A case control study for major trauma in geriatric patients

Development of statewide geriatric patients trauma triage criteria

INTRODUCTION

The geriatric population is unique in the type of traumatic injuries sustained, physiological responses to those injuries, and an overall higher mortality when compared to younger adults. No published, evidence-based, geriatric-specific field destination criteria exist as part of a statewide trauma system. The Trauma Committee of the Ohio Emergency Medical Services (EMS) Board sought to develop specific criteria for geriatric trauma victims.

METHODS

A literature search was conducted for all relevant literature to determine potential, geriatric-specific, field-destination criteria. Data from the Ohio Trauma Registry were used to compare elderly patients, defined as age >70 years, to all patients between the ages of 16 to 69 years with regards to mortality risk in the following areas: (1) Glasgow Coma Scale (GCS) score; (2) systolic blood pressure (SBP); (3) falls associated with head, chest, abdominal or spinal injury; (4) mechanism of injury; (5) involvement of more than one body system as defined in the Barell matrix; and (6) co-morbidities and motor vehicle collision with one or more long bone fracture. For GCS score and SBP, those cut-off points with equal or greater risk of mortality as compared to current values were chosen as proposed triage criteria. For other measures, any criterion demonstrating a statistically significant increase in mortality risk was included in the proposed criteria.

RESULTS

The following criteria were identified as geriatric-specific criteria: (1) GCS score <14 in the presence of known or suspected traumatic brain trauma; (2) SBP <100 mmHg; (3) fall from any height with evidence of traumatic brain injury: (4) multiple body-system injuries; (5) struck by a moving vehicle; and (6) the presence of any proximal long bone fracture following motor vehicle trauma. In addition, these data suggested that elderly patients with specific co-morbidities be given strong consideration for evaluation in a trauma center.

CONCLUSIONS

The state of Ohio is the first state to develop evidence-based geriatric-specific field-destination criteria using data from its state-mandated trauma registry. Further analysis of these criteria will help determine their effects on over-triage and under-triage of geriatric victims of traumatic injuries and the impact on the overall mortality in the elderly.

Blunt thoracic injury in older adults: application of Haddon's phase-factor matrix model

Blunt thoracic injury (BTI) in older adults can lead to grave illness, permanent disability, and even death. Using Haddon's phase-factor matrix model, this article examines the phenomenon of BTI in older adults. Preventive, diagnostic, and treatment interventions are discussed from the perspective of the pre-event, event, and post-event phases. Relevant physiological and pathophysiological changes regarding senescence and injury are reviewed, as are the common mechanisms of blunt trauma and anatomic injury patterns seen in older adults. Considerations for clinical interventions and future research are also presented.

The vulnerable elders survey-13 predicts hospital complications and mortality in older adults with traumatic injury: a pilot study

OBJECTIVES

To determine whether the Vulnerable Elders Survey (VES)-13, a survey based on functional status that has been validated in uninjured older populations, will predict complications and mortality in injured older adults.

DESIGN

Prospective observational pilot study.

SETTING

Level 1 trauma center.

PARTICIPANTS

Sixty-three older adults (≥65) with a traumatic injury who survived and required inpatient care for at least 24 hours.

MEASUREMENTS

PREDICTOR

preinjury VES-13 score (0-10 points, higher=greater risk) obtained by interviewing participants or proxies.

OUTCOMES

composite outcome of one or more medical complications (e.g., aspiration pneumonia, respiratory failure) or death, discharge destination (home, nursing home, death), length of stay, hospital charges. Covariates: Charlson Comorbidity Index (CCI), Injury Severity Score (ISS), and sex.

RESULTS

Of the 63 participants, 30 (48%) were discharged to home and 28 (44%) to a nursing facility, 21 (33%) developed one or more complications, and four (6%) died. In a model that also controlled for ISS and comorbidity, each additional VES-13 point was associated with greater risk of complication or death (odds ratio=1.53 per point, 95% confidence interval=1.12-2.07).

CONCLUSION

The VES-13, in combination with injury severity, may be useful early in the hospital course to predict complications and death in older adults with traumatic injury, potentially identifying candidates who may benefit from additional inpatient geriatric services.

Should age be a factor to change from a level II to a level I trauma activation?

BACKGROUND

Elderly trauma patients have a higher incidence of medical comorbidities when compared with their younger cohorts. Currently, the minimally accepted criteria established by the Committee on Trauma for the highest level of trauma activation (Level I) does not include age as a factor. Should patients older than 60 years with multiple injuries and/or a significant mechanism of injury be considered as part of the criteria for Level I activation? Would these patients benefit from a higher level of activation?

METHODS

The National Trauma Data Bank was queried for the period of January 1, 1999, to December 31, 2008, for all trauma patients and associated injury severity score (ISS). The data abstracted were based on age and ISS.

RESULTS

The National Trauma Data Bank contained 802,211 trauma patients. Seventy-nine percent were younger than 60 years, and 21% were older than 60 years. Our analysis shows that in all levels of injury, patients older than 60 years have an increased risk for morbidity and mortality. We found a threefold increase in morbidity and a fivefold increase in mortality among the older (age >60 years) population with a minor ISS. Elderly patients with a major ISS demonstrated a twofold increase in morbidity and a fourfold increase in mortality.

CONCLUSION

Patients with an ISS between 0 and 15 are often triaged to Level II activation. Our data would suggest that patients older than 60 years should be a criterion for the highest level of trauma activation.

Diaphragmatic Injuries: What Has Changed over a 20-Year Period?

Traumatic diaphragmatic injuries are uncommon events but are associated with a high mortality. We hypothesize that injury pattern has changed over time with increasing prevalence of blunt injuries. A retrospective chart review was performed of 124 patients who sustained traumatic diaphragmatic injuries over the 20-year period between January 1,1986 and December 31, 2005. Penetrating trauma accounted for 65 per cent (80/124) of all diaphragm injuries, and blunt trauma for 35 per cent (44/124). Mean Injury Severity Scores of 19 ± 9 and 34 ± 13 were observed for the penetrating and blunt trauma groups, respectively ( P = 0.001). Blunt traumatic diaphragm injuries increased from 13 per cent in the first 10-year period to 66 per cent in the second 10-year period ( P = 0.001). The overall mortality was 9 per cent (11/124) with 10 deaths resulting from blunt trauma and one resulting from penetrating trauma ( P < 0.001). The mortality rate increased from 3 to 17 per cent over the two decades ( P = 0.007). Our data suggests that over the last 20 years, the increase in mortality associated with traumatic diaphragmatic injury is primarily related to an increase in the proportion of patients with blunt trauma as a cause of their diaphragmatic injury and associated injuries.

