Today I review EM Quick Hits 63‘s* “Imaging decision making in geriatric trauma”.
*Helman, A. Freedman, S. Morgenstern, J. McArther, M. Petrosoniak, A. Long, B. Gotlieb, M. EM Quick Hits 63 – S-TEC and HUS, IM Epinephrine in OHCA, Dengue, Geriatric Trauma Imaging, TTP. Emergency Medicine Cases. March, 2025. https://emergencymedicinecases.com/em-quick-hits-march-2025/. Accessed May 4, 2025.
All that follows is from the above resource.
Imaging decision making in geriatric trauma
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Falls in the older patient can result in significant injuries despite seemingly minor mechanisms.
- For example, there is a 2-5x higher mortality rate in patients >65 with rib fractures, with increasing mortality rates up to 11% and 35% with 6 and >8 rib fractures, respectively
- Pre-existing imaging rules may not have inclusion criteria that fit common patient presentations
CT imaging considerations:
- CT Head/C-Spine: Low threshold if patient >65, or other risk factors such as being on anticoagulants, or a high-risk mechanism.
- Consider no imaging in patients without the main predictors of C-spine injury: head injury, neck pain, and increasing age
- CT Chest/Abdomen/Pelvis: Consider if chest X-ray is abnormal or if chest X-ray is normal but significant pain is present.
- 16% of patients >65 and 28% of patient >85 with blunt chest trauma develop a complication such as pneumonia or respiratory failure
- Chest X-rays demonstrate rib fractures only 50% of the time
- There is conflicting data on whether older patients with radiographically occult injuries e.g. rib fractures require admission
The Eastern Association for the Surgery of Trauma (EAST) developed an imaging decision algorithm for the evaluation of blunt trauma patients > 65 although it has not received external validation. They recommend:
- CT Head and C-spine for all
- CT Chest/Abdomen/Pelvis if there are abnormal torso findings or high-risk factors
- Full CT spine if imaging Chest/Abdo/Pelvis: there is a 15% chance of another fracture elsewhere in the spine with any vertebral fracture
- Stawicki SP, Grossman MD, Hoey BA, Miller DL, Reed JF 3rd. Rib fractures in the elderly: a marker of injury severity. J Am Geriatr Soc. 2004 May;52(5):805-8. doi: 10.1111/j.1532-5415.2004.52223.x. PMID: 15086666.
- McCallum J, et al. Which adults aged 65 and older are at low-risk for cervical spine injuries after low-level falls? CJEM. 2024 Oct;26(10):721-726. doi: 10.1007/s43678-024-00752-x. Epub 2024 Sep 2. PMID: 39222206.
- Lotfipour S, Kaku SK, Vaca FE, Patel C, Anderson CL, Ahmed SS, Menchine MD. Factors associated with complications in older adults with isolated blunt chest trauma. West J Emerg Med. 2009 May;10(2):79-84. PMID: 19561823; PMCID: PMC2691509.
- Chowdhury D. Does a fall from a standing height warrant computed tomography in an elderly patient with polytrauma? World J Emerg Med. 2023;14(4):302-306. doi: 10.5847/wjem.j.1920-8642.2023.040. PMID: 37425080; PMCID: PMC10323510.
- Ho VP, et al. Scanning the aged to minimize missed injury: An Eastern Association for the Surgery of Trauma multicenter study. J Trauma Acute Care Surg. 2025 Jan 1;98(1):101-110. doi: 10.1097/TA.0000000000004390. Epub 2024 Dec 14. PMID: 38797882; PMCID: PMC11599468.
