Acute Care Surgery and the Elderly

  • Patrick K. Kim
  • Donald R. Kauder
  • C. William Schwab


You are asked to evaluate an 80-year-old retired railroad porter who stumbled and fell while walking his dog. He has left upper extremity and forehead abrasions. According to his family, he lives alone and is completely independent. The patient denies any medical problems with the exception of diabetes mellitus and benign prostate hypertrophy. He has a normal mental status and is hemodynamically stable. Outside of the abrasion, patient’s physical examination is unremarkable. Which of the following should be the management plan for this patient?
  1. (A)

    Overnight observation in the hospital

  2. (B)

    Outpatient management

  3. (C)

    Refer patient to a rehabilitation center

  4. (D)

    Obtain plain radiography of the head

  5. (E)

    Obtain head computed tomography scan



Advance Directive Noncardiac Surgery Common Bile Duct Exploration Gastric Volvulus Percutaneous Cholecystostomy 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Pedersen T, Eliasen K, Henriksen E. A prospective study of mortality associated with anaesthesia and surgery: risk indicators of mortality in hospital. Acta Anaesthesiol Scand 1990; 34:176–182.CrossRefPubMedGoogle Scholar
  2. 2.
    Arias E. United States Life Tables, 2001. National Vital Statistics Reports, vol 52, no 14. Hyattsville, MD: National Center for Health Statistics, 2004.Google Scholar
  3. 3.
    U.S. Census Bureau. International Database. Table 094. Midyear Population, by Age and Sex. Available at Scholar
  4. 4.
    Keller SM, Markovitz LJ, Wilder JR, et al. Emergency and elective surgery in patients over age 70. Am Surg 1987; 53:636–640.PubMedGoogle Scholar
  5. 5.
    Barlow AP, Zarifa Z, Shillito RG, et al. Surgery in a geriatric population. Ann R Coll Surg Engl 1989; 71:110–114.PubMedGoogle Scholar
  6. 6.
    Arenal JJ, Bengoechea-Beeby M. Mortality associated with emergency abdominal surgery in the elderly. Can J Surg 2003; 46:111–116.PubMedGoogle Scholar
  7. 7.
    Aalami OO, Fang TD, Song HM, et al. Physiological features of aging persons. Arch Surg 2003; 138:1068–1076.CrossRefPubMedGoogle Scholar
  8. 8.
    Van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. N Engl J Med 2001; 345:1359–1367.CrossRefPubMedGoogle Scholar
  9. 9.
    Levy EG. Thyroid disease in the elderly. Med Clin North Am 1991; 75:151–167.PubMedGoogle Scholar
  10. 10.
    Davis JD, Stern RA, Flashman LA. Cognitive and neuropsychiatric aspects of subclinical hypothyroidism: significance in the elderly. Curr Psychiatry Rep 2003; 5:384–390.CrossRefPubMedGoogle Scholar
  11. 11.
    Biondi B, Palmieri EA, Lombardi G, et al. Effects of subclinical thyroid dysfunction on the heart. Ann Intern Med 2002; 137:904–914.PubMedGoogle Scholar
  12. 12.
    Emmett KR. Nonspecific and atypical presentation of disease in the older patient. Geriatrics 1998; 53:50–52.PubMedGoogle Scholar
  13. 13.
    Morrow DJ, Thompson J, Wilson SE. Acute cholecystitis in the elderly: a surgical emergency. Arch Surg 1978; 113:1149–1152.PubMedGoogle Scholar
  14. 14.
    Smithy WB, Wexner SD, Dailey TH. The diagnosis and treatment of acute appendicitis in the aged. Dis Colon Rectum 1986; 29:170–173.CrossRefPubMedGoogle Scholar
  15. 15.
    Levkoff SE, Cleary PD, Wetle T, et al. Illness behavior in the aged. Implications for clinicians. J Am Geriatr Soc 1988; 36:622–629.PubMedGoogle Scholar
  16. 16.
    Horattas MC, Guyton DP, Wu D. A reappraisal of appendicitis in the elderly. Am J Surg 1990; 160:291–293.CrossRefPubMedGoogle Scholar
  17. 17.
    Franz MG, Norman JG. Delay in presentation accounts for the majority of inflamed appendices. Ann Surg 1996; 223:105–106.CrossRefPubMedGoogle Scholar
  18. 18.
    Watters JM, Blakslee JM, March RJ, et al. The influence of age on the severity of peritonitis. Can J Surg 1996; 39:142–146.PubMedGoogle Scholar
  19. 19.
    Gajic O, Urrutia LE, Sewani H, et al. Acute abdomen in the medical intensive care unit. Crit Care Med 2002; 30:1187–1190.CrossRefPubMedGoogle Scholar
  20. 20.
    Centers for Disease Control and Prevention. National Center for Health Statistics Supplement on Aging Study and Second Supplement on Aging Study. Atlanta, GA: CDC, 1995.Google Scholar