Identification of an age cutoff for increased mortality in patients with elderly trauma

OBJECTIVES

The chosen age cutoff for considering patients with trauma to be "elderly" has ranged from 55 to 80 years in trauma guidelines and studies. The goal of this study was to identify at what age mortality truly increases for older victims of trauma.

METHODS

We performed a cross-sectional study of the Ohio Trauma Registry, a statewide database of all injured patients who died or were admitted for more than 48 hours to both trauma and nontrauma centers. Patients 16 years or older entered into the registry between January 1, 2003, and December 31, 2006, were included. Inhospital mortality rates were obtained and stratified by 5-year age intervals and by injury severity score (ISS). Rates between age groups were compared using logistic regression to identify significant differences in mortality.

RESULTS

Included were 75 658 patients. In logistic regression, patients 70 to 74 years of age had significantly greater mortality than all younger age groups when stratified by ISS (P < or = .001-.004). When considering other 5-year age groups as referent (40-44, 45-49, 50-54, 55-59, 60-64, 65-69 years old), no other group was associated with significantly increased mortality, as compared to younger groups (P > .05 for all).

CONCLUSION

Patients 70 to 74 years of age have significantly greater mortality than all younger age groups when stratified by ISS. Age cutoffs based on younger ages are not associated with significant increases in mortality. An age of 70 years should be considered as an appropriate cutoff for considering a patient to be elderly in future studies of trauma and development of geriatric trauma triage criteria.

‘Normal’ Vital Signs Belie Occult Hypoperfusion in Geriatric Trauma Patients

Base deficit (BD) and lactic acid (LA) are accepted markers of hypoperfusion and predictors of outcome in the trauma patient and we aim to assess the value of these markers in the triage of the elderly with “normal” vital signs. Patients older than age 65 who presented between 1997 and 2004 but who did not have isolated head injuries were included. Three patient groups were established: normal, occult hypoperfusion (OH), and shock. Outcome measures included mortality, hospital length of stay, intensive care unit length of stay, and discharge disposition. One hundred six patients were included in the analysis and had similar Injury Severity Scores. Mean systolic blood pressure was similar in the normal and OH groups. Forty-two per cent of patients had abnormal BD or LA in the emergency room indicating OH. These patients were more likely to have a longer intensive care unit length of stay (8.6 days vs 3 days; P = 0.01) and were also more likely to be discharged to a nursing facility ( P = 0.03). The trend was toward increased mortality in the OH group. OH is a common finding in elderly trauma patients. Outcomes in these patients are different and more like those presenting in shock.

The impact of advanced age on trauma triage decisions and outcomes: a statewide analysis

BACKGROUND

Physiologic variables used in trauma triage criteria may be significantly affected by age, decreasing their predictive value in geriatric trauma.

METHODS

The study population was all adult patients in the Washington State Trauma Registry from 2000 to 2004. Elderly patients were defined as those aged >65 years. Multivariate analyses were conducted to evaluate the relationship between age and trauma triage decisions, need for emergent interventions, and outcomes.

RESULTS

Of 51,227 trauma admissions, 13,820 (27%) were for elderly patients. Elderly patients were significantly less likely to have trauma team activation (14% vs 29%, P <.01), despite a similar percentage of severe injuries (injury severity score > 15), and more often required urgent craniotomy (10% vs 6%, P <.01) and orthopedic procedures (67% vs 51%, P <.01). Heart rate and blood pressure were not predictive of severe injury for those aged >65 years. Undertriaged elderly patients had 4 times the mortality rate and discharge disability of younger patients (both P values <.001).

CONCLUSIONS

Elderly trauma victims are less likely to undergo rapid trauma evaluation and have significantly worse outcomes compared with younger patients. Standard physiologic triage variables may not identify severe injury in older patients.

Assessment of mortality in older trauma patients sustaining injuries from falls or motor vehicle collisions treated in regional level I trauma centers

OBJECTIVE

To compare mortality in elderly trauma patients sustaining fall or motor vehicle collision (MVC) related injuries and who are subsequently treated at regional Level I (tertiary) trauma centers.

SUMMARY BACKGROUND DATA

An increase in the mean age of the Canadian population is leading to a higher proportion of older patients injured in falls who are subsequently treated at Level 1 trauma centers in Quebec. The Level 1 centers were designed to treat younger patients injured in MVCs and violent acts. As a result, discordance may exist between the type of care supplied at these centers and the increased demand for care tailored to older trauma patients.

METHODS

A retrospective cohort study comprised of 4,717 patients over the age of 65; 606 (12.8%) injured in MVCs and 4,111 (87.2%) in falls. The mean (SD) age was 79.6 (8.0) years and 67.9% were female. The mean (SD) Injury Severity Score (ISS) was 10.8 (7.4). Data were obtained from the Quebec Trauma Registry (QTR) for patients treated at 3 Level I trauma centers in the province of Quebec, Canada. The primary outcome measure in this study was mortality.

RESULTS

Being injured in a fall was a strong predictor for mortality, with an odds ratio of 5.11 (95% C.I. = 1.84-14.17, P = 0.002). Additionally, the adjusted mortality rate was 25.3% among fall victims, versus 7.8% for MVC patients. Female gender, older age, higher ISS and an increasing number of injuries were all associated with heightened mortality. In contrast, the number of body regions injured, experiencing complications, sustaining a hip fracture, the Revised Trauma Score, the Prehospital Index and the Charlson (comorbidity) Index had no association with mortality in the Level I centers.

