Trauma in the older adult: epidemiology and evolving geriatric trauma principles

Geriatric chest wall injury: is it time for a new sense of urgency?

Geriatric trauma has become an increasingly recognized management concern for trauma centers, and hospitals alike, on a national scale. The population of the United States is aging, as life expectancy rates have demonstrated a steady climb to an average of 78.8 years of expected life. With pervasive efforts of medical screening, prevention and chronic medical condition management, more elderly people will lead more active lifestyles and will be more predisposed to injury. As best practice guidelines specific for the geriatric trauma population have yet to be developed, many researchers have identified management strategies that have offset complications and mortality rates inherent to this patient population after injury. The impact of rib fractures in the 65-year and older patient population has been well documented, as have the mortality and pneumonia rates yet, historically, little attention has been directed to curtailing these adverse outcomes with more advanced treatment options. With the advent of rib plating for rib fracture fixation and chest wall stabilization, the practice paradigm for rib fracture management is shifting, as a viable operative intervention now exists. In this review, we focus on the characteristics of the geriatric trauma patient, areas of management where improvement opportunities have been identified, chest wall injury in the elderly patient, rib plating as a treatment option and offer our data to facilitate a better understanding of rib plating's impact in the geriatric trauma patient.

Impact of Type and Number of Complications on Mortality in Admitted Elderly Blunt Trauma Patients

BACKGROUND

Advanced age and comorbidities are recognized risk factors for adverse outcomes in elderly trauma patients. However, the contribution of the number and type of complications to in-hospital mortality in elderly blunt trauma admissions has not been extensively studied.

METHODS

A retrospective review of the trauma registry at a level 1 trauma center for blunt trauma patients age ≥65 y hospitalized for at least 2 d between 2010 and 2015.

RESULTS

There were 2467 admissions, with a median age of 81 y and median injury severity score of 9. The most common mechanism of injury was a low-level fall. Approximately 19.6% of admissions had a complication: 11.1% major complications, 8.6% other complications. The in-hospital mortality rate was significantly different (P < 0.001) among the three groups at 16.1% of major complications group, 7.1% of other, and 2.1% of no complications (P < 0.001). On multivariate logistic regression, each major complication increased the odds for in-hospital mortality by 1.59-fold.

CONCLUSIONS

Complications are not infrequent in elderly blunt trauma admissions, despite a generally lower energy mechanism of injury. Each major complication is associated with increased odds of mortality. Multifaceted interventions for prevention and mitigation of complications are indicated.

Motorized scooter injuries in the era of scooter-shares: A review of the national electronic surveillance system

INTRODUCTION

There has been a spike in recent news regarding motorized scooter injuries due to the expansion of scooter sharing companies. Given the paucity of literature on this topic, the purpose of our study was to describe and quantify emergency department encounters associated with motorized scooter related injuries.

METHODS

The National Electronic Injury Surveillance System (NEISS) was queried for motorized scooter related injuries from 2013 to 2017. Patient demographics, diagnosis, injury location, narrative description of incident, and disposition data were collected from emergency department encounters.

RESULTS

There were an estimated 32,400 motorized scooter injuries from 2013 to 2017. The estimated incidence did not change significantly over time with 1.9 cases per 100,000 in 2013 and 2.6 cases per 100,000 in 2017. A 77.0% increase in scooter injuries was noted for millennials from 2016 to 2017. Head injuries were the most common body area injured (27.6%). Fractures or dislocations (25.9%) were the most common diagnosis. The most common site of fracture was the wrist and lower arm (35.4%). There were no deaths. Major orthopaedic injury and concussion were the strongest independent predictors of hospital admission.

CONCLUSIONS

Head injuries were the most commonly injured body part, while fractures or dislocations were the most common diagnosis. These results highlight the importance of using protective equipment while riding motorized scooters, and lay a foundation for future policies requiring helmet use.

Defining the representativeness heuristic in trauma triage: A retrospective observational cohort study

BACKGROUND

Under-triage of severely injured patients presenting to non-trauma centers (failure to transfer to a trauma center) remains problematic despite quality improvement efforts. Insights from the behavioral science literature suggest that physician heuristics (intuitive judgments), and in particular the representativeness heuristic (pattern recognition), may contribute to under-triage. However, little is known about how the representativeness heuristic is instantiated in practice.

METHODS

A multi-disciplinary group of experts identified candidate characteristics of "representative" severe trauma cases (e.g., hypotension). We then reviewed the charts of patients with moderate-to-severe injuries who presented to nine non-trauma centers in western Pennsylvania from 2010-2014 to assess the association between the presence of those characteristics and triage decisions. We tested bivariate associations using χ2 and Fisher's Exact method and multivariate associations using random effects logistic regression.

RESULTS

We identified 235,605 injured patients with 3,199 patients (1%) having moderate-to-severe injuries. Patients had a median age of 78 years (SD 20.1) and mean Injury Severity Score of 10.9 (SD 3.3). Only 759 of these patients (24%) were transferred to a trauma center as recommended by the American College of Surgeons clinical practice guidelines. Representative characteristics occurred in 704 patients (22%). The adjusted odds of transfer were higher in the presence of representative characteristics compared to when they were absent (aOR 1.7, 95% CI: 1.4-2.0, p < 0.001).

CONCLUSIONS

Most moderate-to-severely injured patients present without the characteristics representative of severe trauma. Presence of these characteristics is associated with appropriate transfer, suggesting that modifying physicians' heuristics in trauma may improve triage patterns.

The Impact of Obesity on Outcomes in Geriatric Blunt Trauma

Blunt trauma is poorly tolerated in the elderly, and the degree to which obesity, a known risk factor for suboptimal outcomes in trauma affects this population remains to be determined. The incidence, prevalence, and mortality rates of blunt trauma by demographics, year, and geography were found using datasets from both the Global Burden of Disease database, and a Regional Level II trauma registry. Global Burden of Disease data were extracted from 284 country-year and 976 subnational-year combinations from 27 countries for the period 1990 to 2015. The regional trauma registry was interrogated for patients ≥70 years admitted with blunt trauma between 2014 and 2016. The incidence of elderly blunt trauma from falls increased at a global, national (United States), and state (WV) level from 1990 to 2015 by 78.3 per cent, 54.7 per cent, and 42.7 per cent, respectively with concomitant increases in mortality rates of 5.7 per cent, 102.6 per cent, and 89.3 per cent (P < 0.05). The regional cohort had a statistically similar mortality (obese, n = 320 vs nonobese, n = 926 of 4.8% vs 4.4%, respectively, P > 0.05). The hospital length-of-stay, Glasgow Coma Scale score, and systolic blood pressure on presentation were similar (P > 0.05) as was the Injury Severity Score. Major medical comorbidities were identified in 280 (87.5%) and 783 (84.6%) patients in the obese and nonobese groups, respectively. Blunt trauma, secondary to falls, has increased in elderly patients at a global, national, and state level with a concomitant increase in mortality rates. Although a similar increase in the incidence of blunt trauma in the elderly was noted at a regional center, its mortality has not been increased by obesity, possibly because of similar comorbidity rates.

Efficacy of the Treatment of Elderly Trauma Patients Requiring Intensive Care

Purpose

To evaluate the effectiveness of intensive care for the elderly trauma patients aged 80 years and older.

Methods

Trauma patients admitted to the intensive care unit (ICU) through the emergency room (ER) at our hospital between January 2013 and December 2016 were analyzed. Patients were divided into two groups: patients aged 80 and older (group E) and <80 years old (group Y). Clinical courses and the total treatment costs were compared between the two groups. Data are shown as median (interquartile range).

