Assessment of Silver Trauma Presenting to the Emergency Department: A Rural District General Perspective
Abstract
Background
Silver trauma is an increasingly common presentation within the Emergency Department (ED) especially in rural locations with an ageing population.
Such patients often present with lower mechanisms of injury leading to under recognition of significant trauma and injuries in ED, and therefore inappropriate admission to medical wards.
Aim
To examine silver trauma patients presenting to a district general ED and determine whether injuries are under recognised on initial assessment. A silver trauma bundle was proposed to aid recognition and management of these patients in ED.
Methods
This single-centre retrospective study used Scottish Trauma Audit Group (STAG) data from 01/01/2023 to 31/12/2023. Criteria for inclusion was patients presenting to ED, aged 65 or over with an ISS of ≥9.
Observational data was collated from ED notes, imaging and final discharge letters.
Results
88 patients met inclusion criteria. The most common mechanism of injury was a fall from the same level at 34.
The most common admission destination was orthopaedics (36), followed by general surgery (14) and medicine (16).
Of these 16 patients, 3 had a CT head during their admission which showed an intracranial haemorrhage. None of these patients had a CT head in ED, all presented as a fall from standing and were recorded as GCS 15 on initial assessment.
2 of these patients were transferred to a Neurosurgical unit. Reasons for transfer were recorded as 1. Drop in GCS with new neurology and 2. Increase in size of bleed on repeat imaging.
Conclusion
Patients aged 65 and over can sustain significant trauma from low energy mechanisms.
Intracranial haemorrhage was the primary diagnosis discovered following admission to medicine. None of these patients were transferred without an accompanying change in either clinical condition or imaging findings, but nevertheless this highlights a potential for injury despite initially normal GCS.
Clinicians should have a low threshold for cross sectional imaging and early involvement of seniors, we hope that a silver trauma bundle will aid in recognition and decision making.
Comments
Use of the bundle in practice
This was interesting to read, and the silver trauma bundle looked to be a fantastic prompt for busy ED departments. Have you had any feedback from clinicians completing documentation so far, if this has been implemented into practice and would you consider adding a box for a collateral history?
Thank you.
Re. use of the bundle in practice
Thank you for your question and taking the time to read the poster.
We unfortunately don't have any formal feedback yet but, anecdotally, I have had positive feedback mostly from F2s and clinical fellows new to ED who find the structured layout useful when getting used to assessing these patients. It is a relatively lengthy document (although not compared to the major trauma proforma) and I think this can be off-putting to some people, albeit it is designed as a framework rather than a checklist.
I hope we will be able to get some formal feedback on the coming year and make changes around that.
I currently work in a different department where a similar tool is used and have found that it is often picked up by Nurses at triage and partially completed which then leads to a prompt for the treating clinician, or sometimes as a trigger for escalating patients to majors or resus direct from triage.