  21. 21.
    Eagle KA, Berger PB, Calkins J, et al. ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery—executive summary. Circulation 2002; 105:1257–1267.PubMedGoogle Scholar
  22. 22.
    Fletcher GF, Balady G, Froelicher VF, et al. Exercise standards: a statement for healthcare professionals from the American Heart Association. Circulation 1995; 91:580–615.PubMedGoogle Scholar
  23. 23.
    Smetana GW. Preoperative pulmonary assessment of the older adult. Clin Geriatr Med 2003; 19:35–55.CrossRefPubMedGoogle Scholar
  24. 24.
    Hoogwerf BJ. Postoperative management of the diabetic patient. Med Clin North Am 2001; 85:1213–1228.CrossRefPubMedGoogle Scholar
  25. 25.
    Khoury W, Klausner JM, Ben-Abraham R, et al. Glucose control by insulin for critically ill surgical patients. J Trauma 2004; 57:1132–1138.CrossRefPubMedGoogle Scholar
  26. 26.
    Watters JM, Moulton SB, Clancey SM, et al. Aging exaggerates glucose intolerance following injury. J Trauma 1994; 37:786–791.CrossRefPubMedGoogle Scholar
  27. 27.
    Poldermans D, Boersma E, Bax JJ, et al. The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery. N Engl J Med 1999; 341:1789–1794.CrossRefPubMedGoogle Scholar
  28. 28.
    Zaugg M, Tagliente T, Lucchinetti E, et al. Beneficial effects from beta-adrenergic blockade in elderly patients undergoing noncardiac surgery. Anesthesiology 1999; 91:1674–1686.CrossRefPubMedGoogle Scholar
  29. 29.
    Mangano DT, Layug EL, Wallace A, et al. Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. N Engl J Med 1996; 335:1713–1720.CrossRefPubMedGoogle Scholar
  30. 30.
    Fleisher LA, Eagle KA. Lowering cardiac risk in noncardiac surgery. N Engl J Med 2001; 345:1677–1682.CrossRefPubMedGoogle Scholar
  31. 31.
    Gottlieb SS, McCarter RJ, Vogel RA. Effect of betablockade on mortality among high-risk and low-risk patients after myocardial infarction. N Engl J Med 1998; 339:489–497.CrossRefPubMedGoogle Scholar
  32. 32.
    Sandham JD, Hull RD, Brant RF, et al. A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients. N Engl J Med 2003; 348:5–14.CrossRefPubMedGoogle Scholar
  33. 33.
    Park WY, Thompson JS, Lee KK. Effect of epidural anesthesia and analgesia on perioperative outcome: a randomized, controlled Veterans Affairs cooperative study. Ann Surg 2001; 234:560–571.CrossRefPubMedGoogle Scholar
  34. 34.
    Duggan JM, Zinsmeister AR, Kelly KA, et al. Long-term survival among patients operated upon for peptic ulcer disease. J Gastroenterol Hepatol 1999; 14:1074–1082.CrossRefPubMedGoogle Scholar
  35. 35.
    Hallissey MT, Ratliff DA, Temple JG. Paraoesophageal hiatus hernia: surgery for all ages. Ann R Coll Surg Engl 1992; 74:23–25.PubMedGoogle Scholar
  36. 36.
    Haas O, Rat P, Christophe M, et al. Surgical results of intrathoracic gastric volvulus complicating hiatal hernia. Br J Surg 1990; 77:1379–1381.CrossRefPubMedGoogle Scholar
  37. 37.
    Arthur JD, Edwards PR, Chagla LS. Management of gallstone disease in the elderly. Ann R Coll Surg Engl 2003; 85:91–96.CrossRefPubMedGoogle Scholar
  38. 38.
    Paganini AM, Feliciotti F, Guerrieri M, et al. Laparoscopic cholecystectomy and common bile duct exploration are safe for older patients. Surg Endosc 2002; 16:1302–1308.CrossRefPubMedGoogle Scholar
  39. 39.
    Patterson EJ, McLoughlin RF, Mathieson JR, et al. An alternative approach to acute cholecystitis. Percutaneous cholecystostomy and interval laparoscopic cholecystectomy. Surg Endosc 1996; 10:1185–1188.CrossRefPubMedGoogle Scholar
  40. 40.
    Burdiles P, Csendes A, Diaz JC, et al. Factors affecting mortality in patients over 70 years of age submitted to surgery for gallbladder or common bile duct stones. Hepatogastroenterology 1989; 36:136–139.PubMedGoogle Scholar
  41. 41.
    Bender JS, Magnuson TH, Zenilman ME, et al. Outcome following colon surgery in the octogenarian. Am Surg 1996; 62:276–279.PubMedGoogle Scholar
  42. 42.
    Catena F, Pasqualini E, Tonini V, Avanzolini A, Campione O. Emergency surgery for patients with colorectal cancer over 90 years of age. Hepatogastroenterology 2002; 49:1538–1539.PubMedGoogle Scholar
  43. 43.