Results

A hundred and seven trauma patients were included in the study. There were 26 patients in group E and 81 patients in group Y. There was no significant difference in Injury Severity Score (ISS) (group E, 19 (13, 32); group Y, 17 (14, 25); p=0.708); however, the probability of survival (Ps) was significantly lower in group E (group E, 0.895 (0.757, 0.950); group Y, 0.955 (0.878, 0.986); p=0.004). The duration of ICU stay (days) was significantly longer in group E (10 (5, 23)) than in group Y (4 (3, 9); p=0.001), and the total hospital stay (days) was longer in group E (33 (13, 57)) than in group Y (22 (12, 42); p=0.179). The hospital mortality was higher in group E (11.5%) than in group Y (6.2%) without a significant difference (p=0.365). The total treatment costs were significantly higher in group E ($23,558 (12,456, 42,790) with $1 = ¥110.57) than in group Y ($16,538 (7,412, 25,422); p=0.023).

Conclusions

Elderly trauma patients require longer-term treatment including ICU stay and greater cost with higher hospital mortality compared with young trauma patients.

The Effect of Increasing Age on Outcomes of Digital Revascularization or Replantation

BACKGROUND

The aim of this study was to evaluate the impact of increasing age on rates of digital failure.

METHOD

A retrospective cohort study of digital replantation or revascularization patients was undertaken from 2005 to 2016. Data collected consisted of patient demographics, smoking status, injury mechanisms, procedure types, and postoperative morbidity and mortality. Descriptive statistics and logistic regression were performed to assess outcomes. All comparisons were made between patients older than and younger than 60 years.

RESULTS

Two hundred eighty-three patients underwent replantation or revascularization; 11 percent were older than 60 years. The majority of patients had multiple devascularized digits (70 percent), most commonly inflicted by a blade mechanism (77 percent). Approximately half of the patients underwent revascularization alone (54.4 percent). American Society of Anesthesiologists score and number of comorbidities were significantly greater in the older adult group. Overall, 88 patients (31 percent) experienced digital replantation or revascularization failure, with 12 failures in patients aged 60 years or older. Multivariate logistic regression demonstrated that age did not have an impact on failure rate. Older patients did not experience more major complications, but had significantly higher rates of minor complications (p = 0.0485).

CONCLUSIONS

Older patients presented with significantly higher American Society of Anesthesiologists physical status and number of comorbidities, but did not experience higher rates of digital failure, major perioperative complications, or 30-day mortality. Adults aged 60 years or older should be offered digital replantation or revascularization if medically or surgically indicated.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Investigation of risk factors of geriatric patients with significant brain injury from ground-level fall: A retrospective cohort study in a local Accident and Emergency Department setting

Background:

Trauma was the fifth leading cause of death in Hong Kong in 2013.4 Injuries caused by falls ranked first in traumatic brain injury (TBI) cases among older adults (51%).5 Elderly trauma patients face an increased risk of adverse consequences6 from trauma compared with their younger counterparts, as advanced age itself is already a well-recognized risk factor for less favorable outcomes following trauma. Therefore, identifying factors associated with significant brain injury in geriatric patients in A&E triage is crucial in providing timely care to these patients.

Objectives:

To identify the risk factors for geriatric patients with significant brain injury from ground-level falls and to formulate their association of risk factors with significant brain injury as a consequence from ground-level falls.

Methods:

This was a retrospective study with data collected from the Clinical Data Analysis and Reporting System of Queen Mary Hospital from 1 January 2013 to 31 December 2015. A total of 1101 cases were identified.

Results:

There were 76% of the recruited patients with a normal computed tomography scan. However, the remaining 24% had computed tomography scans indicative of brain injury. Severe head injuries were scored 3 -8 on the Glasgow Coma Scale and moderate head injuries were scored 9 -12. Respectively, these were 20 times (p = 0.005) and 5 times (p = 0.002) more likely to have positive computed tomography findings than patients with a Glasgow Coma Scale score from 13 to 15. Patients with loss of consciousness were two times more likely to have a positive computed tomography result than those without loss of consciousness (p = 0.001). Although warfarin use is a well-established risk factor for intracranial hemorrhage after head injury, in our dataset, the result was not statistically significant. However, the use of new oral anti-coagulants was associated with positive computed tomography findings with patients taking new oral anti-coagulants 2.3 times more likely to have positive computed tomography findings compared with those with no anticoagulant use (p = 0.033).

Conclusions:

Early detection of patients with significant brain injury and aggressive management may prevent secondary injury from the complications of brain injury, hence improving patient mortality and morbidity, and reducing hospital stay and health care costs.

The impact of inpatient palliative care on end-of-life care among older trauma patients who die after hospital discharge

BACKGROUND

Palliative care (PC) is associated with lower-intensity treatment and better outcomes at the end of life. Trauma surgeons play a critical role in end-of-life (EOL) care; however, the impact of PC on health care utilization at the end of life has yet to be characterized in older trauma patients.

METHODS

This retrospective cohort study using 2006 to 2011 national Medicare claims included trauma patients 65 years or older who died within 180 days after discharge. The exposure of interest was inpatient PC during the trauma admission. A non-PC control group was developed by exact matching for age, comorbidity, admission year, injury severity, length of stay, and post-discharge survival. We used logistic regression to evaluate six EOL care outcomes: discharge to hospice, rehospitalization, skilled nursing facility or long-term acute care hospital admission, death in an institutional setting, and intensive care unit admission or receipt of life-sustaining treatments during a subsequent hospitalization.

RESULTS

Of 294,665 patients who died within 180 days after discharge, 2.1% received inpatient PC. Among 5,693 matched pairs, inpatient PC was associated with increased odds of discharge to hospice (odds ratio [OR], 3.80; 95% confidence interval [CI], 3.54-4.09) and reduced odds of rehospitalization (OR, 0.17; 95% CI, 0.15-0.20), skilled nursing facility/long-term acute care hospital admission (OR, 0.43; 95% CI, 0.39-0.47), death in an institutional setting (OR, 0.34; 95% CI, 0.30-0.39), subsequent intensive care unit admission (OR, 0.51; 95% CI, 0.36-0.72), or receiving life-sustaining treatments (OR, 0.56; 95% CI, 0.39-0.80).

CONCLUSION

Inpatient PC is associated with lower-intensity and less burdensome EOL care in the geriatric trauma population. Nonetheless, it remains underused among those who die within 6 months after discharge.

LEVEL OF EVIDENCE

Therapeutic/Care management, level III.

Modelling physical resilience in ageing mice

Geroprotectors, a class of drugs targeting multiple deficits occurring with age, necessitate the development of new animal models to test their efficacy. The COST Action MouseAGE is a European network whose aim is to reach consensus on the translational path required for geroprotectors, interventions targeting the biology of ageing. In our previous work we identified frailty and loss of resilience as a potential target for geroprotectors. Frailty is the result of an accumulation of deficits, which occurs with age and reduces the ability to respond to adverse events (physical resilience). Modelling frailty and physical resilience in mice is challenging for many reasons. There is no consensus on the precise definition of frailty and resilience in patients or on how best to measure it. This makes it difficult to evaluate available mouse models. In addition, the characterization of those models is poor. Here we review potential models of physical resilience, focusing on those where there is some evidence that the administration of acute stressors requires integrative responses involving multiple tissues and where aged mice showed a delayed recovery or a worse outcome then young mice in response to the stressor. These models include sepsis, trauma, drug- and radiation exposure, kidney and brain ischemia, exposure to noise, heat and cold shock.

