Morbidity and mortality in elderly trauma patients

Polytrauma in the elderly: predictors of the cause and time of death

BACKGROUND

Increasing age and significant pre-existing medical conditions (PMCs) are independent risk factors associated with increased mortality after trauma. Our aim was to review all trauma deaths, identifying the cause and the relation to time from injury, ISS, age and PMCs.

METHODS

A retrospective analysis of trauma deaths over a 6-year period at the study centre was conducted. Information was obtained from the Trauma Audit and Research Network (TARN) dataset, hospital records, death certificates and post-mortem reports. The time and cause of death, ISS, PMCs were analysed for two age groups (<65 years and >or= 65 years).

RESULTS

Patients >or= 65 years old were at an increased risk of death (OR 6.4, 95% CI 5.2-7.8, p < 0.001). Thirty-two patients with an ISS of >15 and died within the first 24 hours of admission, irrespective of age, from causes directly related to their injuries. Twelve patients with an ISS of <16, died after 13 days of medical conditions not directly related to their injuries (p = 0.01). Thirty four patients had significant PMCs, of which 11 were <65 years (34.4% of that age group) and 23 were >or= 65 years (95.8% of that age group) (p = 0.02). The risk of dying late after sustaining minor trauma (ISS <16) is increased if a PMC exists (OR 5.5, p = 0.004).

CONCLUSION

Elderly patients with minor injuries and PMCs have an increased risk of death relative to their younger counterparts and are more likely to die of medical complications late in their hospital admission.

Methodological systematic review: mortality in elderly patients with cervical spine injury: a critical appraisal of the reporting of baseline characteristics, follow-up, cause of death, and analysis of risk factors

STUDY DESIGN

Methodologic systematic review.

OBJECTIVE

To determine the validity of reported risk factors for mortality in elderly patients with cervical spine injury.

SUMMARY OF BACKGROUND DATA

In elderly patients with cervical spine injury, mortality has frequently been associated with the type of treatment. To date, however, no review evaluating the validity of reported risk factors for mortality in elderly patients with cervical spine injury has been published.

METHODS

Studies evaluating the treatment of cervical spine injuries in elderly (>/=60 years of age) patients were searched through the Medline and EMBASE databases. In addition to standard methodologic details, reporting of putative confounding baseline characteristics and analysis of risk factors for mortality were appraised critically. For this purpose, patient data presented in included studies were pooled. Exploratory descriptive statistics were used for data analysis.

RESULTS

Twenty-six eligible studies were identified, including a total of 1550 pooled elderly subjects. Except for 2, all studies reported presence or absence of spinal cord injury. Details concerning the severity and/or extent of the injury were reported in 12 (46%) studies. Pre-existing comorbidities were reported in 9 studies (35%). In the pooled subjects, the cause of death was not reported in 155 of 335 deceased patients (42%). Based on own results, 18 (69%) studies reported on risk factors for mortality. Of these studies, 6 (23%) performed statistical analyses of risk factors for mortality outcomes. Only 1 study statistically adjusted potential risk factors for mortality for confounding.

CONCLUSION

Overall, pre-existing comorbidities, concomitant injuries, follow-up and cause of death have been underreported in studies investigating the treatment of cervical spine injuries in elderly patients. To strengthen the validity of risk factors for mortality in future clinical trials, adjustments for appropriately reported putative confounders by regression analysis are mandatory.

Predictors of early mortality after traumatic spinal cord injury: a population-based study

STUDY DESIGN.: Retrospective cohort study. OBJECTIVE.: To identify predictors of early mortality following traumatic spinal cord injury (TSCI). SUMMARY OF BACKGROUND DATA.: Limited information is available on factors associated with early mortality following TSCI. Ability to identify high risk individuals can help to appropriately treat them, and reduce mortality. METHODS.: Early mortality was defined as death occurring during the initial hospital admission. Retrospective analysis of 1995 patients with TSCI, admitted to various hospitals of South Carolina from 1993 to 2003, was performed. There were 251 patients with early mortality. Multivariable logistic regression was used in modeling of early death following TSCI with gender, race, age, Frankel grade, trauma center, level of injury, injury severity score (ISS), traumatic brain injury (TBI), and medical comorbidities as covariates. RESULTS.: Increasing age after 20 years (OR: 1.2, P = <0.0001), male gender (OR: 1.6, P = 0.016), severe (ISS > or =15) systemic injuries (OR: 1.9, P = 0.012), TBI (OR: 3.7, P < 0.0001), 1 or more comorbidities (P < 0.0001), poor neurologic status (P = 0.015), and level 1 trauma center (OR: 1.4, P = 0.026) were significantly associated with early mortality, after adjusting for other covariates. CONCLUSION.: Early mortality following TSCI is influenced by multiple factors. Timely recognition of these factors is crucial for improving survival in the acute care setting. Severe systemic injuries, medical comorbidities, and TBI continue to be the main limiting factors affecting the outcome. These findings also suggest the need to allocate resources for trauma prevention, and promote research towards improving the care of acutely injured patients.

Effectiveness of an educational intervention on levels of pain, anxiety and self-efficacy for patients with musculoskeletal trauma

AIM

This paper is a report of a study of the effectiveness of a pain management educational intervention on level of pain, anxiety and self-efficacy among patients with musculoskeletal trauma and consequent orthopaedic surgery.