CONCLUSIONS

Elderly patients sustaining fall-related injuries and treated at Level I trauma centers are at risk for excess mortality when compared with those injured in MVCs. Effective and efficient methods for treating this population must be determined.

Elderly Patients with Pelvic Fracture: Interventions and Outcomes

We examined the outcome of elderly trauma patients with pelvic fractures. Patients 65 years of age and older (elderly) with pelvic fractures were retrospectively compared with patients younger than 65 years with pelvic fractures and also with elderly patients without fracture. Over the study period, 1223 patients sustained a pelvic fracture (younger than 65 years, n = 1066, 87.2%; elderly, n = 157,12.8%). These patients were also compared with 1770 elderly patients with blunt trauma without fracture. Although the pelvic fracture patients were equally matched for Injury Severity Score (21.2 ± 13.4 nonelderly vs 20.5 ± 13.6 elderly), hospital length of stay was increased in the elderly (12.5 ± 13.1 days vs 11.5 ± 14.1 days) and they had a higher mortality rate (20.4% [32 of 157] vs 8.3% 88 of 1066]). The elderly without fracture also had a higher mortality rate when compared with the younger patients (10.9% [191 of 1760]; P < 0.03). The elderly were more likely to die from multisystem organ failure (25.0% [eight of 32] vs 10.2% [nine of 88]), whereas the nonelderly group was more likely to die from exsanguination (45.5% [40 of 88] younger than 65 years vs 21.9% [seven of 32] 65 years or older; P < 0.05). Elderly patients with pelvic fracture have worse outcomes than their younger counterparts despite aggressive management at a Level I trauma center.

Severe and multiple trauma in older patients; incidence and mortality

OBJECTIVE

To examine the differences between severely injured older patients (aged over 65 years) compared with similarly injured younger adults in terms of incidence, inpatient mortality and factors predicting outcome.

METHODS

Data prospectively entered into the Trauma Audit and Research Network (TARN) database from our level I trauma unit over a 5-year period were retrospectively examined, with 3172 patients included in the final analysis.

RESULTS

Older patients accounted for 13.8% of those with severe injuries (Injury Severity Score 16 or more) and almost 2% of our trauma admissions overall. High energy injuries were responsible for the majority of these injuries though relatively minor trauma became increasingly important in older patients. Mortality rates in the older patients were more than twice those seen in the adult population (19% in the under 40's to almost 50% in the over 75's). Age, Injury Severity Score and Glasgow Coma Score continued to be predictive of mortality in older patients but other factors relevant in younger adults were not.

CONCLUSIONS

Patients in the older group without physiological derangement on admission were still at a relatively high risk of inpatient mortality. This was in contrast to the younger patients, suggesting that it might be more difficult to predict which older patients might benefit from more aggressive monitoring or treatment. Despite increased mortality in older patients, significant survival rates were achieved even in the oldest. Active treatment should not be withdrawn on the basis of age alone.

Does age matter? The relationship between age and mortality in penetrating trauma

PURPOSE

Trauma is a significant cause of mortality among elderly patients, with blunt mechanisms accounting for the majority of deaths in this population. Penetrating trauma promises to evolve as an increasingly important aetiology of mortality in the elderly; particularly as the age composition of the overall population continues to shift. Unfortunately, very little data regarding outcomes following penetrating trauma in the elderly exists. The purpose of this study was to define the relationship between age and mortality following penetrating injuries and determine if differences between outcomes of elderly patients sustaining penetrating and blunt trauma exist.

METHODS

After IRB approval, we conducted a retrospective trauma registry review at an urban Level 1 trauma centre between January 1, 1998 and December 31, 2005. Demographic, injury, and mortality data for all patients were recorded. The relationship between age and mortality for both blunt and penetrating injuries was examined by comparison of age-specific mortality and relative risk of mortality for both mechanisms at 10 year age intervals. Additionally, the relative risk and 95% confidence interval for mortality in each age group were compared.

RESULTS

There were 26,333 blunt trauma admissions and 8843 penetrating trauma admissions during the 8-year study period. The mortality following both blunt and penetrating trauma remained stable until the age of 55 and increased steadily thereafter. When differences in mortality following blunt and penetrating mechanisms were examined, the overall mortality of penetrating trauma was found to be 2.63 times that of blunt (11.0% vs. 4.2%, RR 2.63; 95% CI: 2.42, 2.85, p<0.0001). After adjustment for age and other confounding factors, the relative risk of mortality due to penetrating mechanisms was 1.65 (95% CI: 0.88, 2.89, p=0.10) that of blunt mechanism counterparts. Although statistically higher in penetrating trauma, the relative risk of mortality between penetrating and blunt trauma decreased with increasing age.

CONCLUSION

The mortality rate with respect to penetrating trauma remains relatively constant until the age of 55, increasing thereafter. When compared to blunt trauma, the relationship between age and mortality in penetrating trauma is similar except that the relative mortality in penetrating trauma is significantly higher for each age group.

Increased Fatalities and Cost of Traumatic Injuries in Elderly Pedestrians in Hawaii: A Challenge for Prevention and Outreach

This study was carried out to evaluate and quantify risk factors, mechanisms, and cost of traumatic injuries in Hawaii's elderly and to identify potential preventive strategies. A retrospective review of a prospective database of patients admitted to the only Trauma Center in the Pacific Basin, between January 2000 and December 2001, was conducted. Of 2634 trauma admissions, 11% were ≥65 years of age. Mechanisms of injury included falls, motor vehicle crashes (MVCs), pedestrians hit by automobiles, and miscellaneous causes. The incidence of elderly pedestrians hit by automobiles in Hawaii is higher than previously reported. Hospital mortality rate was highest for the pedestrian hit group, followed by falls, and then MVCs. The pedestrian hit group consumed the largest quantity of resources and MVCs the least. Given the high mortality rate and associated resource consumption in the pedestrian hit group, it would be appropriate to give priority to this group while developing preventive measures for this age group.

The Value of the Trauma Mechanism in the Triage of Severely Injured Elderly

BACKGROUND

The triage of trauma patients is currently based on the trauma mechanism. However, it is known that elderly patients can sustain severe injuries due to insignificant trauma mechanisms. As such, triage methods might be questionable.