Geriatric Trauma Protocol

Study design for a quality improvement project. Objective was to implement a geriatric trauma protocol (GTP) based on American College of Surgeons recommendations to improve patient outcomes. Geriatric trauma patients comprise a vulnerable and high-risk trauma population, and must be treated with specific protocols that take into account physiological, psychosocial, environmental, and pharmacological needs. A growing body of research and organizations such as the American College of Surgeons and the Eastern Association for the Surgery of Trauma recommend that a specific trauma protocol for geriatric adults must be utilized in hospitals and trauma centers. A retrospective chart review was conducted to assess geriatric patient outcomes prior to GTP implementation. Surgical residents then received training on the GTP, including performing additional diagnostics, referrals, and discussing goals of care early in treatment. The GTP was then implemented for 8 weeks and monitored to determine its effects on patient outcomes. The training for surgical residents in the GTP yielded a 9.2% increase in provider knowledge. The results of the GTP showed a reduced length of stay and increased geriatric consultations. More patients received a full evaluation by the trauma team, contributing the reduced length of stay. The use of a GTP shows promise in being able to improve patient outcomes, including morbidity and mortality. The principles of the GTP can be applied in all clinical settings, especially emergency rooms, which are on the frontlines of initial evaluations. In order to improve health care delivery to an aging population, organizations and clinicians should adopt a specialized GTP into their practices.

The Impact of Trauma Center Volume on Observed/Expected Mortality: Does Size Matter?

Relationship between trauma center patient volume (TCV) and mortality remains inconclusive. Our aim was to determine the relationship between TCVs and observed/expected (O/E) all-cause mortality. This is the first study to evaluate the relationship between trauma center (TC) volumes and O/E all-cause mortality with no exclusion. Review of prospectively collected data from 94 TCs using the National Sample Program from the National Trauma Data Bank 2013. TCs were stratified into five groups based on TCV: <701, 701 to 1200, 1201 to 1700, 1701 to 2200, and >2200 yearly patient encounters. Chi-square and coefficient of determination were used for data analysis with a statistical significance defined as P-value < 0.05. A total of 139,324 trauma patients with blunt and penetrating injuries were evaluated from the National Sample Program. Of which, 63.6 per cent were male, 70.6 per cent white, and the average age was 41 years. The data were stratified by TCV into five groups with average O/Es ranging from 0.69 to 0.86 (P > 0.05). The coefficient of determination between TCV and O/E was r = 0.14 and r2 = 0.02. When controlling for Injury Severity Score, the correlation between mechanism of injury (blunt vs penetrating) and O/E mortality was r = 20.025. The group with the lowest average volumes had statistically significantly worse outcomes than the group with next higher volumes and also worse than the group with the highest volumes (Group 5, P = 0.04). Higher TC volumes correlated with higher injury severity and lower O/E mortality.

Wiser with Age? Increased Per-Surgeon Elderly Patient Volume is Associated with Lower Postinjury Complications

We hypothesize that higher elderly patient volume per trauma surgeon is associated with fewer clinical complications. This is a retrospective cohort study which included elderly patients admitted to trauma surgery service within a five-year period, from 2009 to 2013, at two Level I trauma centers in Florida. Trauma surgeons were stratified into three groups depending on patient volume. Primary outcomes were postinjury complications and in-hospital mortality, and secondary outcomes were hospital length of stay (LOS), intensive care unit LOS, and ventilator days. A total of 2379 elderly patients were included in this study. Elderly patient volume per surgeon did not significantly differ based on years in practice after fellowship (P = 0.88). The higher volume group had lower incidence of complications (15% complication rate, P = 0.02), compared with the average and low-volume group (18.1 and 21%, respectively), and had significantly lower rates of acute respiratory failure (P = 0.04) and acute renal failure (P = 0.004). In-hospital mortality was not affected by volume. Hospital LOS was decreased in the higher volume group (mean LOS 7.4 days, P < 0.001). There appears to be a relationship between elderly patient volume and outcome, independent of surgeon years of experience.

An increasing number of hand injuries in an elderly population - a retrospective study over a 30-year period

Background

Both the number and the proportion of elderly people in the society increase. The number of elderly subjects with a disability due to a disease has decreased resulting in more active elderly. Therefore, an increase in numbers of injury in the elderly population can be expected; a hypothesis that was investigated in the present study.

Methods

Two-hundred sixteen patients with an age of > 65 years, and admitted to a hand surgery ward with a hand injury, were retrospectively collected at four different 2-years periods over a 30 years time (1980–81 to 2010–11). Information about patient gender, age at injury, injury place and mechanism (s), injured structures, duration of hospital stay, number of out patient visits and rehabilitation visits as well as social status was collected. The injuries were classified with the Modified Hand Injury Severity Score (MHISS).

Results

Most injured patients were men (72%) and the number of patients who reported to be healthy significantly decreased (67% to 18%) during the study period. The number of injuries increased over the study period (n = 24 to n = 83/2-year period). Outside home was the most common injury place and a saw or a fall was the most frequent injury mechanism. Several fingers were most often injured. The majority of the injuries were classified to be Minor or Moderate (MHISS) and a fracture was the most common injured structure.

Conclusions

We found an increased number of hand injuries over a 30-year period in combination with a decrease in patients reported health treated at a hand surgery ward. Further studies regarding hand trauma in the elderly population will be valuable for future prevention and rehabilitation of this patient group.

New Immobilization Guidelines Change EMS Critical Thinking in Older Adults With Spine Trauma

OBJECTIVE

The impact of immobilization techniques on older adult trauma patients with spinal injury has rarely been studied. Our advisory group implemented a change in the immobilization protocol used by emergency medical services (EMS) professionals across a region encompassing 9 trauma centers and 24 EMS agencies in a Rocky Mountain state using a decentralized process on July 1, 2014. We sought to determine whether implementing the protocol would alter immobilization methods and affect patient outcomes among adults ≥60 years with a cervical spine injury.

METHODS

This was a 4-year retrospective study of patients ≥60 years with a cervical spine injury (fracture or cord). Immobilization techniques used by EMS professionals, patient demographics, injury characteristics, and in-hospital outcomes were compared before (1/1/12-6/30/14) and after (7/1/14-12/31/15) implementation of the Spinal Precautions Protocol using bivariate and multivariate analyses.

RESULTS

Of 15,063 adult trauma patients admitted to nine trauma centers, 7,737 (51%) were ≥60 years. Of those, 237 patients had cervical spine injury and were included in the study; 123 (51.9%) and 114 (48.1%) were transported before and after protocol implementation, respectively. There was a significant shift in the immobilization methods used after protocol implementation, with less full immobilization (59.4% to 28.1%, p < 0.001) and an increase in the use of both a cervical collar only (8.9% to 27.2%, p < 0.001) and not using any immobilization device (15.5% to 31.6%, p = 0.003) after protocol implementation. While the proportion of patients who only received a cervical collar increased after implementing the Spinal Precautions Protocol, the overall proportion of patients who received a cervical collar alone or in combination with other immobilization techniques decreased (72.4% to 56.1%, p = 0.01). The presence of a neurological deficit (6.5% vs. 5.3, p = 0.69) was similar before and after protocol implementation; in-hospital mortality (adjusted odds ratio = 0.56, 95% confidence interval: 0.24-1.30, p = 0.18) was similar post-protocol implementation after adjusting for injury severity.

