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Pharmacology

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Geriatric Trauma and Critical Care

Abstract

The use of prescription medication is more common in the geriatric population. As trauma in the elderly continues to rise, the trauma surgeon is increasingly faced with older patients on complex medication regimens. This chapter will review drug metabolism in the elderly and changes which occur with the aging process. The more common antiplatelet and anticoagulant medications and options for treatment or reversal, the impact of beta-blockers, and the basic approach to delirium and pain management will also be reviewed.

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Bibliography

  • Abood GJ, Luchette FA. The management of the trauma patient with medically-altered coagulation. Am Surg. 2008;74:784–92.

    PubMed  Google Scholar 

  • Ageno W, Gallus AS, Wittkowsky A, Crowther M, Hylek EM, Palareti G. Oral anticoagulant therapy: antithrombotic and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141: e44S–88.

    Article  CAS  PubMed  Google Scholar 

  • Altman R, Scazziota A, Lourdes DE, Herrera M, Gonzalez C. Recombinant factor VIIa reverses the inhibitory effect of aspirin or clopidogrel on in vitro thrombin generation. J Thromb Haemost. 2006;4:2022–7.

    Article  CAS  PubMed  Google Scholar 

  • American Geriatric Society. The management of persistent pain in older persons. J Am Geriatr Soc. 2002;50:S205–24.

    Article  Google Scholar 

  • Arbabi S, Ahrns KS, Wahl WL, et al. Beta-blocker use is associated with improved outcomes in adult burn patient. J Trauma. 2004;56: 265–9.

    Article  CAS  PubMed  Google Scholar 

  • Arbabi S, Campion EM, Barker M, Dimo M, Hemmila MR, Ahrns KS, Niederbichler AD, Wahl WL. Beta blocker use is associated with improved outcomes in adult trauma patients. J Trauma. 2006;62: 56–62.

    Article  Google Scholar 

  • Bonville DJ, Ata A, Jahraus CB, Arnold-Lloyd T, et al. Impact of preinjury warfarin and antiplatelet agents on outcomes of trauma patients. Surgery. 2011;150:861–8.

    Article  PubMed  Google Scholar 

  • Breitbart W, Marotta R, Platt MM, et al. A double—blind trial of haloperidol, chlorpromazine and lorazepam in the treatment of delirium in hospitalized AIDS patients. Am J Psychiatry. 1996;153:231–7.

    CAS  PubMed  Google Scholar 

  • Brewer ES, Reznikov B, Liberman RF, et al. Incidence and predictors of intracranial hemorrhage after minor head trauma in patients taking anticoagulant and antiplatelet medication. J Trauma. 2011;70:E1–5.

    Article  CAS  PubMed  Google Scholar 

  • Broadhurst C, Wilson K. Immunology of delirium: new opportunities for treatment and research. Br J Psychiatry. 2001;179:288–9.

    Article  CAS  PubMed  Google Scholar 

  • Campbell PG, Sen A, Yadla S, Jabbour P, Jallo J. Emergency reversal of antiplatelet agents in patients presenting with an intracranial hemorrhage: a clinical review. World Neurosurg. 2010;74:279–85.

    Article  PubMed  Google Scholar 

  • Delafuente JC. Pharmacokinetic and pharmacodynamic alterations in the geriatric patient. Consult Pharm. 2008;23(4):324–34.

    Article  PubMed  Google Scholar 

  • Downey DM, Monson B, Butler KL, Fortuna Jr GR, Saxe JM, Markert RJ, McCarthy MC. Does platelet administration affect mortality in elderly dead-injured patients taking antiplatelet medications? Am Surg. 2009;75:1100–3.

    PubMed  Google Scholar 

  • Dwyer LL, Han B, Woodwell DA, Rechsteiner EA. Polypharmacy in nursing home residents in the United States: results of the 2004 National Nursing Home Survey. Am J Geriatr Pharmacother. 2010;8:63–72.

    Article  PubMed  Google Scholar 

  • Eagle KA, Froehlic JB. Reducing cardiovascular risk in patients undergoing noncardiac surgery. N Engl J Med. 1996;335:1761–3.

    Article  CAS  PubMed  Google Scholar 

  • Eerenberg ES, Kamphuisen PW, Sijpkens MK, Meijers JC, Buller HR, Levi M. Reversal of rivaroxaban and dabigatran by prothrombin complex concentrate: a randomized, placebo-controlled crossover study in healthy subjects. Circulation. 2011;124:1573–9.