OBJECTIVE

To evaluate whether current trauma triage criteria are appropriate in severely injured elderly patients.

METHODS

To analyze the effect of the trauma mechanism on triage and treatment, consecutive patients ≥ 55 years of age, with an injury severity score > 15, treated from 2002 to 2005 were divided into those who sustained a high-energy trauma (HET) versus a low energy trauma (LET). Pre-hospital and in-hospital data, injury characteristics, and data on mortality and disablement one year postinjury (sickness impact profile) were analyzed for HET and LET groups.

RESULTS

Age, sex and co-morbidity rate were similar in 84 HET patients and 107 LET patients. HET patients (mean ISS 28) received more sophisticated trauma care than LET patients (mean ISS 22), although mortality was similar (38 vs. 34%). Long-term disablement was also similar (median SIP scores 4 vs. 6). Severe head injuries and the Revised Trauma Score were related to mortality. Physical disablement was related to preexisting co-morbidities. No variables were related to psychosocial disablement.

CONCLUSIONS

In elderly people a low energy trauma may lead to severe consequences. Not only the trauma mechanism, but also age, co-morbidity, and the likelihood of a brain injury should be leading in the triage and subsequent management of severely injured elderly.

An Appraisal of Trauma in the Elderly

To review the trends of trauma in the elderly experienced at our trauma center compared with other Level I trauma centers. This was a retrospective trauma registry analysis (1996–2003) of 2783 blunt trauma in elderly (BTE) and 4568 adult (BTA) patients in a Level 1 trauma center. Falls and motor vehicular crashes were the most common mechanisms noted in 47 per cent and 31 per cent (84% and 13% in BTE, 25% and 42% in BTA). BTE were sicker, with higher Injury Severity Scores (ISS), lengths of stay, and mortality (5% vs 2%, P value < 0.05). ISS was 5.2-fold higher in nonsurvivors to survivors in BTA and 2.4-fold in BTE. Elevation in ISS resulted in higher linear increase in mortality in BTE ( vs BTA) at any ISS level. Mortality in patients with ISS ≥ 25 was 43.5 per cent vs 23.8 per cent. ISS ≥ 50 had 31 per cent adult survivors but no elderly survivors. Among isolated injuries, head trauma in the elderly carried the highest mortality, at 12 per cent (19% in patients with an Abbreviated Injury Score ≥3). Abdominal injuries were the most lethal (18.3% and 41.2% in patients with an Abbreviated Injury Score ≥3) in multiple trauma victims (41% vs 18% in isolated trauma). There was 4.4-fold increased mortality in the presence of thoracic trauma. Combined head, chest, and abdominal trauma carried the worst prognosis. Thirty-four per cent of BTE and 88 per cent of BTA patients were discharged home. Elderly patients need more aggressive therapy, as they are sicker with higher mortality.

Geriatric trauma: special considerations in the anesthetic management of the injured elderly patient

Modern society is characterized as having an ever enlarging population of older adults. There are more elderly patients, and the average age of this group is increasing. The anesthetic management of surgery for the elderly trauma victim is more complicated than in younger adults. Evaluation of the physiologic status of the geriatric patient should take into account the variability of the changes associated with advancing age. Care of the injured elderly patient requires thorough preoperative assessment and planning and the involvement of a multidisciplinary clinical team knowledgeable about and interested in the management of the elderly surgical patient.

Injury in the Elderly and End-of-Life Decisions

The elderly constitute the fastest growing sector of the population of the United Stated and geriatric trauma patients are presenting for care with increasing frequency. These patients are challenging particularly because of their vulnerability to severe injury, limited physiologic response to stress, and frequent presence of comorbid medical conditions complicating care. Many elderly trauma victims require prolonged intensive care and some fail to improve or succumb despite the best efforts because of the extent of their injuries and their underlying disease. These patients may present profound ethical challenges for trauma surgeons as the goals of care shift from salvage to end-of-life care.

Long-Term Survival of Medicare Patients With Head Injury

BACKGROUND

An increasing number of older patients are being hospitalized with traumatic brain injury (TBI). Knowledge of their expected long-term survival may be useful in making clinical decisions.

METHODS

Patients age 65 or older admitted for the first time with head injury (ICD-9 800-804 or 850-854) during 1999 were identified in a complete national sample of fee-for-service Medicare hospitalization and denominator data. Cases were categorized by age, sex, maximum Abbreviated Injury Score (AISmax), and Charlson comorbidity score. Survival was determined at hospital discharge, and (using the denominator file) at 1, 6, 12, and 24 months after the initial hospital admission.

RESULTS

For all cases (n = 30,684), the hospital mortality was 14.3%, but was cumulatively 19.75%, 30.5%, 36.1%, and 44.9% at successive times up to 24 months. Long-term mortality was higher with increased age, comorbidity, or AISmax, and higher in men. These effects persisted with multivariate logistic regression analysis and were used to construct a simplified prediction score for clinical use.

CONCLUSIONS

The mortality for older patients with TBI is much higher than for an uninjured control population. The relative risk for death remains elevated after hospital discharge and for at least 2 years. Awareness of the expected prognosis may help family members and health care providers make appropriate clinical decisions during acute hospitalization.

The effect of pre-existing medical conditions and age on mortality after injury

BACKGROUND

Pre-existing medical conditions (PMCs) have been shown to increase mortality after trauma even after adjustment for the effect of chronological aging. It has been suggested that there is an interaction between injury severity and physiologic reserve, such that diminished physiologic reserve will have an adverse effect on survival at lower injury severity, but that at higher levels of injury severity, physiologic reserve will have much less of an impact.

METHODS

Records of 65,743 patients, admitted after trauma, were extracted from the database of the United Kingdom Trauma Network to explore the impacts of age, gender and PMCs on mortality, and modification of these effects by severity of injury.

