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402
E. Rausa et al.
28.3 Neurotrauma
Physiology in traumatic brain injury (TBI) is determined by two phases. The rst
phase consists in a cellular disruption or death leading to a neurological impairment.
The second phase results in microenviromental changes, edema, and inammation.
In EPs, these phases are exacerbated by the age-related physiological changes
because aging decreases the brain’s plasticity and its ability to repair the damage.
Additionally, TBI conduces to further cellular loss and may boost any disease progression [28].
Medical treatment should evaluate several factors in EPs. Considering the high rate
of EPs with hypertension, maintaining an appropriate blood pressure and, consequently,
a correct cerebral oxygenation may be challenging [29]. In EPs, the heart ejection should
be precisely calculated to determine all the further uid management. Currently, the
mainstays in TBI treatment are as follows: (1) balance hypoxia and hypotension; (2)
carefully avoid hypoperfusion from hyperventilation; (3) administer anticonvulsants
over the rst 7days after the trauma; and (4) do not administer steroids [30].
As the brain volume in EPs is reduced and the dead space between the brain and
the head bone is enlarged, the likelihood of a substantial brain swelling with a consequent increased intracranial pressure needing surgical intervention is rare.
Mannitol remains the most efcient drug in the control of increased intracranial
pressure in these patients, even though a decreased function of the astrocytic gap
junctions may result in a mannitol hyperfunction worsening the cerebral edema.
More recently, several studies have shown that statins reduce the risk of both inhospital mortality and 12-month adverse outcome [31, 32].
From the surgical perspective, guidelines currently recommend evacuating an
acute subdural hematoma when it is >10mm and/or midline shift is >5mm on CT
scan, regardless of the patient’s Glasgow Coma Scale (GCS) [30]. While this recommendation is well established for young patients, it is vague and controversial
with regard to EPs. However, EPs who underwent craniotomy for hematoma evacuation showed acceptable outcomes (in-hospital mortality 5–16%) and a similar ability to return to the baseline when compared to younger counterparts. EPs may
require more scrupulous care over the period of hospitalization and a longer hospital
stay and rehabilitation. Historically, the vast majority of subdural hematoma cases
were treated conservatively and resulted in a chronic event. Patients have occasionally reported headache and/or minor mental changes; less than 10% have reported
substantial neurological symptoms [29].
Recent studies, however, pointed out that chronic subdural hematoma (CSDH) is
not a disease free of long-term complications. Miranda etal. found that the CSDH
effect in the long term in EPs leads to a mortality rate of 26.3% at 6months and 32%
at 12months [33]; similar results are reported in patients after hip fractures [34]. It
might be postulated that CSDH after TBI exacerbates preexisting comorbidities and
affects the brain functions, resulting in an increased rate of mortality [33].
Further studies looking at specic TBI cohorts of EPs indicated “male gender” as
a predictive factor for a worse outcome. Women reported better outcomes, and it is
likely to be due to estrogen and progesterone, which act in the reparation process [35].
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It is well established that falls represent the most common mechanism for TBI.In
this context, more efforts should be addressed toward the prevention of such injuries. Several studies listed a number of strategies to decrease the probability of these
traumatic events happen. Incentivization has been suggested as an encouragement
to compliance in elderly to medications, as the careful choice of the more appropriate antihypertensive (thiazide-type diuretic therapy reduces hip and pelvic fracture
risk compared with other antihypertensive medications), and as the promotion of
physical exercise to strengthen their musculoskeletal systems [36, 37].
Of note, the vast majority of EPs are on anticoagulation therapy, which deeply
affects outcomes. Anticoagulants make treatment much more demanding and challenging [38]. Howard etal. found a relationship between an increased risk of mortality in EPs and those on warfarin who fall [39]. However, this relationship has
been debated in the literature, and the data are still contradictory.
Over the last decade, new oral anticoagulants (NOACs) are available worldwide.
NOACs are as efcient as warfarin but relatively safer. The action mechanism consists in the direct inhibition of the coagulation cascade. NOACs have a shorter halflife compared to warfarin (8–16h vs 1week, respectively) and are, thus, easier to
manage. The major limitation of NOACs is the lack of a specic antidote [40]. The
RE-LY trial documented that low doses of NOACs decrease the risk of intracranial
hemorrhage as compared with warfarin; conversely, high doses result in a similar
risk [41].