CONCLUSIONS

There were no differences in neurologic deficit or patient disposition in the older adult patient with cervical spine trauma despite changes in spinal restriction protocols and resulting differences in immobilization devices.

End-of-Life Decision-Making for Patients With Geriatric Trauma Cared for in a Trauma Intensive Care Unit

BACKGROUND

The geriatric trauma population is growing and fraught with poor physiological response to injury and high mortality rates. Our primary hypothesis analyzed how prehospital and in-hospital characteristics affect decision-making regarding continued life support (CLS) versus withdrawal of care (WOC). Our secondary hypothesis analyzed adherence to end-of-life decisions regarding code status, living wills, and advanced directives.

MATERIALS AND METHODS

We performed a retrospective review of patients with geriatric trauma at a level I and level II trauma center from January 1, 2007, to December 31, 2014. Two hundred seventy-four patients met inclusion criteria with 144 patients undergoing CLS and 130 WOC.

RESULTS

A total of 13 269 patients with geriatric trauma were analyzed. Insurance type and injury severity score (ISS) were found to be significant predictors of WOC ( P = .013/.045). Withdrawal of care patients had shorter time to palliative consultation and those with geriatrics consultation were 16.1 times more likely to undergo CLS ( P = .026). Twenty-seven (33%) patients who underwent CLS and 31 (24%) patients who underwent WOC had a living will, advanced directive, or DNR order ( P = .93).

CONCLUSIONS

Of the many hypothesized predictors of WOC, ISS was the only tangible independent predictor of WOC. We observed an apparent disconnect between the patient's wishes via living wills or advanced directives "in a terminal condition" and fulfillment during EOL decision-making that speaks to the complex nature of EOL decisions and further supports the need for a multidisciplinary approach.

End-of-Life Care in Older Patients After Serious or Severe Traumatic Brain Injury in Low-Mortality Hospitals Compared With All Other Hospitals

Importance

More than 80% of older patients die or are seriously impaired within 1 year after severe traumatic brain injury (TBI). Given their poor survival, information about end-of-life care is a relevant marker of high-value trauma care for these patients. In-hospital mortality is commonly used to measure quality of trauma care; however, it is not known what type of end-of-life care hospitals with the best survival outcomes provide to those who die.

Objective

To determine whether end-of-life care for older patients with TBI is correlated with in-hospital mortality.

Design, Setting, and Participants

A retrospective cohort study using 2005-2011 national Medicare claims from acute care hospitals was conducted. Medicare beneficiaries aged 65 years or older who were admitted with serious or severe TBI were included. Transferred patients, those treated at low-volume hospitals, and those who died on the date of admission were excluded. Low-mortality hospitals were those in the lowest quartile for in-hospital mortality using standardized mortality rates adjusting for age, sex, race/ethnicity, comorbidity, and injury severity. Patients at low-mortality hospitals were compared with patients at all other hospitals. The study was conducted from January 2005 to December 2011. Data analysis was conducted between August 2016 and February 2017.

Main Outcomes and Measures

End-of-life care outcomes for patients who died in hospital or 30 days or less after discharge included gastrostomy and tracheostomy placement during the TBI admission and enrollment in hospice.

Results

Of 363 hospitals included in the analysis, 91 (25.1%) were designated as low-mortality. The cohort included 34 691 patients (median age, 79 years; interquartile range, 72-84 years; 40.8% women). Of these patients, 55.8% of those at low-mortality hospitals and 62.5% at all other hospitals died in the hospital or 30 days or less after discharge (P < .01). Among patients who died in the hospital (n = 16 994), end-of-life care was similar at low-mortality hospitals and all other hospitals. For patients who survived the TBI admission and died 30 days or less after discharge (n = 4027), those at low-mortality hospitals underwent fewer gastrostomy (15.9% vs 24.0%; adjusted OR, 0.61; 95% CI, 0.52-0.72) or tracheostomy (18.2% vs 24.9%; adjusted OR, 0.71; 95% CI, 0.60-0.83) procedures and received more hospice care (66.3% vs 52.5%; adjusted OR, 1.72; 95% CI, 1.50-1.96).

Conclusions and Relevance

For older patients with serious or severe TBI, hospitals with the lowest in-hospital mortality perform fewer high-intensity treatments at the end of life and enroll more patients in hospice without increasing cumulative mortality 30 days or less after discharge.

Intramural oesophageal haematoma following traumatic neck injury

This case describes a previously well 90-year-old woman who presented with neck pain, swelling, dysphagia and hoarseness following a motor vehicle collision. Oesophageal oedema was visualised on CT of cervical spine and subsequent CT angiography highlighted an actively bleeding intramural oesophageal haematoma (IOH) extending from the cervical oesophagus to the carina. This rare phenomenon (IOH) has been described as a possible consequence of blunt trauma to the neck; however, we found no cases resulting from acceleration/deceleration injury. Although this was a potentially life-threatening injury, our patient made a full recovery with conservative management.

Challenges in the Management of Geriatric Trauma: A Case Report

This article describes geriatric trauma and commonly associated difficulties emphasizing both the epidemiology and assessment of geriatric trauma. There is little data guiding decisions for trauma patients 65 years or older, as there are many unique characteristics to the geriatric population, including comorbidities, medications, and the aging physiology. The geriatric population in the United States has been steadily climbing for the last 20 years and is projected to continue on this trend. Although each patient presents differently, there remains a need for the consistent utilization of standard guidelines to help dictate care for geriatric patients, particularly for patients not receiving care at a trauma center. This review uses a case study about an elderly woman with many comorbidities, followed by a comprehensive discussion of geriatric trauma and the challenges that result from a lack of guideline utilization to direct management.

Cervical Fractures: Does Injury Level Impact the Incidence of Dysphagia in Elderly Patients?

Dysphagia is common in the elderly with significant consequences such as aspiration and malnutrition. This study seeks to investigate oropharyngeal dysphagia in elderly patients with cervical fractures and determine whether the level of cervical fracture impacts the incidence of swallowing dysfunction. Records of trauma patients ≥65 admitted with cervical fractures over a 76-month period to a level 1 trauma center were reviewed. History of dysphagia, stroke, tracheostomy or spinal cord injury were excluded criteria, leaving 161 patients for analysis. Evaluation of swallowing function was performed to identify dysphagia and variables were analyzed. A total of 161 patients met inclusion criteria and 42 (26.1%) had dysphagia. Patients with dysphagia were older (84.1 ± 8.93 vs. 79.9 ± 8.48, p = 0.006), had higher hospital length of stay (9.0 ± 4.48 vs. 4.6 ± 3.30, p = <0.0001), and were more likely to have intensive care unit days (52.4% vs. 21.8%, p = 0.0002). Non-operatively-managed patients with C1 fractures were more likely to have dysphagia than patients without C1 fractures (29.2% vs. 7.1%, p = 0.0008). After regression analysis, C1 fracture increased the likelihood of dysphagia by four times (OR = 4.0; 95% CI 1.2–13.0). Oropharyngeal dysphagia is common in elderly patients with cervical fracture. Non-operatively-managed patients with C1 fractures are at increased risk and may benefit from more vigorous surveillance.