RESULTS

PMCs were categorized as absent (23%), present (23%), or unrecorded (54%). There was an increase in mortality with increasing age at all levels of injury severity. Presence of a PMC was associated with a marked increase in mortality of patients with minor injuries (odds ratio [OR] = 5.9, 95% confidence interval [CI] 4.4, 8.0) or moderate injuries (OR = 2.0, 95% CI 1.4, 2.9), but not in those with more severe injuries (OR = 1.1, 95% CI 0.9, 1.4). The impact of age and male gender were also somewhat more pronounced for patients with less severe injuries.

CONCLUSION

These findings support the hypothesis of an interaction between physiologic reserve and injury severity, where PMCs are associated with increased mortality when combined with low to moderate severity injuries, but not when combined with more severe injuries.

Vital Capacity as a Predictor of Outcome in Elderly Patients with Rib Fractures

BACKGROUND

This study tests the relationships between early bedside vital capacity (VC) measurement and morbidity, mortality, and resource consumption in geriatric blunt chest trauma patients with rib fractures.

METHODS

This was a retrospective study examining all patients > or = 65 years old with rib fractures who had a VC measured within 48 hours of their emergency department evaluation. Outcome variables included pulmonary complications, death from pulmonary complications, hospital length of stay (LOS), intensive care unit length of stay (ICU LOS), and discharge disposition.

RESULTS

Thirty-eight patients met the study criteria. The mean age was 80.2 (+/-7.4) years, the mean number of rib fractures was 3.6 (+/-1.6), and the mean ISS was 6.9 (+/-4.7). VC and the percentage of the predicted vital capacity (pVC) were both inversely correlated with LOS (p = 0.0076 and p = 0.0172, respectively). Linear regression analysis suggested that patients with a VC < 1.4 L or < 55% of their pVC had a LOS > 3 days. Mean VC was 36% higher in patients who were discharged home versus those discharged to an extended care facility (ECF; p = 0.025). There was a trend toward significance when comparing VC to ICU LOS (p = 0.079), but none in predicting pulmonary complications (p = 0.3299). No correlations between VC and mortality can be drawn given the single death in the cohort.

CONCLUSIONS

Bedside VC is a simple measurement which could predict LOS in elderly patients with rib fractures and may identify those patients requiring ECF upon discharge. Further prospective study may highlight the utility of emergency room VC in determining the disposition of these patients.

Trauma and falls in the elderly

The number of people living longer and staying active continues to rise, resulting in an increase in the incidence of trauma-related vis-its by older persons to emergency departments. The elderly sustain a disproportionate share of fractures and serious injury, and represent a unique subset of patients with special needs and considerations. This article reviews the current literature on the management of elderly patients with trauma, including the physiologic changes of aging relevant to the management of trauma, injury patterns unique to geriatric victims of trauma, and aspects particular to resuscitation and general management of geriatric trauma victims. We include a discussion of the evaluation and management of falls in the elderly, including assessment of fall risk.

A Simple Fall in the Elderly: Not So Simple

BACKGROUND

The goal of this study was to evaluate the burden of falls in the elderly in a Canadian tertiary trauma center.

METHODS

Patients admitted to Charles-LeMoyne Hospital with a low velocity fall (LVF) from April 1, 1993 to March 31, 2000 were individually reviewed. Elderly was defined as age 65 years and older. A region was considered to be injured if Abbreviated Injury Scale was greater than or equal to 2.

RESULTS

There were 2,333 patients with LVF, 41.4% of all blunt trauma admissions. Median Injury Severity Score was 9 for elderly compared with 5 for young (p < 0.001). Injuries were significantly more frequent to head, face, thorax, and lower limbs in the elderly. Mortality (13.4% versus 0.9%; p < 0.001), length of stay (median = 15 versus 3 days; p < 0.001) and long-term care facility reference (19.3% versus 1.1%, p < 0.001) were significantly higher in the elderly.

CONCLUSIONS

LVF is a frequent cause of admission for trauma in the elderly. Despite the apparent benign nature of the mechanism, LVF is associated with more severe injuries and worse outcome.

Road traffic injuries in the elderly

OBJECTIVE

Elderly victims of motor vehicle collisions are increasing with the aging population. This study aimed to investigate the injury pattern of elderly victims involved in motor vehicle collisions.

METHODS

This was a retrospective study using data from the Victorian State Trauma Outcome Registry and Monitoring Group (VSTORM) from June 2001 to July 2003, Australian Bureau of Statistics year 2001 population estimates, and Victoria Transport Accident Commission year 2001 total road death toll. Elderly victims were defined as age 65 and above. Comparison of fatality rates and general injury patterns for the elderly and young victims was undertaken.

RESULTS

The total fatality rate of the elderly group was almost double that of the younger group. The elderly victims had a higher rate of chest injuries (23.42% v 18.17%; p = 0.003). The three most common chest injuries of the elderly victims were rib fractures (23.58%), flail chest (9.55%), and sternum fractures (5.97%). Elderly chest injured patients also had longer intensive care unit stay compared with the younger group (7.96 days v 5.31 days; p = 0.048).

CONCLUSIONS

Elderly victims of motor vehicle collisions have a higher risk of chest injuries, especially of chest wall injuries. Age specific injury patterns are important in determining primary and secondary prevention strategies.

The current status of road user injuries among the elderly in Germany: a medical and technical accident analysis

BACKGROUND

The incidence and treatment of injuries involving the elderly road user are of increasing importance for all fields of trauma care to ensure the best possible outcomes.

METHODS

Traffic accident reports were analyzed through technical and medical investigation for the involvement of elderly citizens.

RESULTS

In 12,309 documented traffic accidents between 1985 and 1998, 1,843 elderly citizens (65 years and older) were involved, 1,260 of which were reported to have been injured. The mean Injury Severity Score among the injured elderly citizens was 7.3. Of the injured elderly road users, 39.5% were car occupants, 27.4% were bicyclists, 29.6% were pedestrians, 1.8% were truck occupants, and 1.7% were motorcyclists. Of the elderly road users in cars, 53% were not injured, in contrast to only 1.1% of the bicyclists and 0.8% of the pedestrians. Serious or severe injuries (Maximum Abbreviated Injury Scale, >/=2] occurred for 36.5% of the injured elderly road users as car occupants (unrestrained, 58%; restrained, 34%), 57.4% as bicyclists, and 65.4% as pedestrians

CONCLUSION

A high rate of motor injuries is associated with vehicle accidents and increased levels of severity among the elderly population. This finding is especially evident for elder pedestrians and bicyclists. Also of note, the elderly even appear to be at risk for sustaining an increased level of injury severity when they are restrained or belt protected.

