Thoracic

Chapter

Abstract

Elderly patients pose a great challenge to the trauma practitioner. They often present with significantly reduced physiologic reserve and a host of medications. Standard triage criteria used for the general population may be misleading in the elderly. Diagnoses can be delayed and they do not tolerate complications as well as their younger counterparts. This chapter will discuss the care of the elderly patient with thoracic trauma. General considerations to include mechanisms of injury, the general effect of aging on patient function, and outcomes after trauma will be examined. The initial trauma management of patients will be reviewed from A to E with special considerations for the elderly patient. Diagnostic tests, from chest radiographs to chest computed tomography, will be reviewed. Specific injuries will then be carefully considered: pulmonary contusions, pneumothorax, hemothorax, empyema, tracheobronchial injury, blunt cardiac injury, blunt aortic injury, diaphragmatic injury, thoracic duct injury, and esophageal injury. Understanding the physiologic changes attendant with age and their impact in the care of an elderly patient with thoracic trauma will hopefully help all practitioners care for these challenging patients.

Keywords

Depression Cage Aspirin Lidocaine Triglyceride 

References

  1. 1.
    Victorino GP, Chong TJ, Pal JD. Trauma in the elderly patient. Arch Surg. 2003;138:1093–8.PubMedCrossRefGoogle Scholar
  2. 2.
    Demetriades D, Karaiskakis M, Velmahos G, et al. Effect on outcome of early intensive management of geriatric trauma patients. Br J Surg. 2002;89:1319–22.PubMedCrossRefGoogle Scholar
  3. 3.
    Gregg SC, Heffernan DS, Legere JT, et al. The multiply injured trauma patient: resuscitation, rehabilitation, recovery. Med Health R I. 2010;93(4):112, 115–6.PubMedGoogle Scholar
  4. 4.
    McGwin Jr G, Reiff DA, Moran SG, Rue 3rd LW. Incidence and characteristics of motor vehicle collision-related blunt thoracic aortic injury according to age. J Trauma. 2002;52:859.PubMedCrossRefGoogle Scholar
  5. 5.
    Bauer TK, Lindenbaum K, Sroka MA, Engel S, Linder R, Verheyen F. Fall risk increasing drugs and injuries of the frail elderly – evidence from administrative data. Pharmacoepidemiol Drug Saf. 2012;21(12):1321–7. doi: 10.1002/pds.3357.PubMedCrossRefGoogle Scholar
  6. 6.
    Ferraris VA, Bernard AC, Hyde B. The impact of antiplatelet drugs on trauma outcomes. J Trauma Acute Care Surg. 2012;73(2):492–7.PubMedCrossRefGoogle Scholar
  7. 7.
    Hamel MB, Henderson WG, Khuri SF, Daley J. Surgical outcomes for patients aged 80 and older: morbidity and mortality from major noncardiac surgery. J Am Geriatr Soc. 2005;53:424–9.PubMedCrossRefGoogle Scholar
  8. 8.
    Lotfipour S, Kaku SK, Vaca FE, et al. Factors associated with complications in older adults with isolated blunt chest trauma. West J Emerg Med. 2009;10(2):79–84.PubMedCentralPubMedGoogle Scholar
  9. 9.
    Bulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib fractures in the elderly. J Trauma. 2000;48:1040–7.PubMedCrossRefGoogle Scholar
  10. 10.
    Harrington DT, Phillips B, Machan J, et al. Factors associated with survival following blunt chest trauma in older patients: results from a large regional trauma cooperative. Arch Surg. 2010;145(5):432–7.PubMedCrossRefGoogle Scholar
  11. 11.
    Shorr RM, Rodriguez A, Indeck MC, Crittenden MD, Hartunian S, Cowley RA. Blunt chest trauma in the elderly. J Trauma. 1989;29(2):234–7.PubMedCrossRefGoogle Scholar
  12. 12.
    Perdue PW, Watts DD, Kaufmann CR, Trask AL. Differences in mortality between elderly and younger adult trauma patients: geriatric status increases risk of delayed death. J Trauma. 1998;45(4):805–10.PubMedCrossRefGoogle Scholar
  13. 13.
    Heffernan DS, Thakkar RK, Monaghan SF, et al. Normal presenting vital signs are unreliable in geriatric blunt trauma victims. J Trauma. 2010;69(4):813–20.PubMedCrossRefGoogle Scholar
  14. 14.
    Hasler RM, Exadaktylos AK, Bouamra O, Benneker LM, Clancy M, Sieber R, Zimmermann H, Lecky F. Epidemiology and predictors of cervical spine injury in adult major trauma patients: a multicenter cohort study. J Trauma Acute Care Surg. 2012;72(4):975–81.PubMedGoogle Scholar
