experience after having this long discussion. And the nice thing about this is that you can determine if their code status that they wish for is congruent with their goals. So with everything you've already talked about, you know what the patient's primary goals are. And if they tell you, for instance, that their primary goal is longevity, they want to be here as long as possible, no matter what, but then they tell you that they're, you know, DNR or DNI, it kind of throws up a red flag that there may be some misunderstanding and that there probably needs to be some more discussions going forward to clarify. And I'll also say, you know, that as everyone knows, goals of care conversations and advanced care planning conversations, they're not static. So these are ongoing conversations that should occur over time and throughout a hospitalization. It's great if they're multidisciplinary, that's our goal always in this particular patient. We would want to have geriatrics involved, trauma surgery involved. We want to have neurosurgery involved, everyone there so that they could update the patient, family or the patient, and help them understand what's going on in the clinical course. And it's also really important to reassess kind of advanced care planning discussions before any planning procedures, common procedures, you know, like tracheostomy or PEG, just to make sure that the goals haven't changed and that they're still, the procedures are in line with what the patient would want going forward. So that wraps up my talk about the geriatric assessment today. Thanks for your attention. And now we're going to move into another fabulous geriatric topic, fall prevention with Laura Gamino. Okay, I am Laura Gamino. I'm here at the level one pediatric and adult trauma centers in Oklahoma City. And I'm the injury preventionist here. And I know you all are seeing this and living this that falls are the leading cause of fatal and non-fatal injuries among adults age 65 and over. And when we're talking about geriatrics here or older adults, we are saying 65. I know there's plenty of, you know, 85 year olds and so on still climbing mountains and doing all the things they want to do. And we also know 50 year olds who may be, you know, older than their age. The baby boomers beginning in 2011, they started turning 65 and people do turn 65 every day. So we do have this silver tsunami and it is huge as you all have seen. And the rates have increased 30% in the last 10 years. So when we're talking about TBI related death, unintentional falls to represent the second leading cause. And here we see fall related elderly TBI rate from 2002 to 2017. And males are orange, females gray, and just the overall is blue. And here's 2011 right here. And it's just going on up, up, up. And when we want to know who falls the most, it's women. Women fall the most and with age increased falling. So 85 years and up. And the ethnicity that falls the most is American Indian and Alaska natives. And I wanted to point out here, as far as the gender, women do fall more, but men climb more often from falls. And what are men doing? Well, they're on ladders and they're up in the attic and they're putting up Christmas lights and they're trimming trees and they're doing all sorts of things. And I had a friend that recently retired. He said, the number one rule of retirement is get rid of the ladders. And I couldn't agree more. Here, you can find your state. I'm right here. And as you can see, that's the darkest color. So our fall rate is about one in three people. And even if you're a lighter state, as you can see, it's going to be one in four or one in five. So we're all in this together. And here's our first poll question. What is the average cost to the community for a geriatric patient who falls? Okay, the answer is, it's all of them. So for hospitalization only, roughly costs about 37,000 per patient in 2019 dollars. Falls do cost in 2019 dollars, 813 million. And those were on the fatal falls. 54 million on the non-fatal falls. So it's all higher than I can count for sure. And when we look at this, this is comparing, looking at 2018, we had the total older adults in and elders defined as 65 or older, 53 million people. 36 million of those people did have a fall in 2018 and 8 million of them did have injuries. And we extrapolate that out to 2030. Older, total older adults expected to be 73 million. And we see that they expect 53 million falls with 12 million injuries. And in 2018, we had 88 older adults. And I from fall every day, every single day, every day. And so in 2030, it would be predicted to be over that. Okay, so here's the second polling question. Is your facility using evidence-based fall prevention program? Excellent, the majority, 85%. You have an evidence-based course, but not yet. If you don't know or you're not sure, no worries. We can help. And I'll tell you some really nice tools. The CDC came out with this compendium of effective fall interventions. This is for community dwelling adults. It's now in its third edition. It organizes them in exercise interventions, home modification or clinical. And they are from all over the world. And then we can go through these questions. And this has CDC also put, which is the guide to implementation. So we wanna find a mobility program that meets the needs of your clients. You can assess that. You know the program will work if you take it from the compendium because they're all evidence-based. And resources that are needing. Is it funding, staffing, space for classes? And what should we consider? In our fall prevention program, the Metropolitan Library System has been really excellent. And so has the YMCA, senior nutrition sites, senior centers and the faith-based community too. It's wonderful. Everybody has gotten on board. And how can we support and sustain the program? Is it grant funded that may run out or so on and so forth? Do you have funding? And this is the last question. The current buzzword replacing fall prevention. And is it mobility, independence, balance, or you didn't know? In public health, we always try to state things in the positive. And so that's why we're trying to get away from fall prevention. Mobility, 45%, excellent. Independence and balance, good word though. I think you all do well. So mobility is the word that is the buzzword now. And we're looking at kind of a new thing that we