Trauma in Nonagenarians and Centenarians: Review of 137 Consecutive Patients

The purpose of this study was to examine the hospital course and outcomes of elderly trauma patients. We accomplished a retrospective review of all consecutive trauma patients admitted to a level II trauma center from January 2000 to April 2002. Gender, Injury Severity Score (ISS), length of stay (LOS), operative procedure, morbidity, and mortality of patients ≥90 years of age were compared with younger patients. Of 2645 trauma admissions, 137 patients (5%) were ≥90 years (range, 90 to 108 years; mean, 93.1 years); 5 patients were ≥100 years. One hundred eleven (81%) patients were female; 26 (19%) male. Average ISS for patients ≥90 was 8.75 and was 7.78 for younger patients. One hundred sixteen elderly patients (85%) had ISS < 15. Falls were the most common mechanism of injury (93%), usually ground-level falls (64%). Two hundred ninety-two injuries included 133 fractures and 102 soft tissue injuries. Thirty-four elderly patients (25%) and 733 younger patients (29%) required surgery. Complications developed in 8 per cent of older and 6 per cent of younger patients. Hospital LOS averaged 4.36 days for older and 3.51 days for younger patients. Six older (4.4%) and 63 younger (2.5%) patients died. ISS scores and LOS were slightly higher in elderly patients, but morbidity and mortality were comparable in both groups.

Preexisting conditions and mortality in older trauma patients

BACKGROUND

Among older trauma patients, those with preexisting chronic medical conditions (CMCs) appear to have an elevated risk of death. Whether this association is dependent on the severity of injury or other occult factors remains unanswered. This study evaluated the association between preexisting CMCs and risk of death among older trauma patients according to injury severity.

METHODS

This was a retrospective cohort study using data from the National Trauma Data Bank, a registry of trauma patients admitted to 131 trauma centers across the United States. The main outcome measure was in-hospital mortality.

RESULTS

In patients 50 to 64 years of age who sustain severe (Injury Severity Score [ISS] of 26+) and moderate injuries (ISS of 16-25), the presence of one or more CMCs is not associated with an increased relative risk (RR) of death (RR, 0.80 and 95% confidence interval [CI], 0.71-0.90; RR, 1.09 and 95% CI, 0.95-1.24, respectively). Those with minor injuries (ISS < 16) have increased risk of death (RR, 2.80; 95% CI, 2.33-3.36). For those patients 65 years of age and older who sustain severe, moderate, and minor injuries, the pattern of results is similar (RR, 0.91 and 95% CI, 0.83-1.00; RR, 1.13 and 95% CI, 1.04-1.23; and RR, 1.88 and 95% CI, 1.73-2.05, respectively).

CONCLUSION

Older trauma patients with CMCs who present with minor injuries should be considered to have an increased risk of death when compared with their nonchronically ill counterparts.

Elderly Trauma Inpatients in New York State: 1994???1998

BACKGROUND

The aging of the population in the United States has led to an increase in geriatric trauma. This study aimed to examine the characteristics and outcomes of geriatric trauma patients in New York State.

METHODS

Four groups of elderly trauma patients (ages 40-64, 65-74, 75-84, and 85+ years) were contrasted with younger adults ages 13 to 39 years with respect to mechanism of injury, discharge disposition, hospital length of stay, comorbidities, and type of hospital in which they were treated. Also, the independent association of each group with in-hospital mortality was investigated for patients with blunt injuries using logistic regression.

RESULTS

There was a 17.6% increase between 1994 and 1998 in the number of traumatic injuries qualifying for the New York State Trauma Registry in the 75- to 84-year-old group and a 16.4% increase in the group ages 85 years or older, despite a decrease in traumatic injuries in other age groups. The majority of these injuries among the patients 75 years of age or older resulted from low falls (from the same level). The mortality rate rose substantially with age, from 5.1% to 5.9% to 9.4% to 12.3% to 15.8%, respectively, for the groups ages 13 to 39, 40 to 64, 65 to 74, 75 to 84, and 85 or more years. Also, fewer than 20% of the patients older than 75 years died within 1 day after admission to the hospital, as compared with 44% of the patients younger than 65 years. The groups ages 40 to 64, 65 to 74, 75 to 84, and 85 years or older were all independent (increasingly) significant predictors of mortality for all three mechanisms of injury investigated. The adjusted odds ratios for mortality relative to patients who were 13 to 39 years of age were 2.67, 8.41, 17.40, and 34.98, respectively, for the groups ages 40 to 64, 65 to 74, 75 to 84, and 85 years or older.

CONCLUSIONS

Trauma is a serious and escalating problem for the elderly, and increasing age is a significant risk factor for patient mortality.

Skeletal injury patterns in older females

Injury patterns in elderly patients are different from those in younger patients. With recent emphasis on osteoporosis and its effects, we looked at a continuous series of patients from one Level 1 trauma center regarding injury patterns by gender. For all patients older than 65 years, and including all mechanisms, older women were more likely to sustain forearm and wrist fractures than were older men. For the individual mechanism of motor vehicle collision there was a significant increase in the extremity Abbreviated Injury Scores in older women compared with older men. Similarly, older women were more likely to sustain lower leg fractures and distal upper extremity fractures than were older men. This raises the possibility that increased bone loss, as seen in older women, may be reflected in the injury patterns they sustained given the same mechanism. More work is warranted in this region to potentially diminish these effects.

Mortality risk after head injury increases at 30 years

BACKGROUND

Age has long been recognized as a critical factor in predicting outcomes after head injury, with individuals older than 60 years predicted to have a worse outcome than those younger than 60. The object of this study was to determine the effect of age by decade of life beginning at birth in patients with head injuries of all levels of severity.