28.4 Pelvic Fracture
The pelvis is the strongest bone unit in the body and its fracture is considered to be
secondary to high-energy injury (13–18%). However, comorbidities (osteoporosis,
arthritis, and osteopenia), preexisting conditions (previous surgery, metastases), and
age may weaken the bone pattern and make it prone to fracture even in cases of lowenergy trauma [42].
Comparing EPs to their younger counterparts, differences in the mechanism,
hospitalization, and outcomes are evident. While younger patients typically sustain
such fractures from high-energy traumas, such as motor vehicle collisions, in EPs,
low-energy trauma—usually falls from standing—is the most common cause [43].
Therefore, prevention of falls should be taken into consideration when striving to
decrease the risk factors. In addition, pelvic fractures are more prevalent among
males in younger patients and among females in EPs. The difference in prevalence
between sexes is presumably attributable to the hormonal changes in females (estrogen and progesterone decline) which unleash subsequent osteoporosis [44]. In 64%
of pelvis fractures, preexisting osteoporosis is present and this rises to 94% in
<60-year-old patients [45].
Mortality in EPs (7.6%) is mostly related to hemorrhage; this is four times higher
than in younger patients, where morbidity is due to incomplete healing and/or nerve
damage [46]. Pelvic fracture management is standardized in two groups, whether or
not the patient is hemodynamically stable [47].
404
Anterior Posterior Compression
23
E. Rausa et al.
Due to the anatomy, pelvic trauma may involve different organs and systems
(bones, genitourinary viscera, rectum, small intestine, major vessels, and pudendal
nerves); thus, the management of such trauma may be demanding and require a
polyspecialistic treatment. Moreover, in EPs, bones are weaker and ligaments and
the skin are less exible; thus, the incidence of more complex fractures such as
Morel-Lavallee, Malgaigne, or open-book fracture increases. Nonetheless, concomitant drugs, such as anticoagulants, which EPs are often on, may contribute to persistent bleeding and increase of the hemodynamic instability risk [48].
Primary classication is based on the fracture stability. Stable fractures are
dened as fractures of the pelvic ring, acetabular fractures, and pubic branch.
Unstable fractures are characterized by pelvic fractures in more sites (Malgaigne
fracture or open-book fracture). The Young and Burgess system is the most accepted
worldwide (Fig.28.1) [49]. According to this classication, angiographic embolization is predominantly required in anterior posterior compression, in vertical shear,
or in combined fracture patterns (Fig.28.1) [50].
1
Lateral Compression
1
Ver tical Shear
Fig. 28.1 Young and Burgess pelvic fracture classication
2
3
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According to ATLS, the rst assessment is based on clinical ndings and pain
site. Physical examination is essential to determine the anatomical site entailed in
the trauma, which requires further investigations. Bimanual compression of the iliac
wings can rule out either vertical or rotational instability [51]. Pelvic X-ray represents the rst radiological investigation. Inlet, outlet, or judet views may offer additional data. CT scan may be useful in suspected active bleeding in order to dene the
site of a subsequent angiographic embolization if necessary [52]. When underlying
osteoporosis is suspected, an extensive investigation, including of levels of calcium,
thyroid function, and sexual hormones in the serum, should be carried out [48].
As previously mentioned, management is primarily based on the clinical presentation. In EPs who have a poor physiological reserve to get through a trauma, a
comprehensive assessment of the patient should be carried out. Comorbidities
should be taken into consideration, especially for potential medication interactions.
It is likely that home therapy might interact with drugs administered over the course
of hospitalization, causing confusion and obnubilation. A prompt correction of
coagulopathy in patients on anticoagulants is essential (Table28.1), while desmopressin may help to treat patients with chronic kidney disease [53].
The clinical examination and the radiological investigations looking at potential bleeding dene the diagnostic phase. Once the site of bleeding is identied,
and even supposing there is active bleeding but the patient is hemodynamically
stable, conservative treatment (bed rest, minimally invasive interventions, and
pain control) is preferred. Occasionally, the sites of hemorrhage are multiple, and
in one third of pelvic fractures, sources of bleeding are outside of the pelvic
borders [54].