    Article  CAS  PubMed  Google Scholar 

  • Eikelboom JW, Hirsh J, Spencer FA, Baglin TP, Weitz JI. Antiplatelet drugs: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141:e89S–119.

    Article  CAS  PubMed  Google Scholar 

  • Ely EW, Shintani A, Truman B, et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA. 2004;291:1753–62.

    Article  CAS  PubMed  Google Scholar 

  • Ely EW, Inouye SK, Bernard DR, et al. Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA. 2001;286:2703–10.

    Article  CAS  PubMed  Google Scholar 

  • Escolar G, Arellano-Rodrigo E, Reverter JC, et al. Reversal of apixaban induced alterations of hemostasis by different coagulation factor concentrates: studies in vitro with circulating human blood. 2012. http://circ.ahajournals.org/content/early/2012/06/20/CIR.0b013e3182611cc2.citation.

  • Fortuna GR, Mueller EW, James LE, Shutter LA, Butler KL. The impact of preinjury antiplatelet and anticoagulant pharmacotherapy on outcomes in elderly patients with hemorrhagic brain injury. Surgery. 2008;144:598–605.

    Article  PubMed  Google Scholar 

  • Friese RS, Barber R, McBride D, Bender J, Gentilello LM. Could beta-blockade improve outcome after injury by modulating inflammatory profiles? J Trauma. 2008;64:1061–8.

    Article  CAS  PubMed  Google Scholar 

  • Garcia DA, Baglin TP, Weitz JI, Samama MM. Parenteral anticoagulants: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141:e24S–43.

    Article  CAS  PubMed  Google Scholar 

  • Gibson SJ, Helme RD. Age-related differences in pain perception and report. Clin Geriatr Med. 2001;17:433–56, v–vi.

    Article  CAS  PubMed  Google Scholar 

  • Gibson SJ, Farrell M. A review of age differences in the neurophysiology of nociception and the perceptual experience of pain. Clin J Pain. 2004;20:227–39.

    Article  PubMed  Google Scholar 

  • Godier A, Miclot A, Le Bonniec B, et al. Evaluation of prothrombin complex concentrate and recombinant activated Factor VII to reverse rivaroxaban in a rabbit Model. Anesthesiology. 2012;116(1): 94–102.

    Article  CAS  PubMed  Google Scholar 

  • Herndon DN, Hart DW, Wolf SE, et al. Reversal of catabolism by beta-blockade after severe burns. N Engl J Med. 2001;345:1223–9.

    Article  CAS  PubMed  Google Scholar 

  • Holbrook A, Schulman S, Witt DM, et al. Evidence-based management of anticoagulant therapy: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141:e152S–84.

    Article  CAS  PubMed  Google Scholar 

  • Holland L, Warkentin TE, Refaai M, Crowther MA, Johnston MA, Sarode R. Suboptimal effect of a three-factor prothrombin complex concentrate (Profilnine-SD) in correcting supratherapeutic international normalized ratio due to warfarin overdose. Transfusion. 2009;49:1171–7.

    Article  CAS  PubMed  Google Scholar 

  • Inouye SK. Delirium in older persons. N Engl J Med. 2006;354: 1157–65.

    Article  CAS  PubMed  Google Scholar 

  • Inouye SK, Bogardus Jr ST, Charpentier PA, et al. A multi-component intervention to prevent delirium in hospitalized older patients. N Engl J Med. 1999;340:669–76.

    Article  CAS  PubMed  Google Scholar 

  • Ivascu FA, Howells GA, Junn FS, Bair HA, Bendick PJ, Janczyk RJ. Rapid warfarin reversal in anticoagulated patients with traumatic intracranial hemorrhage reduces hemorrhage progression and mortality. J Trauma. 2005;59:1131–9.

    Article  CAS  PubMed  Google Scholar 

  • Ivascu FA, Howells GA, Junn FS, Bair HA, Bendick PJ, Janczyk RJ. Predictors of mortality in trauma patients with intracranial hemorrhage on preinjury aspirin or clopidogrel. J Trauma. 2008;65: 785–8.

    Article  CAS  PubMed  Google Scholar 

  • Jones K, Sharp C, Mangram AJ, Dunn EL. The effects of preinjury clopidogrel use on older trauma patients with head injuries. Am J Surg. 2006;192:743–5.

    Article  CAS  PubMed  Google Scholar 

  • Juliebø V, Bjøro K, Krogseth M, et al. Risk factors for preoperative and postoperative delirium in elderly patients with hip fracture. J Am Geriatr Soc. 2009;57:1354–61.