    Tsugawa K, Koyanagi N, Hashizume M, et al. Therapeutic strategy of emergency surgery for colon cancer in 71 patients over 70 years of age in Japan. Hepatogastroenterology 2002; 49:393–398.PubMedGoogle Scholar
  44. 44.
    Koperna T, Kisser M, Schulz F. Emergency surgery for colon cancer in the aged. Arch Surg 1997; 132:1032–1037.PubMedGoogle Scholar
  45. 45.
    Temple CL, Huchcroft SA, Temple WJ. The natural history of appendicitis in adults: a prospective study. Ann Surg 1995; 221:278–281.CrossRefPubMedGoogle Scholar
  46. 46.
    Franz MG, Norman J, Fabri PJ. Increased morbidity of appendicitis with advancing age. Am Surg 1995; 61:40–44.PubMedGoogle Scholar
  47. 47.
    Primatesta P, Goldacre MJ. Inguinal hernia repair: incidence of elective and emergency surgery, readmission and mortality. Int J Epidemiol 1996; 26:835–839.CrossRefGoogle Scholar
  48. 48.
    Arenal JJ, Rodriguez-Vielba P, Gallo E, et al. Hernias of the abdominal wall in patients over the age of 70 years. Eur J Surg 2002; 168:460–463.CrossRefPubMedGoogle Scholar
  49. 49.
    Alvarez Perez JA, Baldonedo RF, Bear IG, et al. Emergency hernia repairs in elderly patients. Int Surg 2003; 88:231–237.PubMedGoogle Scholar
  50. 50.
    Brittenden J, Heys SD, Eremin O. Femoral hernia: mortality and morbidity following elective and emergency surgery. J R Coll Surg Edinb 1991; 36:86–88.PubMedGoogle Scholar
  51. 51.
    Ohana G, Manevwitch I, Weil R, et al. Inguinal hernia: challenging the traditional indication for surgery in asymptomatic patients. Hernia 2004; 8:117–120.CrossRefPubMedGoogle Scholar
  52. 52.
    Mingoli A, Puggioni A, Sgarzini G, et al. Incidence of incisional hernia following emergency abdominal surgery. Ital J Gastroenterol Hepatol 1999; 31:449–453.PubMedGoogle Scholar
  53. 53.
    Morris JA Jr, MacKenzie EJ, Damiano AM, et al. Mortality in trauma patients: the interaction between host factors and severity. J Trauma 1990; 30:1476–1482.PubMedCrossRefGoogle Scholar
  54. 54.
    Schwab CW, Kauder DR. Trauma in the geriatric patient. Arch Surg 1992; 127:701–706.PubMedGoogle Scholar
  55. 55.
    Knudson MM, Lieberman J, Morris JA Jr, et al. Mortality factors in geriatric blunt trauma patients. Arch Surg 1994; 129:448–453.PubMedGoogle Scholar
  56. 56.
    McMahon DJ, Shapiro MB, Kauder DR. The injured elderly in the trauma intensive care unit. Surg Clin North Am 2000; 80:1005–1019.CrossRefPubMedGoogle Scholar
  57. 57.
    Harbrecht BG, Peitzman AB, Rivera L, et al. Contribution of age and gender to outcome of blunt splenic injury in adults: multicenter study of the eastern association for the surgery of trauma. J Trauma 2001; 51:887–895.CrossRefPubMedGoogle Scholar
  58. 58.
    Vollmer DG. Age and outcome following traumatic coma: why do older patients fare worse? J Neurosurg 1991; 75:S37–S49.Google Scholar
  59. 59.
    Davis JW, Kaups KL. Base deficit in the elderly: a marker of severe injury and death. J Trauma 1998; 45:873–877.CrossRefPubMedGoogle Scholar
  60. 60.
    Grossman MD, Miller D, Scaff DW, et al. When is an elder old? Effect of preexisting conditions on mortality in geriatric trauma. J Trauma 2002; 52:242–246.CrossRefPubMedGoogle Scholar
  61. 61.
    Jacobs DG, Plaisier BR, Barie PS, et al. Practice management guidelines for geriatric trauma: the EAST practice management guidelines work group. J Trauma 2003; 54:391–416.CrossRefPubMedGoogle Scholar
  62. 62.
    Angelos P. Ethical guidelines in surgical patient care. J Am Coll Surg 1999; 188:55–58.CrossRefPubMedGoogle Scholar
  63. 63.
    Baluss ME, Lee KF. Legal considerations for palliative care in surgical practice. J Am Coll Surg 2003; 197:323–330.CrossRefPubMedGoogle Scholar
  64. 64.
    Darzins P, Molloy DW, Harrison C. Treatment for lifethreatening illness. N Engl J Med 1993; 329:736.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2007

Authors and Affiliations

  • Patrick K. Kim
    • 1
  • Donald R. Kauder
    • 1
  • C. William Schwab
    • 2
  1. 1.Department of Surgery, Division of Traumatology and Surgical Critical Care, University of Pennsylvania School of MedicineHospital of the University of PennsylvaniaPhiladelphiaUSA
  2. 2.Department of Surgery, Division of Traumatology and Surgical Critical CareUniversity of Pennsylvania Medical CenterPhiladelphiaUSA

Personalised recommendations