Improving geriatric trauma outcomes: A small step toward a big problem

BACKGROUND

Because of the unique physiology and comorbidities of injured geriatric patients, specific interventions are needed to improve outcomes. The purpose of this study was to assess the effect of a change in triage criteria for injured geriatric patients evaluated at an American College of Surgeons Level I trauma center.

METHODS

As of October 1, 2013, all injured patients 70 years or older were mandated to have the highest-level trauma activation upon emergency department (ED) arrival regardless of physiology or mechanism of injury. Patients admitted before that date were designated as PRE; those admitted after were designated as POST. The study period was from October 1, 2011, through April 30, 2015. Data collected included demographics, mechanism of injury, hypotension on admission, comorbidities, Injury Severity Score (ISS), ED length of stay (LOS), complications, and mortality. Bivariate and multivariable analyses were used to compare outcomes between the study groups (p < 0.05 was considered significant). χ or Fisher's exact test was used as appropriate for bivariate analyses of categorical variables; patients' ages were compared using the Wilcoxon rank-sum test.

RESULTS

A total of 2,269 patients (mean, 80.63 years; mean ISS, 12.2; PRE, 1,271; POST, 933) were included in the study. On multivariable analysis, increasing age, higher ISS, and hypotension were associated with higher mortality. POST patients were more likely to have an ED LOS of 2 hours or shorter (odds ratio, 1.614; 95% confidence interval, 1.088-2.394) after controlling for hypotension, ISS, and comorbidities. POST mortality significantly decreased (odds ratio, 0.689; 95% confidence interval, 0.484-0.979).

CONCLUSION

Based on age alone, the focused intervention of a higher level of trauma activation decreased ED LOS and mortality in injured geriatric patients.

LEVEL OF EVIDENCE

Therapeutic/care management study, level IV.

The effect of age and demographics on rib shape

Elderly populations have a higher risk of rib fractures and other associated thoracic injuries than younger adults, and the changes in body morphology that occur with age are a potential cause of this increased risk. Rib centroidal path geometry for 20 627 ribs was extracted from computed tomography (CT) scans of 1042 live adult subjects, then fitted to a six-parameter mathematical model that accurately characterizes rib size and shape, and a three-parameter model of rib orientation within the body. Multivariable regression characterized the independent effect of age, height, weight, and sex on the rib shape and orientation across the adult population, and statistically significant effects were seen from all demographic factors (P < 0.0001). This study reports a novel aging effect whereby both the rib end-to-end separation and rib aspect ratio are seen to increase with age, producing elongated and flatter overall rib shapes in elderly populations, with age alone explaining up to 20% of population variability in the aspect ratio of mid-level ribs. Age was not strongly associated with overall rib arc length, indicating that age effects were related to shape change rather than overall bone length. The rib shape effect was found to be more strongly and directly associated with age than previously documented age-related changes in rib angulation. Other demographic results showed height and sex being most strongly associated with rib size, and weight most strongly associated with rib pump-handle angle. Results from the study provide a statistical model for building rib shapes typical of any given demographic by age, height, weight, and sex, and can be used to help build population-specific computational models of the thoracic rib cage. Furthermore, results also quantify normal population ranges for rib shape parameters which can be used to improve the assessment and treatment of rib skeletal deformity and disease.

Severe trauma in the geriatric population

Geriatric trauma constitutes an increasingly recognized problem. Aging results in a progressive decline in cellular function which leads to a loose of their capacity to respond to injury. Some medications commonly used in this population can mask or blunt the response to injury. Falls constitute the most common cause of trauma and the leading cause of trauma-related deaths in this population. Falls are complicated by the widespread use of antiplatelets and anticoagulants, especially in patients with brain injury. Under-triage is common in this population. Evaluation of frailty could be helpful to solve this issue. Appropriate triaging and early aggressive management with correction of coagulopathy can improve outcome. Limitation of care and palliative measures must be considered in cases with a clear likelihood of poor prognosis.

Factors Associated With Nontransfer in Trauma Patients Meeting American College of Surgeons' Criteria for Transfer at Nontertiary Centers

Importance

Secondary triage from nontertiary centers is vital to trauma system success. It remains unclear what factors are associated with nontransfer among patients who should be considered for transfer to facilities providing higher-level care.

Objective

To identify factors associated with nontransfer among patients meeting American College of Surgeons (ACS) guideline criteria for transfer from nontertiary centers.

Design, Setting, and Participants

A retrospective cohort study was performed using multilevel logistic regression to ascertain factors associated with nontransfer from nontertiary centers, including demographics, injury characteristics, and center resources. With information obtained from the National Trauma Data Bank (January 1, 2007, to December 31, 2012), relative proportion of variance in outcome across centers was determined for patient-level and center-level attributes. In all, 96 528 patients taken to nontertiary centers (levels III, IV, V, and nontrauma centers) that met ACS guideline transfer criteria were eligible for inclusion. Data analysis was performed from March 17, 2016, to May 20, 2016.

Main Outcomes and Measures

The primary outcome was nontransfer from a nontertiary center.

Results

Among 96 528 patients meeting ACS guideline criteria for transfer taken initially to nontertiary centers, 55 611 (57.6%) were male and the median age was 52 years (interquartile range, 28-77 years). Only 19 396 patients (20.1%) underwent transfer. Patient-level factors associated with nontransfer included age older than 65 years (adjusted odds ratio [AOR], 1.70; 95% CI, 1.46-1.98; P < .001), severe chest injury (AOR, 1.63; 95% CI, 1.42-1.89; P < .001), and commercial insurance (vs self-pay: AOR, 1.39; 95% CI, 1.15-1.67; P < .001). Center-level factors associated with nontransfer included larger bed size (>600 vs <200 beds: AOR, 9.22; 95% CI, 7.70-11.05; P < .001), nontrauma center (vs level III centers: AOR, 2.71; 95% CI, 2.44-3.01; P < .001), university affiliation (vs community: AOR, 9.68; 95% CI, 8.03-11.66; P < .001), more trauma surgeons (per surgeon: AOR, 1.08; 95% CI, 1.06-1.09; P < .001), and more neurosurgeons (per surgeon: AOR, 1.25; 95% CI, 1.23-1.28; P < .001). For-profit status was associated with nontransfer at nontrauma centers (AOR, 1.55; 95% CI, 1.39-1.74; P < .001), but not at level III, IV, and V trauma centers. Overall, patient-level factors accounted for 36% and center-level factors accounted for 58% of the variation in transfer practices. Patient-level factors accounted for more variation at level III, IV, and V trauma centers (44%), but less variation at nontrauma centers (13%).

Conclusions and Relevance

Only 1 in 5 patients meeting ACS transfer criteria underwent transfer. Factors associated with nontransfer may be useful for trauma system stakeholders to target education and outreach to guide development of more inclusive trauma systems. Further study is necessary to critically evaluate whether these ACS criteria identify patients who require transfer.

Base excess, a useful marker in the prognosis of chest trauma in the geriatric population

OBJECTIVE

To determine the usefulness of the determination of base excess in a cohort of elderly patients admitted to an intensive care unit (ICU) with a diagnosis of chest trauma.

MATERIAL AND METHOD

Two hundred and forty-nine patients were included aged 65 years and over with a diagnosis of thoracic trauma who required admission to the ICU. We made a statistical analysis in order to determine the association of the first base excess levels with mortality during the unit stay.