    Article  PubMed  Google Scholar 

  • Kennedy DM, Cipolle MD, Pasquale MD, Wasser T. Impact of preinjury warfarin use in elderly trauma patients. J Trauma. 2000;48(3): 451–3.

    Article  CAS  PubMed  Google Scholar 

  • Khorsand N, Veeger NJ, Muller M, et al. Fixed versus variable dose of prothrombin complex concentrate for counteracting vitamin K antagonist therapy. Transfus Med. 2011;21:116–23.

    Article  CAS  PubMed  Google Scholar 

  • Kollef MH, Levy NT, Ahrens TS, Schaiff R, Prentice D, Sherman G. The use of continuous IV sedation is associated with prolongation of mechanical ventilation. Chest. 1998;114:541–8.

    Article  CAS  PubMed  Google Scholar 

  • Kubitza D, Becka M, Mueck W, et al. Effects of renal impairment on the pharmacokinetics, pharmacodynamics, and safety of rivaroxaban, an oral, direct Factor Xa inhibitor. Br J Clin Pharmacol. 2010;70(5):703–12.

    Article  CAS  PubMed  Google Scholar 

  • Lat I, McMillian W, Taylor S, et al. The impact of delirium on clinical outcomes in mechanically ventilated surgical and trauma patients. Crit Care Med. 2009;37:1898–905.

    Article  PubMed  Google Scholar 

  • Lavoie A, Ratte S, Clas D, Demers J, Moore L, Martin M, Berferon E. Preinjury warfarin use among elderly patients with closed head injuries in a trauma center. J Trauma. 2004;56:802–7.

    Article  PubMed  Google Scholar 

  • Liu MY. Protective effects of propranolol on experimentally head-injured mouse brains. J Formos Med Assoc. 1995;94:386–90.

    CAS  PubMed  Google Scholar 

  • Lombard SA, Robbertze R. Perioperative use of β-blockers in the elderly patient. Anesthesiol Clin. 2009;27:581–97.

    Google Scholar 

  • Lundström M, Olofsson B, Stenvall M, et al. Postoperative delirium in old patients with femoral neck fracture: a randomized intervention study. Aging Clin Exp Res. 2007;19:178–86.

    Article  PubMed  Google Scholar 

  • Mangano DT, Layug EL, Wallace A, et al. Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. Multicenter Study of Perioperative Ischemia Research Group. N Engl J Med. 1996;335:1713–20.

    Article  CAS  PubMed  Google Scholar 

  • Mathieson T, Benediktsdottir K, Johnsson H, Lindqvist M, von Holst H. Intracranial traumatic and non-traumatic haemorrhagic complications of warfarin treatment. Acta Neurol Scand. 1995;91: 208–14.

    Article  Google Scholar 

  • Mina AA, Bair HA, Howells GA, Bendick PJ. Intracranial complications of preinjury anticoagulation in trauma patients with head injury. J Trauma. 2002;53:668–72.

    Article  CAS  PubMed  Google Scholar 

  • Mohammadi AA, Bakhshaeekia A, Alibeigi P, et al. Efficacy of propranolol in wound healing for hospitalized burn patients. J Burn Care Res. 2009;30:1013–7.

    Article  PubMed  Google Scholar 

  • Mountain D, Sistenich V, Jacobs IG. Characteristics, management and outcome of adults with major trauma taking pre-injury warfarin in a Western Australian population from 2000 to 2005: a population-based cohort study. Med J Aust. 2010;193:202–6.

    PubMed  Google Scholar 

  • Neideen T, Lam M, Brasel KJ. Preinjury beta blockers are associated with increased mortality in geriatric trauma patients. J Trauma. 2008;65:1016–20.

    Article  CAS  PubMed  Google Scholar 

  • Ohm C, et al. Effects of antiplatelet agents on outcomes for elderly patients with traumatic intracranial hemorrhage. J Trauma. 2005;58:518–22.

    Article  CAS  PubMed  Google Scholar 

  • Ott MM, Eriksson E, Vanderkolk W, Christianson D, Davis A, Scholten D. Antiplatelet and anticoagulation therapies do not increase mortality in the absence of traumatic brain injury. J Trauma. 2010;68:560–3.

    Article  CAS  PubMed  Google Scholar 

  • Pandharipande P, Cotton BA, Sintani A, et al. Motoric subtypes of delirium in mechanically ventilated surgical and trauma intensive care unit patients. Intensive Care Med. 2007;33:1726–31.