didn't learn, we were being educated, but one in four adults, that's 25% of everyone who is now 65 will live to be 90 years old or older. And when we talk about optimal mobility, it's doing what we want, getting where we want to, when we want to. And my mobility plan, it's not just, we're all planning for retirement financially, but we also need to plan mobility-wise and increase our exercise, reduce polypharmacy, just like Dr. Devon was talking about, important. And vision every year, we wanna have adequate lighting. When we think about adequate lighting, don't forget the garage, the porches, and lots of people like light. I mean, excuse me, lamps for soft light. And we may need more than that now. I mean, we wanna eliminate hazards. Everyone likes throw rugs, they like them, they're pretty, they're cute, they're very attached to them, they're called trip rugs. And so we need to really make sure that they are either on a non-skid surface, but even then they're tricky and just really reevaluate our home area. And mobility could be considered a vital sign. So that's another thought that can help us. And the CDC came out with what they call STEADI, and it is stopping elderly accidents, deaths, and injuries. And they screen patients for fall risk, and then you can assess modifiable risk factors. Do they have a vitamin D deficiency that you can supplement? Do they have a vestibular disorder that can be helped? And then the intervention. So it really is like a whole physician tool guide. And here's some of the popular mobility programs. And Sit and Be Fit can introduce a patient to mobility, and it's on PBS and it's real gentle sitting exercises. Otago, that is from Australia, Matter of Balance, really helps with fear of falling. And we know that that can be a vicious cycle. If people are afraid to fall, they may not wanna get up or walk or anything, decreasing their movement. And then that just makes them more frail, because you lose muscle mass and so on. Stepping On, several classes, Type B. Bingo Size is relatively new. It's out of Western Kentucky University, and it just combines bingo with health education and some fun things. It's been very popular where it's been. Aging Mastery Program, the National Council on Aging, and it has some weekly classes for 10 weeks. And it doesn't just touch on aging, it talks about financially, advanced planning and so forth like that. And all those things when people are getting together and just in a social group, very, very, very positive. I wanna give a shout out to TCIA. The last time that we met in person in 2019 in Vegas, they brought in some trainers and they trained 20 IP professionals in matter of balance. And they came from all over. Woody Guthrie is an Oklahoma native. Look, from California to the New York Islands. Here we are. They had people from everywhere. And several hundred coaches have been trained from this one class. So they did really good. And here's some helpful websites that even have, you know, assisted, you know, captioning, talk about captioning telephones, you know, a light box, you know, anything like that. So there you go. Thank you so much. Very good. Thank you very much, everyone. Do we have time for perhaps one question? I see in the chat box here, I think it's a question for Dr. Johnson regarding the use of the ICE protocol, chestnut study. Can you hear me okay? Yes, we can. So that's in reference to this particular patient, or that's not something that we participate with at our institution. So I don't know if I can be as helpful with that protocol. Dr. Christmaston, are you guys using that at your facility perhaps, or? Oh, for me, that one doesn't particularly ring, you know, ring a bell. And, you know, I'd be interested to see too, at a lot of these institutions, what, you know, what people are doing as far as management. I know for us at our institution, most of the, you know, the ICU, all the medical management, if you will, really falls under the auspices of the trauma team and the critical care group with neurosurgery being involved for the, you know, procedural and higher level decision-making. And, you know, I'd like to hear from panelists or two about that. And then the other thing to really focus on here is we've seen the costs and everything that are associated with these falls. And the reality is all of this could have been prevented, which really gets to how we spend money in the healthcare system and what we do. And you realize that the true lives saved and the dollars saved, if we actually invested more in injury prevention. Thank you. I would just add for the ICE protocol, my understanding of it, and again, it's not something we do at our institution, but it's basically an effort to piece together all available clinical data to avoid invasive intracranial monitoring, which would certainly make sense in the elderly population. It's one fewer procedure to do. But the best evidence that we have so far is that we are surprisingly bad with the exception of extremes at predicting ICP unless there is an invasive direct monitor of it. So a lot of times, I mean, there have been studies where neurosurgeons and radiologists have looked at CT scans. They were given exams. They were told to basically guess the intracranial pressure. And these are in patients that already have as a control ICP monitoring, and we're not very good at it. So I'm not yet aware of compelling evidence to suggest that we don't have a role for this. And I see this other question that just popped up. So I do think we're going to get a more standardized approach. We certainly need one. One talk that I do give for trauma compares neurotrauma to some other aspects of neurosurgery, from intracranial hemorrhage to aneurysmal subarachnoid hemorrhage, and we have such good protocols. In trauma, they're in practice, and there's a lot of good evidence and protocols that have been published, but in practice, it really varies even across university level one trauma centers. So some will put an EVD and intracranial monitoring in every severe TBI. Other programs just don't do that, even level one trauma centers. So there is not a lot of national standardization, and there is an opportunity to do so, and I think eventually we will develop a more standardized approach. We're not there yet, though. Wonderful. Well, thank you very much.

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