RESULTS

Two hundred and forty-nine patients, with a mean APACHE II score of 16.21±7.87 and 24.45±14.16 ISS. Mean ICU stay was 12.74±16.85 days and the mean hospital stay was 26.55±30.1 days. Statistical analysis showed an association with mortality in patients whose blood pressure was lower than 110mmHg on admission, with an OR=4.11 (95% CI 1.91 to 8.85) compared to patients with blood pressure between 110 and 140mmHg. Those patients who had base excess levels on admission of less than -6mmol/L also showed increased mortality compared to patients with higher levels, with an OR=3.12 (95% CI 1.51 to 6.42).

CONCLUSIONS

The presence of a base excess level of less than -6 is associated with increased mortality in elderly patients with initial blood pressure between 110 and 140mmHg, diagnosed with thoracic trauma and who require admission to ICU. Routine measurement of this parameter in this population may show the clinical usefulness of assessing possible hidden hypoperfusion.

Creating a Geriatric-Focused Model of Care in Trauma With Geriatric Education

The literature suggests that by 2050, about 40% of all trauma patients will be over age 65 years. We already exceeded this prediction at Lehigh Valley Health Network in 2013, with 46.6% of the Pennsylvania trauma registry qualifiers being age 65 or greater, and 17.7% age 85 and greater. Currently, only 8.8% of trauma centers incorporate Geriatric Resource Programs into trauma care. Our trauma team has incorporated geriatric education for nurses by incorporating an educational nursing program called Nurses Improving Care for Healthsystem Elders, to improve outcomes, reduce hospital complications, and reduce health care costs for this high-risk population. The older adult population is on the rise and trauma nurses must be provided the tools to care for this high-risk patient group.

Early neurological deterioration in older adults with traumatic brain injury

INTRODUCTION

Traumatic brain injuries (TBIs) and resulting fatalities among older adults increased considerably in recent years. Neurological deterioration often goes unrecognized at the injury scene and patients arrive at emergency departments with near-normal Glasgow Coma Scale (GCS) scores. This study examined the proportion of older adults experiencing early neurological deterioration (prehospital to emergency department), associated factors, and association of the magnitude of neurological deterioration with TBI severity.

METHODS

This secondary analysis of National Trauma Data Bank Research Datasets included patients who were age ⩾65, sustained a TBI, and transported from the injury scene to an emergency department. Data analysis included chi-square analysis, t-tests, and logistic regression. Long-term anticoagulant/antiplatelet therapy was not associated with deterioration.

RESULTS

Of the sample of 91,886 patients, 13,913 (15.1%) experienced early neurological deterioration. Adjusting for covariates, age, gender, head AIS_max injury severity, and probability of death were associated with early deterioration. Patients with severe and critical head injuries had the highest odds of early neurological deterioration (OR=1.41 [CI=1.22-1.63] and OR=1.98 [CI=1.63-2.40], p<0.001).

DISCUSSION/CONCLUSIONS

Prehospital providers, nurses, physicians, and other providers have opportunities to optimize outcomes from older adult TBI through early recognition of neurological deterioration, rapid transport to facilities for definitive treatment, and targeted rehabilitation.

Geriatric assault victims treated at U.S. trauma centers: Five-year analysis of the national trauma data bank

INTRODUCTION

While geriatric trauma patients have begun to receive increased attention, little research has investigated assault-related injuries among older adults. Our goal was to describe characteristics, treatment, and outcomes of geriatric assault victims and compare them both to geriatric victims of accidental injury and younger assault victims.

PATIENTS AND METHODS

We conducted a retrospective analysis of the 2008-2012 National Trauma Data Bank. We identified cases of assault-related injury admitted to trauma centers in patients aged ≥60 using the variable "intent of injury."

RESULTS

3564 victims of assault-related injury in patients aged ≥60 were identified and compared to 200,194 geriatric accident victims and 94,511 assault victims aged 18-59. Geriatric assault victims were more likely than geriatric accidental injury victims to be male (81% vs. 47%) and were younger than accidental injury victims (67±7 vs. 74±9 years). More geriatric assault victims tested positive for alcohol or drugs than geriatric accident victims (30% vs. 9%). Injuries for geriatric assault victims were more commonly on the face (30%) and head (27%) than for either comparison group. Traumatic brain injury (34%) and penetrating injury (32%) occurred commonly. The median injury severity score (ISS) for geriatric assault victims was 9, with 34% having severe trauma (ISS≥16). Median length of stay was 3 days, 39% required ICU care, and in-hospital mortality was 8%. Injury severity was greater in geriatric than younger adult assault victims, and, even when controlling for injury severity, in-hospital mortality, length of hospitalization, and need for ICU-level care were significantly higher in older adults.

CONCLUSIONS

Geriatric assault victims have characteristics and injury patterns that differ significantly from geriatric accidental injury victims. These victims also have more severe injuries, higher mortality, and poorer outcomes than younger victims. Additional research is necessary to improve identification of these victims and inform treatment strategies for this unique population.

A Comprehensive Investigation of Comorbidities, Mechanisms, Injury Patterns, and Outcomes in Geriatric Blunt Trauma Patients

The geriatric population is growing and trauma providers are often tasked with caring for injuries in the elderly. There is limited information regarding injury patterns in geriatric trauma patients stratified by mechanism of injury. This study intends to investigate the comorbidities, mechanisms, injury patterns, and outcomes in geriatric blunt trauma patients. A retrospective study of the 2012 National Trauma Databank was performed. Adult blunt trauma patients were identified; geriatric (>/=65) patients were compared with younger (<65) patients regarding admission demographics and vital signs, mechanism and severity of injury, and comorbidities. The primary outcome was injuries sustained and secondary outcomes included mortality, length of stay in the intensive care unit and hospital, and ventilator days. There were 589,830 blunt trauma patients who met the inclusion criteria, including 183,209 (31%) geriatric and 406,621 (69%) nongeriatric patients. Falls were more common in geriatric patients (79 vs 29%, P < 0.0001). Geriatric patients less often had an Injury Severity Score >/=16 (18 vs 20%, P < 0.0001) but more often a head Abbreviated Injury Scale >/=3 (24 vs 18%, P < 0.0001) and lower extremity Abbreviated Injury Scale >/=3 (24% vs 8%, P < 0.0001). After logistic regression older age was an independent risk factor for mortality for the overall population and across all mechanisms. Falls are the most common mechanism for geriatric trauma patients. Geriatric patients overall present with a lower Injury Severity Score, but more often sustain severe injuries to the head and lower extremities. Injury patterns vary significantly between older and younger patients when stratified by mechanism. Mortality is significantly higher for geriatric trauma patients and older age is independently associated with mortality across all mechanisms.

Genitourinary trauma in geriatric patients

PURPOSE OF REVIEW

The geriatric population is the fastest growing segment of the population, and geriatric trauma patients are increasingly common. Caring for this population has unique challenges. The goal of the review is to identify factors that may help in the care of geriatric patients suffering from genitourinary trauma.

RECENT FINDINGS

Multiple factors lead to inferior outcomes in patients with geriatric trauma including failure to rescue, treatment in lower volume trauma centers, and undertriage of geriatric patients. Improvement in geriatric trauma outcomes occurs with the use of dedicated geriatric consult teams. The surgical management of genitourinary injuries in the geriatric population remains unchanged.

SUMMARY

Interventions for geriatric patients differ from younger populations. Direct changes in overall management of the geriatric population lead to improved outcomes. The treatment of geriatric trauma patients with genitourinary injuries is similar to a younger cohort. The lack of recent studies in clinical outcomes in this population has been identified as a gap in knowledge that will require future research to answer.