STUDY DESIGN

The New York State Trauma Registry was searched for head injuries from January 1, 1994 to December 31, 1995; the 13,908 cases found were placed into age groups by decade. Data were sought for each patient on demographics, Glasgow Coma Score, ICD-9 injury code, New Injury Severity Score (NISS), and mechanism of injury. These data were analyzed with chi-square and one-way ANOVA tests, with significance set at p < 0.05.

RESULTS

The risk of dying was significantly increased in patients beginning at 30 years of age compared with those in the younger age groups, with the greatest increases occurring after age 60 (p < 0.001). For the population with available Glasgow Coma Score data (n = 12,844), the mortality rate for patients ages 0 to 30 was 10.9%, and for patients ages 31 to 50 was 12.4%. The mean Glasgow Coma Score for nonsurvivors ages 0 to 20 (3.9) and for nonsurvivors ages 31 to 50 (5.1) were significantly different, with a risk ratio of 1.3 (p < 0.001).

CONCLUSIONS

The risk of dying for patients suffering head injuries increases as early as 30 years of age, making it necessary for health-care providers to consider increased monitoring and treatment for patients in this younger age group.

Fall-related injuries in the elderly in Tehran

During 13 months of data gathering, all injury-related information concerning trauma patients was gathered according to International Classification of Diseases, 10th revision (ICD-10). The severity of the injury was calculated according to Abbreviated Injury Scale (AIS-90) in six major university hospitals in Tehran. Twelve percent of 8000 hospitalised trauma patients were elderly (65 years or older) and 70% of them (675 patients) had suffered from fall-related injuries. Falling on the ground and falling on stairs were the most common kinds of injury (with 462 (68%) and 122 (18%) cases, respectively). In the home and on the street were the most common sites of fall occurrence (with 520 cases (77%) and 91 cases (13.5%), respectively). After adjustment for the gender, kind of fall and Injury Severity Score, it was shown that the elderly were more prone to death than their younger counterparts (odds ratio=5.8, 95% CI for odds ratio: 2.3-7.2), but there was no significant difference in mortality rate between elderly men and women. Further studies are needed to evaluate personal and environmental risk factors for falls in our population. Furthermore, significantly higher mortality rate in our elderly trauma victims necessitates prudent attention to elderly trauma care in our teaching hospitals.

Functional outcomes in octogenarian trauma

BACKGROUND

Outcome data on geriatric trauma patients (GTPs) (age >or= 65) focus on mortality and resource use. We examined mortality and outcome in GTPs and octogenarian trauma patients (OTPs) (age >or= 80). We hypothesized that OTPs would have worse functional outcomes than GTPs as defined by functional independence measurement (FIM) scales.

METHODS

Our study was a 13-year retrospective analysis of a statewide trauma database. Isolated hip fractures and intubation with Glasgow Coma Scale scores of 3 at admission were excluded. Demographic data, preexisting conditions, complications, discharge destination, mortality, and FIM were analyzed.

RESULTS

OTPs constituted 17742 (40.9%) of 43297 GTPs admitted to trauma centers. Falls (64.4%) and motor vehicle collisions (24.5%) were predominant. Average Injury Severity Score (ISS) was higher in GTPs (11.5 +/- 9.2 vs. 10.8 +/- 8.3, p = 0.001). Cardiac disease was the most common preexisting condition. Diabetes, obesity, and pulmonary disease were more common in GTPs than in OTPs (p = 0.001). Dementia, congestive heart failure, and hematologic disease were more common in OTPs than in GTPs (p = 0.001). Pulmonary and infectious complications were most common and occurred with equal frequency in OTPs and GTPs. Mortality rates were higher (10.0% vs. 6.6%, p = 0.001) for OTPs overall and when stratified into low (<10), moderate (11-20), and high (>20) ISS subgroups (p = 0.001). Discharge destination was most often home (53.3% vs. 28.8%, p = 0.001) or a rehabilitation facility (20.0% vs. 17.4%, p = 0.001) for GTPs versus OTPs. OTPs were discharged to skilled nursing facilities (37.2% vs. 14.9%, p = 0.001) far more often than GTPs. FIM at discharge was lower in all categories for OTPs. Modified dependence in locomotion and transfer was seen for OTPs but not GTPs overall and when stratified by ISS subgroups (p = 0.001). Some dependence in feeding was seen for OTPs but not GTPs with high injury severity (p = 0.001). Otherwise, feeding, expression, and social independence were preserved for both OTPs and GTPs.

CONCLUSION

Functional outcomes after blunt trauma are worse for OTPs; however, functional independence in feeding and social interaction are preserved in OTPs even with moderate injury severity.

Long-term outcomes after injury in the elderly

BACKGROUND

The lasting impact of injury on lifestyle in the elderly remains poorly defined. The purpose of this study was to determine the long-term quality-of-life outcomes in elderly trauma patients.

METHODS

The trauma registry at a regional trauma center was used to identify hospital survivors of injury > or = 65 years old discharged from April 1996 to March 1999. The 36-Item Short Form (SF-36) Health Survey was administered to this group by telephone interview and the scores compared with age-adjusted Canadian norms. Comparisons with test were made for continuous data.

RESULTS

Complete data collection was achieved in 128 of 171 (75%) study patients. The mean Injury Severity Score was 21, the mean initial Glasgow Coma Scale score was 13, and the mean age was 74. Most (97%) were victims of blunt trauma. Compared with Canadian age-adjusted norms, there was a significant (p < 0.05) decrease in seven of eight SF-36 domains: Physical Functioning, Role-Physical and Role-Emotional (limitations secondary to physical and emotional health), Social Functioning, Mental Health, Vitality, and General Health. Before injury, most (98%) were living independently at home. However, at long-term follow-up (mean, 2.8 years; range, 1.5-4.5 years), only 63% were living independently and 20% still required home care.

CONCLUSION

Although the majority of elderly injury survivors achieve independent living, long-term follow-up indicates significant residual disability in quality of life as measured by the SF-36.

Effect of patients' age on management of acute intracranial haematoma: prospective national study

OBJECTIVE

To determine whether the management of head injuries differs between patients aged > or =65 years and those <65.

DESIGN

Prospective observational national study over four years.