    Article  PubMed  Google Scholar 

  • Pergolizzi J, Böger RH, Budd K, et al. Opioids and the management of chronic severe pain the elderly: consensus statement of an international expert panel with focus on the six clinically most often used World Health Organization step III opioids (buprenorphine, fentanyl, hydromorphone, methadone, morphine, oxycodone). Pain Pract. 2008;4:287–313.

    Article  Google Scholar 

  • Pieracci FM, Eachampati SR, Shou J, Hydo LJ, Barie PS. Use of long-term anticoagulation is associated with traumatic intracranial hemorrhage and subsequent mortality in elderly patients hospitalized after falls: analysis of the New York State Administrative Database. J Trauma. 2007a;63:519–24.

    Article  CAS  PubMed  Google Scholar 

  • Pieracci FM, Eachampati SR, Shou J, Hydo LJ, Barie PS. Degree of anticoagulation, but not warfarin use itself, predicts adverse outcomes after traumatic brain injury in elderly trauma patients. J Trauma. 2007b;63:525–30.

    Article  CAS  PubMed  Google Scholar 

  • Pisani MA, McNicoll L, Inouye SK. Cognitive impairment in the intensive care unit. Clin Chest Med. 2003;24:727–37.

    Article  PubMed  Google Scholar 

  • Poldermans D, Boersma E. Beta-blocker therapy in noncardiac surgery. N Engl J Med. 2005;353:412–4.

    Article  CAS  PubMed  Google Scholar 

  • Roache V. Etiology and management of delirium. Am J Med Sci. 2003;325:20–30.

    Article  Google Scholar 

  • Robinson BRH, Mueller EW, Henson K, Branson RD, Barsoum S, Tsuei BJ. An analgesia-delirium-sedation protocol for critically ill trauma patients reduces ventilator days and hospital length of stay. J Trauma. 2008;65:517–36.

    Article  CAS  PubMed  Google Scholar 

  • Sarode R, Matevosyan K, Bhagat R, Rutherford C, Madden C, Beshay JE. Rapid warfarin reversal: a 3-factor prothrombin complex concentrate and recombinant factor VIIa cocktail for intracerebral hemorrhage. J Neurosurg. 2012;116(3):491–7.

    Article  CAS  PubMed  Google Scholar 

  • Sivamini RK, Pullar CE, Manabat-Hidalgo CG, et al. Stress-mediated increases in systemic and local epinephrine impair skin wound healing: potential new indication for beta blockers. PLoS Med. 2009;6:e12.

    Article  Google Scholar 

  • Smith SC, Blair SN, Bonow RO, et al. AHA/ACC Scientific Statement: AHA/ACC guidelines for prevention heart attack and death in patients with atherosclerotic cardiovascular disease: 2001 update. A statement for healthcare professional from the American Heart Association and the American College of Cardiology. Circulation. 2001;104:1577–9.

    Article  PubMed  Google Scholar 

  • Spektor S, Agus S, Merkin V, Constantini S. Low-dose aspirin prophylaxis and risk of intracranial hemorrhage in patients older than 60 years of age with mild or moderate head injury: a prospective study. J Neurosurg. 2003;99:661–5.

    Article  PubMed  Google Scholar 

  • van Aart L, Eijkhout HW, Kamphuis JS, et al. Individualized dosing regimen for prothrombin complex concentrate more effective than standard treatment in the reversal of oral anticoagulant therapy: an open, prospective randomized controlled trial. Thromb Res. 2006;118:313–20.

    Article  PubMed  Google Scholar 

  • Watanabe M, Siddiqui FM, Qureshi AI. Incidence and management of ischemic stroke and intracerebral hemorrhage in patients on dabigatran etexilate treatment. Neurocrit Care. 2012;16:203–9.

    Article  PubMed  Google Scholar 

  • Zhou W, Schwarting S, Illanes S, et al. Hemostatic therapy in experimental intracerebral hemorrhage associated with the direct thrombin inhibitor dabigatran. Stroke. 2011;42:3594–9.

    Article  PubMed  Google Scholar 

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Correspondence to Wendy L. Wahl MD .

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Wahl, W.L., Miller, J.T. (2014). Pharmacology. In: Yelon, J., Luchette, F. (eds) Geriatric Trauma and Critical Care. Springer, New York, NY. https://doi.org/10.1007/978-1-4614-8501-8_34

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  • DOI: https://doi.org/10.1007/978-1-4614-8501-8_34

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