Effect of Geriatric-Specific Trauma Triage Criteria on Outcomes in Injured Older Adults: A Statewide Retrospective Cohort Study

OBJECTIVES

To evaluate the effect on outcomes of the Ohio Department of Public Safety statewide geriatric triage criteria, established in 2009 for emergency medical services (EMS) to use for injured individuals aged 70 and older.

DESIGN

Retrospective cohort study of the Ohio Trauma Registry.

SETTING

All hospitals in Ohio.

PARTICIPANTS

Individuals aged 70 and older in the Ohio Trauma Registry from January 2006 through December 2011, 3 years before and 3 years after criteria adoption (N = 34,499).

MEASUREMENTS

Primary outcomes were in-hospital mortality and discharge to home. Criteria effects were assessed using chi-square tests, multivariable logistic regression, interrupted time series plots, and multivariable segmented regression models.

RESULTS

After geriatric criteria were adopted, the proportion of older adults qualifying for trauma center transport increased from 44% to 58%, but EMS transport rates did not change (44% vs 45%). There was no difference in unadjusted mortality (7.1% vs 6.6%) (P = .10). In adjusted analyses, subjects with an injury severity score (ISS) less than 10 had lower mortality after adoption (3.0% vs 2.5%) (odds ratio (OR) = 0.81, 95% confidence interval (CI) = 0.70-0.95, P = .01). Discharge to home increased after adoption in the adjusted analysis (OR = 1.06, 95% CI = 1.01-1.11, P = .02). There were no time-dependent changes for either outcome.

CONCLUSION

Although the proportion of older adults meeting criteria for trauma center transport substantially increased with geriatric triage criteria, there were no increases in trauma center transports. Adoption of statewide geriatric triage guidelines did not decrease mortality in more severely injured older adults but was associated with slightly lower mortality in individuals with mild injuries (ISS <10) and with more individuals discharged to home. Improving outcomes in injured older adults will require further attention to implementation and use of geriatric-specific criteria.

[Evolution of mortality in severe chest trauma in the elderly patient]

INTRODUCTION

Persons older than 65 years represent about 30% of all cases requiring care for traumatic injury, and is the fifth leading cause of death. Thus, it is considered important to search for epidemiological parameters that can identify this population group.

PATIENTS AND METHOD

A retrospective, observational, and comparative study was conducted on patients aged 65 years and over admitted to the Intensive Care Unit of tertiary hospital with a primary diagnosis of severe chest trauma between January 1992 and January 2012. A logistic regression was performed to determine the probability of hospital death in relation to the year of hospitalisation.

RESULTS

The cohort included 235 patients. Univariate logistic regression analysis showed a gradual decrease in the probability of death over the years, with an OR of 0.95 [95% CI; 0.90 to 0.99] for each year of admission after 1992 (P=.029). The multivariate model showed an association of mortality with patient age (OR: 1.08 for year over 65), the score on the scale APACHE II (OR: 1.1 for each point obtained), and need for mechanical ventilation (OR: 5.36).

CONCLUSIONS

This study shows a decrease in mortality over the years, with an association that remained after adjustment for different confounding parameters.

Trauma in elderly people: access to the health system through pre-hospital care

Objective:

to identify the prevalence of trauma in elderly people and how they accessed the health system through pre-hospital care.

Method:

documentary and retrospective study at a mobile emergency care service, using a sample of 400 elderly trauma victims selected through systematic random sampling. A form validated by experts was used to collect the data. Descriptive statistical analysis was applied. The chi-square test was used to analyze the association between the variables.

Results:

Trauma was predominant among women (52.25%) and in the age range between 60 and 69 years (38.25%), average age 74.19 years (standard deviation±10.25). Among the mechanisms, falls (56.75%) and traffic accidents (31.25%) stood out, showing a significant relation with the pre-hospital care services (p<0.001). Circulation, airway opening, cervical control and immobilization actions were the most frequent and Basic Life Support Services (87.8%) were the most used, with trauma referral hospitals as the main destination (56.7%).

Conclusion:

trauma prevailed among women, victims of falls, who received pre-hospital care through basic life support services and actions and were transported to the trauma referral hospital. It is important to reorganize pre-hospital care, avoiding overcrowded hospitals and delivering better care to elderly trauma victims.

Elderly trauma

Across the world, the population is aging. Adults 65 years and older make up one of the fastest growing segments of the US population. Trauma is a disease process that affects all age groups. The mortality and morbidity that result from an injury can be influenced by many factors including age, physical condition, and comorbidities. The management of the elderly trauma patient can present some unique challenges. This paper addresses the differences that occur in the management of elderly patient who has been injured. This paper also includes a discussion of how to prevent injury in the elderly.

Post-trauma mortality increase at age 60: a cutoff for defining elderly?

BACKGROUND

There has been an increasing emphasis on identifying elderly trauma patients. However, definitions based solely on age vary widely, ranging from age 55 to 80 years, hampering optimal trauma management for older patients. The goal of this study was to develop an objective, data-driven definition for "elderly" in trauma care by evaluating mortality risk as a function of age.

METHODS

We conducted a retrospective analysis of 872,861 adult (≥18 years) patients from the National Trauma Data Bank's National Sample Program from 2003 to 2010. The primary outcome was risk-adjusted in-hospital mortality determined using multivariate logistic regression. Contribution of age to mortality was investigated through step-wise regression and percent of R² attributable to age. We searched for straight-line trends in mortality rate at each age using the spline function of Statistical Analysis Software.

RESULTS

Statistically significant increases in mortality rate were noted at ages 37, 60, and 78. Age was found to contribute 10% to mortality compared with greater than 80% for Glasgow coma scale and injury severity score combined.

CONCLUSIONS

Our findings suggest using age 60 years as a data-driven definition of "elderly" in trauma.

Acute trauma and multiple injuries in the elderly population

PURPOSE OF REVIEW

Traumatic injuries in the rapidly growing elderly population pose a significant challenge to the healthcare community. These injuries are associated with significant morbidity and mortality, and as a result cause a financial burden on the medical system. Although normal decline in physiologic reserve can provide some explanation for these poor outcomes, there is significant room for improvement. This review will summarize recent literature around the evaluation and management of elderly trauma patients with a particular focus on those with hip fractures.

RECENT FINDINGS

It is becoming increasingly evident that customized evaluation and management of elderly trauma patients is a key factor in improving outcomes. Geriatric-specific triage and assessment criteria have been developed and initial results are encouraging. In particular, the use of frailty as an assessment tool in these patients has been shown to be an independent predictor of outcomes. Further, assessment of these tools in elderly trauma patients with hip fractures has provided a wealth of information about their use and limitations.

SUMMARY

Differentiated, geriatric-specific triaging, assessment and treatment pathways in the care of elderly trauma patients will ultimately lead to improvements in outcomes. These improvements have already started to be seen in the realm of orthogeriatrics.