  15. 15.
    Lehmann R, Beekley A, Casey L, et al. The impact of advanced age on trauma triage decisions and outcomes: a statewide analysis. Am J Surg. 2009;197(5):571–5.PubMedCrossRefGoogle Scholar
  16. 16.
    Moore EE, Knudson MM, Burlew CC, Inaba K, Dicker R, Biffle WL, Malhotra AK, et al. Defining the limits of resuscitative emergency department thoracotomy: a contemporary western trauma association perspective. J Trauma. 2011;70(2):334–9.PubMedCrossRefGoogle Scholar
  17. 17.
    Von Kuenssberg Jehle D, Stiller G, Wagner D. Sensitivity in detecting free intraperitoneal fluid with the pelvic views of the FAST exam. Am J Emerg Med. 2003;21(6):476–8.CrossRefGoogle Scholar
  18. 18.
    Kirkpatrick AW, Sirois M, Laupland KB, et al. Hand-held thoracic sonography for detecting post-traumatic pneumothoraces: the Extended Focused Assessment with Sonography for Trauma (EFAST). J Trauma. 2004;57:288–95.PubMedCrossRefGoogle Scholar
  19. 19.
    Alrajhi K, Woo MY, Vaillancourt C. Test characteristics of ultrasonography for the detection of pneumothorax: a systematic review and meta-analysis. Chest. 2012;141(3):703–8.PubMedCrossRefGoogle Scholar
  20. 20.
    Trupka A, Waydhas C, Hallfeldt KK, et al. Value of thoracic computed tomography in the first assessment of severely injured patients with blunt chest trauma: results of a prospective study. J Trauma. 1997;43(3):405–11.PubMedCrossRefGoogle Scholar
  21. 21.
    Roudsari B, Psoter KJ, Fine GC, Jarvik JG. Falls, older adults, and the trend in utilization of CT in a level I trauma center. AJR Am J Roentgenol. 2012;198(5):985–91.PubMedCrossRefGoogle Scholar
  22. 22.
    Plurad D, Green D, Demetriades D, Rhee P. The increasing use of chest computed tomography for trauma: is it being overutilized? J Trauma. 2007;62(3):631–5.PubMedCrossRefGoogle Scholar
  23. 23.
    Inaba K, Lustenberger T, Recinos G, et al. Does size matter? A prospective analysis of 28–32 versus 36–40 French chest tube size in trauma. J Trauma Acute Care Surg. 2012;72(2):422–7.PubMedGoogle Scholar
  24. 24.
    Maxwell RA, Campbell DJ, Fabian TC, et al. Use of presumptive antibiotics following tube thoracostomy for traumatic hemopneumothorax in the prevention of empyema and pneumonia–a multi-center trial. J Trauma. 2004;57(4):742–8.PubMedCrossRefGoogle Scholar
  25. 25.
    Bosman A, de Jong MB, Debeij J, et al. Systematic review and meta-analysis of antibiotic prophylaxis to prevent infections from chest drains in blunt and penetrating thoracic injuries. Br J Surg. 2012;99(4):506–13.PubMedCrossRefGoogle Scholar
  26. 26.
    Watkins TR, Nathens AB, Cooke CR, et al. Acute respiratory distress syndrome after trauma: development and validation of a predictive model. Crit Care Med. 2012;40(8):2295–303.PubMedCentralPubMedCrossRefGoogle Scholar
  27. 27.
    Miller PR, Croce MA, Kilgo PD, et al. Acute respiratory distress syndrome in blunt trauma: identification of independent risk factors. Am Surg. 2002;68(10):845–50.PubMedGoogle Scholar
  28. 28.
    Stitzel JD, Kilgo PD, Weaver AA, et al. Age thresholds for increased mortality of predominant crash induced thoracic injuries. Ann Adv Automot Med. 2010;54:41–50.PubMedCentralPubMedGoogle Scholar
  29. 29.
    Wolfman NT, Myers WS, Glauser SJ, Meredith JW, Chen MY. Validity of CT classification on management of occult pneumothorax: a prospective study. AJR Am J Roentgenol. 1998;171:1317–20.PubMedCrossRefGoogle Scholar
  30. 30.
    Collins JC, Levine G, Waxman K. Occult traumatic pneumothorax: immediate tube thoracostomy versus expectant management. Am Surg. 1992;58:743–6.PubMedGoogle Scholar
  31. 31.
    DuBose J, Inaba K, Demetriades D, Scalae TM, O’Connor J, Menaker J, Morales C, et al. Management of post-traumatic retained hemothorax: a prospective, observational, multicenter AAST study. J Trauma Acute Care Surg. 2012;72(1):11–22; discussion 22–4; quiz 316.PubMedGoogle Scholar
  32. 32.
    Schweigert M, Beron M, Dubecz A, et al. Video-assisted thoracoscopic surgery for posttraumatic hemothorax in the very elderly. Thorac Cardiovasc Surg. 2012;60(7):474–9.PubMedCrossRefGoogle Scholar