Table 28.1 Commonly antiplatelet/anticoagulants agents
Antiplatelet/
anticoagulant agents
(brand name)
Warfarin (Coumadin) 20–60h 2–5days Vitamin K
Aspirin 20min Life of the
Clopidogrel (Plavix) 6–7h 7–10days Antiplatelet: ADP
Prasugrel (Efent) 6–7h
Ticlopidine (Ticlid) 12h
Abciximab (ReoPro) 10–30min 48h Antiplatelet:
Eptibatide (Integrilin) 2.5h 96h
Tiroban (Aggrastat) 2h 48h
Fondaparinux (Arixtra) 17–21h 2–4days Bind antithrombin Protamine sulfate
Enoxaparin (Lovenox) 4.5–7h 12h
Dabigatran (Pradaxa) 12–17h 2–4days Direct thrombin (II)
Half-life
Duration of
action
platelet
(7–10days)
Mechanism of
action
antagonist (inhibits
factors II, VII, IX,
and X)
Antiplatelet:
thromboxane
inhibitor
receptor/P2Y12
inhibitors
glycoprotein IIb/
IIIa inhibitors
inhibitor
Reversal agents
Fresh frozen
plasma, vitamin
K, prothrombin
complex
concentrate
Desmopressin;
platelets may give
temporary reversal
Desmopressin;
platelets may give
temporary reversal
Desmopressin;
platelets may give
temporary reversal
(more effective
with heparin)
Unknown
406
E. Rausa et al.
Usually, any small amount of bleeding in hemodynamically stable patients is controlled by putting in place a pelvic binder, which stabilizes the fracture. Although arterial
bleeding is unusual, its presence should be investigated with radiological investigations
when suspected. Such bleeding is unlikely to be controlled with immobilization, and
more invasive treatment (i.e., angioembolization and/or surgery) is required [55].
A mobilization as early as possible is recommended to prevent the bone resorption and to decrease the risk of pulmonary infection and vascular or gastrointestinal
complications. The average hospital stay for EPs who sustain a pelvic fracture is
around 21days. Subsequently, a long rehabilitation is frequently required; however,
a complete return to the motility at the baseline is rare, and EPs may need a cane to
resume daily activities [56].
28.5 Penetrating Trauma
Trauma is the fth leading cause of death in EPs. Blunt trauma (falls, motor vehicle
injuries, or pedestrian collision) is the most common, but outcomes are favorable
[57]. The same cannot be said for penetrating trauma, which is relatively rare but
with an extremely poor prognosis. This poor prognosis is due to the scarce physiological reserve in association with several comorbidities; of note is preexisting cardiovascular disease, which requires the administration of anticoagulants.
Penetrating trauma is most commonly due to a suicide attempt. Social context
(urban setting) and comorbidities (depression and chronic pain) may deeply affect
EP quality of life. Self-inicted injury rates increase with aging (46.2% between 65
and 74years of age and 51.5% over 75years of age). This type of injury represents
a clear public issue [58].
In 80% of suicide attempts, rearms are predominantly employed, and the head
is the site most commonly involved (54.2%), with an extremely high mortality (over
90%). Additional anatomical sites of penetrating trauma are the thorax (13.5%) and
abdomen (8.2%). In assaulted patients, the thorax and abdomen are the most commonly involved area (43%), followed by the extremities (16.9%). Higher mortality
is recorded in suicide attempts (60%) as compared to assault-related patients (25%)
or unintentional penetrating injuries (9%) [58].
Given the complex history and home therapy often present in EPs, these patients
should be closely assessed and monitored. It has been demonstrated that the classic
hemodynamic criteria (systolic BP <90mmHg or heart rate >120/min), which are
typically applied in trauma team activation, are inadequate in EPs. Heffernan etal.
compared the blood pressure and the heart rate in geriatric and younger patients and
found that vital signs are unreliable in geriatric patients. In fact, this study showed
that mortality in geriatric patients increases when the blood pressure and the heart
rate are <110mmHg and >130beats/min, respectively. Conversely, in their younger
counterparts, vital sign limits are <95mmHg and >90beats/min, respectively [22].
This difference is presumably attributable to a substantial physiological change
in EPs causing a poor reserve, in addition to medications (such as beta-blockers,
anticoagulants, and diuretics) which may affect the vital signs and lead to a misleading trauma classication. In these patients, a sudden deterioration has always to be
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expected, even though hemodynamically stable on presentation; thus, prompt and
aggressive treatment should be preferred [59].