Nerve regeneration in chitosan conduits and in autologous nerve grafts in healthy and in type 2 diabetic Goto-Kakizaki rats

Knowledge about nerve regeneration after nerve injury and reconstruction in appropriate diabetic animal models is incomplete. Short-term nerve regeneration after reconstruction of a 10-mm sciatic nerve defect with either a hollow chitosan conduit or an autologous nerve graft was investigated in healthy Wistar and diabetic Goto-Kakizaki (GK) rats. After 21 days, axonal outgrowth, the presence of activated and apoptotic Schwann cells and the thickness of the formed matrix in the conduits were measured. In general, nerve regeneration was superior in autologous nerve grafts. In chitosan conduits, a matrix, which was thicker in diabetic rats, was formed and was positively correlated with length of axonal outgrowth. Axonal outgrowth in conduits and in nerve grafts extended further in diabetic rats than in healthy rats. There was a higher percentage of activating transcription factor 3 (ATF3)-immunostained cells in nerve segments from healthy rats than in diabetic rats after autologous nerve graft reconstruction. In chitosan conduits, more cleaved caspase 3-stained Schwann cells were generally observed in the matrix from the diabetic rats than in healthy rats. However, there were fewer apoptotic cells in the distal segment in diabetic rats reconstructed with a chitosan conduit. Preoperative glucose levels were positively correlated with axonal outgrowth after both reconstruction methods. Axonal regeneration was better in autologous nerve grafts than in hollow chitosan conduits and was enhanced in diabetic GK rats compared to healthy rats after reconstruction. This study provides insights into the nerve regeneration process in a clinically relevant diabetic animal model.

Orthogeriatrics in the management of frail older patients with a fragility fracture

This review article examines the role of orthogeriatric management for frail older patients with a fragility fracture. The history of orthogeriatrics and its application in clinical practice around the world is reported, and an evidence-based evaluation for the effect of orthogeriatric management on patient morbidity and mortality is also provided. It has been more than 50 years since the role of the geriatrician in the management of patients with a hip fracture was first described. The evidence that supports an orthogeriatric model of care has grown exponentially over the last decade. This evidence base is primarily related to hip fractures and demonstrates reduced morbidity and mortality rates amongst patients managed with a recognised model of orthogeriatric care. The societal and economic burden of hip fracture has led to health economic evaluations within this field, many of which have concluded that orthogeriatric management results in cost-effective clinical practice. Based on existing clinical and economic research, national clinical practice guidelines have been developed in several countries which recommend orthogeriatric participation in the management of older patients with a hip fracture. Compliance with such guidance has already demonstrated improved patient outcomes. Although the pathogenesis and prognosis of other types of fragility fracture may be as poor, there is a dearth of clinical research that evaluates the effect of orthogeriatric management on such injuries. Looking to the future, orthogeriatric management is likely to become more widespread, and the robust collection and reporting of patient outcomes from national registries will provide a greater understanding of the impact of orthogeriatric models in the care of all frail older patients with any type of fragility fracture.

Comorbidity polypharmacy score and its clinical utility: A pragmatic practitioner's perspective

Modern medical management of comorbid conditions has resulted in escalating use of multiple medications and the emergence of the twin phenomena of multimorbidity and polypharmacy. Current understanding of how the polypharmacy in conjunction with multimorbidity influences trauma outcomes is limited, although it is known that trauma patients are at increased risk for medication-related adverse events. The comorbidity-polypharmacy score (CPS) is a simple clinical tool that quantifies the overall severity of comorbidities using the polypharmacy as a surrogate for the "intensity" of treatment necessary to adequately control chronic medical conditions. Easy to calculate, CPS is derived by counting all known pre-injury comorbid conditions and medications. CPS has been independently associated with mortality, increased risk for complications, lower functional outcomes, readmissions, and longer hospital stays. In addition, CPS may help identify older trauma patients at risk of post-emergency department undertriage. The goal of this article was to review and refine the rationale for CPS and to provide an evidence-based outline of its potential clinical applications.

Traumatic Spinal Cord Injury Emergency Service Triage Patterns and the Associated Emergency Department Outcomes

Paralysis is an indication for trauma patients to be preferentially triaged by emergency services to designated level I or II trauma centers (TC). We sought to describe triage practices for patients with acute traumatic spinal cord injury (TSCI) and its associated emergency department (ED) outcomes. Adults ages ≥ 18 years with a diagnosis of acute TSCI (International Classification of Diseases-9: 806 and 952) in the 2006-2011 United States Nationwide Emergency Department Sample were included in these analyses. Outcomes assessed include triage to non-trauma centers (NTC), which is referred to as "under-triage," and ED mortality. Of 117,444 adults with TSCI, 33.4% were under-triaged to NTC. Under-triage was more prevalent with increasing age. Among patients under-triaged to NTC, 37.4% had new injury severity score (NISS) >15, representing severe injuries or polytrauma. Among patients with NISS >15, the odds of ED mortality in NTC were four-fold greater compared to level I trauma centers (TC-I) (adjusted odds ratio [AOR] = 4.06; 95% confidence interval = 1.87-8.79; p < 0.001). In conclusion, under-triage of adults with acute TSCI occurred in at least one-third of the cases. Patients triaged to NTC rather than TC-I experienced higher likelihood of death in the ED even after controlling for personal and injury characteristics. Further research is necessary to elucidate detailed clinical and logistical factors that may be associated with under-triage of acute TSCI, to facilitate interventions aimed at improving patient experience and outcomes.

Low Energy Trauma in Older Persons: Where to Next?

The global population is increasing rapidly with older persons accounting for the greatest proportion. Associated with this rise is an increased rate of injury, including polytrauma, for which low energy falls has become the main cause. The resultant growing impact on trauma resources represents a major burden to the health system. Frailty, with its related issues of cognitive dysfunction and sarcopenia, is emerging as the unifying concept that relates both to the initial event and subsequent outcomes. Strategies to better assess and manage frailty are key to both preventing injury and improving trauma outcomes in the older population and research that links measures of frailty to trauma outcomes will be critical to informing future directions and health policy. The introduction of "Geriatric Emergency Departments" and the development of "Fracture Units" for frail older people will facilitate increased involvement of Geriatricians in trauma care and aid in the education of other health disciplines in the core principles of geriatric assessment and management. Collectively these should lead to improved care and outcomes for both survivors and those requiring end of life decisions and palliation.

Fall-Related Injuries in Community-Dwelling Older Adults in Qom Province, Iran, 2010-2012

Background:

Falls and related injuries are common health problems in the elderly. Fractures, brain and internal organ injuries and death are the common consequences of the falls, which result in dependence, decreased self-efficacy, fear of falling, depression, restricted daily activities, hospitalization and admission to the nursing home and impose costs on the individual and the society.

Objectives:

The purpose of this study was to determine the types of fall-related injuries and the related risk factors in the elderly population of Qom province, Iran.

Patients and Methods:

This retrospective study was performed on 424 elderly people (65 years and over) referred to Shahid Beheshti Hospital, Qom, Iran, due to falls between 2010 and 2012. The ICD-10 codes of external causes of injury from w00 to w19 related to falls were selected from the health information system of the hospital and demographic variables of the patients and external causes of falls were extracted after accessing the files of the patients. Data were analyzed using SPSS version 18 (SPSS Inc., USA). The duration of hospital stay and its relationship with underlying variables were investigated using t test and ANOVA. The level of significance was considered P < 0.05.

Results:

Among 424 elderly people, 180 cases (42.45%) were male and the mean age of the patients was 78.65 ± 7.70 years. Fall on the same level from slipping, tripping, and stumbling was the most common external cause with 291 victims (68.60%), and hip fracture in 121 patients (29.00%), intertrochanteric fracture in 112 patients (26.90%), and traumatic brain injury in 51 patients (12.20%) were the most common causes of hospital stay. The mean hospital stay was 7.33 ± 3.63 days.

Conclusions:

Lower limb fracture and traumatic brain injury were the most common causes of hospitalization, which resulted in the longest hospital stay and highest hospitalization costs in the elderly.