  33. 33.
    Kiser AC, Obrien SM, Detterbeck FC. Blunt tracheobronchial injuries: treatment and outcomes. Ann Thorac Surg. 2001;71(6):2059–65.PubMedCrossRefGoogle Scholar
  34. 34.
    Glazer ES, Meyerson SL. Delayed presentation and treatment of tracheobronchial injuries due to blunt trauma. J Surg Educ. 2008;65(4):302–8.PubMedCrossRefGoogle Scholar
  35. 35.
    Gomez-Caro A, Ausin P, Moradiellos FJ, et al. Role of conservative medical management of tracheobronchial injuries. J Trauma. 2006;61(6):1426–34.PubMedCrossRefGoogle Scholar
  36. 36.
    Ismailov RM, Ness RB, Redmond CK, et al. Trauma associated with cardiac dysrhythmias: results from a large matched case–control study. J Trauma. 2007;62(5):1186–91.PubMedCrossRefGoogle Scholar
  37. 37.
    Keough V, Letizia M. Blunt cardiac injury in the elderly trauma patient. Int J Trauma Nurs. 1998;4:38–43.PubMedCrossRefGoogle Scholar
  38. 38.
    Neschis DG, Scalea TM, Flinn WR, Griffith BP. Blunt aortic injury. N Engl J Med. 2008;359(16):1708–16.PubMedCrossRefGoogle Scholar
  39. 39.
    Arthurs ZM, Starnes BW, Sohn VY, et al. Functional and survival outcomes in traumatic blunt thoracic aortic injuries: an analysis of the National Trauma Databank. J Vasc Surg. 2009;49:988.PubMedCrossRefGoogle Scholar
  40. 40.
    Fabian TC, Davis KA, Gavant ML, et al. Prospective study of blunt aortic injury: helical CT is diagnostic and antihypertensive therapy reduces rupture. Ann Surg. 1998;227(5):666–76.PubMedCrossRefGoogle Scholar
  41. 41.
    Fabian TC, Richardson JD, Croce MA, et al. Prospective study of blunt aortic injury: multicenter trial of the American Association for the Surgery of Trauma. J Trauma. 1997;42(3):374–80.PubMedCrossRefGoogle Scholar
  42. 42.
    Camp Jr PC, Rogers FB, Shackford SR, et al. Blunt traumatic thoracic aortic laceration in the elderly: an analysis of outcome. J Trauma. 1994;37:418–23.PubMedCrossRefGoogle Scholar
  43. 43.
    Garcia-Toca M, Naughton PA, Matsumura JS, et al. Endovascular repair of blunt traumatic thoracic aortic injuries seven-year single-center experience. Arch Surg. 2010;145(7):679–83.PubMedCrossRefGoogle Scholar
  44. 44.
    Riesenman PJ, Brooks JD, Farber MA. Acute blunt traumatic injury to the descending thoracic aorta. J Vasc Surg. 2012;56(5):1274–80. doi: 10.1016/j.jvs.2012.04.035. Epub 2012 Jun 23.PubMedCrossRefGoogle Scholar
  45. 45.
    Demetriades D, Velmahos GC, Scalea TM, Jurkovich GJ, Karmy-Jones R, Teixeira PG, Hemmila MR, et al. Diagnosis and treatment of blunt thoracic aortic injuries: changing perspectives. J Trauma. 2008;64(6):1415–8; discussion 1418–9.PubMedCrossRefGoogle Scholar
  46. 46.
    Hirose H, Gill IS, Malangoni MA. Nonoperative management of traumatic aortic injury. J Trauma Acute Care Surg. 2006;60(3):597–601.CrossRefGoogle Scholar
  47. 47.
    Caffarelli AD, et al. Early outcomes of deliberate nonoperative management for blunt thoracic aortic injury in trauma. J Thorac Cardiovasc Surg. 2010;140(3):598–605.PubMedCrossRefGoogle Scholar
  48. 48.
    Kidane B, et al. Natural history of minimal aortic injury following blunt thoracic aortic trauma. Can J Surg. 2012;55(6):377–81.PubMedCentralPubMedCrossRefGoogle Scholar
  49. 49.
    Lewis JD, Starnes SL, Pandalai PK, et al. Traumatic diaphragmatic injury: experience from a level I trauma center. Surgery. 2009;146(4):578–83; discussion 583–4.PubMedCrossRefGoogle Scholar
  50. 50.
    Hanna WC, Ferri LE, Fata P, Razek T, Mulder DS. The current status of traumatic diaphragmatic injury: lessons learned from 105 patients over 13 years. Ann Thorac Surg. 2008;85(3):1044–8.PubMedCrossRefGoogle Scholar
  51. 51.
    Hsu YP, Chen RJ, Fang JF, Lin BC. Blunt diaphragmatic rupture in elderly patients. Hepatogastroenterology. 2005;52(66):1752–8.PubMedGoogle Scholar
  52. 52.
    Apostolakis E, Akinosoglou K, Koletsis E, Dougenis D. Traumatic chylothorax following blunt thoracic trauma: two conservatively treated cases. J Card Surg. 2009;24(2):220–2.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  1. 1.Department of SurgeryRhode Island HospitalProvidenceUSA

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