Demetriades etal. found that assigning a specic activation code for severely
injured patients over 70years of age reduced the risk of misleading trauma classication and is helpful in enabling the prompt treatment of the patient. Applying these
criteria, this study reported a consistent reduction in mortality (p=0.003) [11].
A recent study reported better outcomes for severely injured patients transported
to trauma hospital rather than a non-trauma center [60]. As soon as the patient is
admitted, a detailed history should be gathered and any home therapy scrupulously
evaluated. As bleeding in EPs may be a challenge to control, the anticoagulants
need to be promptly interrupted and the coagulopathy corrected if the ISS is high
[59]. Multiple hemoglobin tests may help in assessing EPs whose vital signs are
affected by anticoagulants and beta-blockers. In these patients, vital signs “wrongly”
considered stable may conceal potentially life-threating bleeding. ATLS guidelines
should be adopted. Radiological investigations need to be completed while monitoring vital signs continuously, and angioembolization or aggressive interventions
should be considered in the rst phase of the evaluation [61].
Fluid administration needs to be managed carefully because the physiological
response between hypovolemia and edema in EPs is extremely thin. However, a
regulated hydration and bicarbonate administration reduce nephropathy. In trauma
patients, thermoregulatory response may be dysregulated, causing hypothermia,
acidosis, and coagulopathy. Therefore, hypothermia prevention through the administration of warm uids represents a mainstay in the management of trauma [62].
Surgical management is related to the injured area and whether or not vital signs
are stable. If vital signs are stable, further investigations (such as CT scan, endoscopy, and bronchoscopy) should be considered and a conservative treatment evaluated. Patients with penetrating trauma to the neck need an emergency operation if
the vascular or aerodigestive system is involved and vital signs are unstable.
Historically, less than 15–20% of penetrating neck injuries need surgery [63, 64].
In cases of chest trauma with hemodynamic instability, the surgical approach preferred is an emergency thoracotomy or median sternotomy, depending on the site
involved. In cases of penetrating trauma to the lower part of the left thorax, a diagnostic
laparoscopy might be considered to evaluate the diaphragm. The vast majority of cases
of penetrating trauma to the chest (nearly 80%) may be managed with a chest drain [
65].
Penetrating trauma to the abdomen which results in peritonitis or in hemodynamic instability requires an emergency laparotomy [66]. An emergency laparoscopy should be taken into consideration in left thoracoabdominal trauma in order to
rule out lacerations to the diaphragm [61].
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E. Rausa et al.
Bowel Obstructions
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
29
GennaroPerrone, LucaAnsaloni, FedericoCoccolini,
SalomoneDi Saverio, MassimoSartelli, andFaustoCatena
In elderly patients, bowel obstruction (BO) accounts for 10–12% of the PS access
for abdominal pain and are intestinal obstructions [1]. Obstruction is three times
more common in older adults than in younger patients [2]. After biliary disease, BO
is the second most common reason for emergency surgical interventions in this
group [3].
The ileum is the most common site of obstruction (most mobile tube, smoother,
thinner, therefore more exposed to adhesions and hernias compared to the large
bowel). The three most common causes of all small bowel occlusions (SBO) are
adhesions (50–75%), hernias (15%), and neoplasms (15%). Gallstone ileum is a
rare disease that accounts for 1–4% of mechanical obstructions.
Intra-abdominal adhesions following abdominal surgery represent a major
unsolved problem. They are the rst cause of SBO (Fig.29.1). Diagnosis is based on
clinical evaluation, water-soluble contrast follow-through, and computed tomography scan. Adhesive SBO requires appropriate management with a proper diagnostic
and therapeutic pathway. Indication and length of nonoperative management (NOM)
and appropriate timing for surgery may represent an insidious issue. Single therapeutic strategies are typically unsuccessful in preventing peritoneal adhesions due to the
G. Perrone • F. Catena (*)
Department of Emergency Surgery, Maggiore Hospital, Parma, Italy
L. Ansaloni • F. Coccolini
General Surgery Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
S. Di Saverio
Department of Surgery, Maggiore Hospital, Bologna, Italy
M. Sartelli
Department of Surgery, Macerata Hospital, Macerata, Italy
© Springer International Publishing AG, part of Springer Nature 2018
A. Crucitti (ed.), Surgical Management of Elderly Patients,
https://doi.org/10.1007/978-3-319-60861-7_29
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