SETTING

25 Scottish hospitals that admit trauma patients.

PARTICIPANTS

527 trauma patients with extradural or acute subdural haematomas.

MAIN OUTCOME MEASURES

Time to cranial computed tomography in the first hospital attended, rates of transfer to neurosurgical care, rates of neurosurgical intervention, length of time to operation, and mortality in inpatients in the three months after admission.

RESULTS

Patients aged > or =65 years had lower survival rates than patients <65 years. Rates were 15/18 (83%) v 165/167 (99%) for extradural haematoma (P=0.007) and 61/93 (66%) v 229/249 (92%) for acute subdural haematoma (P<0.001). Older patients were less likely to be transferred to specialist neurosurgical care (10 (56%) v 142 (85%) for extradural haematoma (P=0.005) and 56 (60%) v 192 (77%) for subdural haematoma (P=0.004)). There was no significant difference between age groups in the incidence of neurosurgical interventions in patients who were transferred. Logistic regression analysis showed that age had a significant independent effect on transfer and on survival. Older patients had higher rates of coexisting medical conditions than younger patients, but when severity of injury, initial physiological status at presentation, or previous health were controlled for in a log linear analysis, transfer rates were still lower in older patients than in younger patients (P<0.001).

CONCLUSIONS

Compared with those aged under 65 years, people aged 65 and over have a worse prognosis after head injury complicated by intracranial haematoma. The decision to transfer such patients to neurosurgical care seems to be biased against older patients.

Oxygen transport and organ dysfunction in the older trauma patient

OBJECTIVES

To determine baseline values of cardiac index (CI) and oxygen transport variables in patients with multiple trauma within 24 hours of admission to a level I trauma center.

METHOD

This project was part of a larger study comparing methods of measuring oxygen consumption (VO2) in 38 severely injured patients. Measurements of CI, oxygen delivery (DO2), and VO2 were performed every 6 hours for 24 hours. Patients were monitored for multiple organ dysfunction syndrome.

RESULTS

The mean age was 59 (+/- 17) years, with 74% (n = 28) of patients 50 years or older. Patients 65 years or older had significantly lower levels of CI, DO2, and VO2. Initial age-related differences in CI (P < .001) persisted at each time period (P < .0136). Younger patients generated a higher DO2 at each time period (P < .0005). Even though there were persistent age-related differences in VO2 over time (P < .0001), no interaction between age and time was found. Survivors had lower scores for multiple organ dysfunction syndrome than did nonsurvivors (P < .0001), all of whom were 50 years or older. Mortality was 21%.

CONCLUSIONS

All patients were hypermetabolic, but older patients were much less so. Younger patients progressively had increased CI and DO2 levels, whereas older patients started with low levels that remained so. Patients in each age group appeared to lock into a level of VO2 that did not change over time. These findings underscore the vulnerability of older patients to poor outcomes. As the magnitude of the postinjury response is partly age-dependent, future research should differentiate patient characteristics associated with positive outcomes among elderly trauma patients.

Isolated traumatic brain injury: age is an independent predictor of mortality and early outcome

BACKGROUND

Geriatric trauma patients have a worse outcome than the young with comparable injuries. The contribution of traumatic brain injury (TBI) to this increased mortality is unknown and has been confounded by the presence of other injuries. The purpose of this study was to investigate the role of age in the mortality and early outcome from isolated TBI.

METHODS

This was a retrospective analysis of all adult patients with isolated TBI (Abbreviated Injury Scale score > or = 3) admitted during a 5-year period to two Level I trauma centers. Mortality, Glasgow Outcome Scale score at discharge, therapy, and complications were compared for elderly (age > or = 65 years) and younger patients.

RESULTS

Of 694 patients, 22% were defined as elderly. The mortality for the elderly group was twice that of their younger counterparts (30% vs. 14%, p < 0.001), even for those with mild to moderate TBI (Glasgow Coma Scale score of 9-15). Thirteen percent of elderly survivors had a poor functional outcome (Glasgow Outcome Scale score of 2 or 3) at hospital discharge versus 5% in the young group (p < 0.01). Independent factors associated with a high mortality were age and Glasgow Coma Scale score.

CONCLUSION

The mortality from TBI is higher in the geriatric population at all levels of head injury. In addition, functional outcome at hospital discharge is worse. Although some of this increased mortality may be explained by complications or type of head injury, age itself is an independent predictor for mortality in TBI.

Trauma in the very elderly: a community-based study of outcomes at trauma and nontrauma centers

BACKGROUND

Little research has examined trauma outcomes in the very elderly (>80 years), the fastest growing subset of our geriatric population. Our objective was to describe demographics, mechanism of injury and injury severity of very elderly trauma patients and examine the association between trauma center (TC) verification and hospital mortality in this age group.

METHODS

Retrospective cohort study. Database consisted of a 1996 countywide trauma registry. Subjects consisted of patients > 80 years of age. The setting consisted of Level I (TCI) and Level II (TCII) trauma centers, and acute care (AC) hospitals. The z score analysis was performed using the Major Trauma Outcome Study and a county-specific risk/outcome equation. In addition, a logistic regression model examined hospital mortality (outcome variable) using age, ISS, arrival GCS, and TC verification as predictor variables. Statistical analysis included descriptive statistics; ANOVA; and forward stepwise logistic regression model (OR; 95% CI).

RESULTS

Four hundred fifty-five patients with a mean age of 85.9 (+/-4.8) years (range 80-101). Overall mortality was 9.9%. Using z score analysis, survival at TCII performed as predicted (-1.59), while AC performed less than predicted (-3.41). In the regression model, GCS (OR 0.68; CI 0.57-0.79), ISS (OR 1.1; CI 1.05-1.2) and AC setting (OR 3.2; CI 1.1-9.5) predicted hospital mortality. TCs had significantly better outcomes than AC hospitals in a subset of severely injured patients (ISS 21-45) (56% v 8% survival; p < 0.01).

CONCLUSION

Risk-adjusted outcomes, in this population, differed between TC and AC settings. Head injury, injury severity, and lack of TC verification are associated with hospital mortality in very elderly trauma patients.