BACKGROUND

Substantial evidence supports the use of preoperative education to improve patient outcomes. Educational interventions are common in preparing patients for orthopaedic surgery.

METHODS

A pre- and post-test design (quasi-experimental) was employed in 2006 with patients assigned either to a control (usual care) or an experimental group (usual care plus educational intervention). The 30-minute educational intervention consisted of information about pain, coping strategies and breathing relaxation exercises. The outcome measures were scores for pain, anxiety, self-efficacy, analgesic use and length of hospital stay and these were measured before surgery and on day 2, day 4, day 7, 1 month and 3 months after surgery.

RESULTS

A total of 125 patients completed the study (control, n = 63; experimental = 62). The experimental group reported statistically significantly lower levels of pain, less anxiety and better self-efficacy during hospitalization (before surgery to day 7), as compared to the control group. The experimental group had more requests for analgesics at day 2 only. There were no statistically significant effects on length of stay. At the 3-month evaluation, a statistically significant effect on anxiety level was found in favour of the experimental group.

CONCLUSION

Patients may benefit from this educational intervention in terms of relieving pain, anxiety and improving self-efficacy, and the educational intervention could be incorporated as part of routine care to prepare musculoskeletal trauma patients for surgery.

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.

Mortality in elderly patients after cervical spine fractures

BACKGROUND

Despite an increased risk of cervical spine fractures in older patients, little is known about the mortality associated with these fractures and there is no consensus on the optimal treatment. The purposes of this study were to determine the three-month and one-year mortality associated with cervical spine fractures in patients sixty-five years of age or older and to evaluate potential factors that may influence mortality.

METHODS

We performed a retrospective review of all cervical spine fractures in patients sixty-five years of age or older from 1991 to 2006 at two institutions. Information regarding age, sex, race, treatment type, neurological involvement, injury mechanism, comorbidity, and mortality were collected. Overall risk of mortality and mortality stratified by the above factors were calculated at three months and one year. Cox proportional-hazard regression was performed to identify independent correlates of mortality.

RESULTS

Six hundred and forty patients were included in our analysis. The mean age was eighty years (range, sixty-five to 101 years). Two hundred and ninety-four patients (46%) were male, and 116 (18%) were nonwhite. The risk of mortality was 19% at three months and 28% at one year. The effect of treatment on mortality varied with age at three months (p for interaction = 0.03) but not at one year (p for interaction = 0.08), with operative treatment being associated with less mortality for those between the ages of sixty-five and seventy-four years. A higher Charlson comorbidity score, male sex, and neurological involvement were all associated with increased risk of mortality.

CONCLUSIONS

Operative treatment of cervical spine fractures is associated with a lower mortality rate at three months but not at one year postoperatively for patients between sixty-five and seventy-four years old at the time of fracture.

The effect of pelvic fracture on mortality after trauma: an analysis of 63,000 trauma patients

BACKGROUND

The understanding of the mortality risk posed by pelvic fracture is incomplete. The purposes of this study were (1) to compare the mortality risk associated with a pelvic fracture with the risk conferred by other injuries and (2) to determine if the association of a pelvic fracture with mortality varies when combined with other known risk factors.

METHODS

Trauma registry records from two level-I trauma centers were examined. Regression analysis was done on 63,033 patients to assess the odds ratio for mortality associated with pelvic fracture compared with other variables such as age, shock, head injury, abdominal or chest injury, and extremity injury. A second analysis was carried out to determine if the impact of a pelvic fracture on mortality varied when combined with other known risk factors for mortality.

RESULTS

Logistic regression analysis demonstrated that pelvic fracture was significantly associated with mortality (p < 0.001). The odds ratio for mortality associated with a pelvic fracture (approximately 2) was similar to that posed by an abdominal injury. Hemodynamic shock, severe head injury, and an age of sixty years or more all had an odds ratio for mortality greater than that associated with pelvic fracture.

CONCLUSIONS

For the majority of trauma patients, pelvic fracture is significantly associated with a greater risk of mortality. However, pelvic fracture is one variable among many that contribute to mortality risk, and it must be considered in relation to these other variables.

The effects of intraoperative positioning on patients undergoing early definitive care for femoral shaft fractures

OBJECTIVES

To determine if there is a difference in morbidity and mortality in orthopaedic trauma patients with femoral shaft fractures undergoing early definitive care with intramedullary (IM) nails in the supine versus the lateral position.

DESIGN

Retrospective cohort study, single centered.

SETTING

One level 1 trauma center.

PATIENTS

Nine hundred eighty-eight patients representing 1027 femoral shaft fractures treated with IM nails were identified through a prospectively gathered database between 1987 and 2006.

INTERVENTION

Antegrade IM nail insertion with reaming of the femoral canal in either the supine or lateral position.

OUTCOME MEASURES

Mortality was the primary outcome. Admission to intensive care unit (ICU) was the secondary outcome measure and a surrogate measure of morbidity. Literature review was performed to identify factors shown to contribute to morbidity and mortality in orthopaedic trauma patients. Intraoperative position in either the supine or lateral position was added to this list. Logistic regression analysis was performed to determine the magnitude and effect of the independent variables on each of the study end points. To determine if a more significant trend toward less favorable outcomes was observed with increasing severity of injury, particularly injuries of the chest and thorax, subgroup analysis was performed for all those with a femur fracture and an Injury Severity Score > or =18 and all those with a femur fracture and an Abbreviated Injury Score chest > or =3.

RESULTS

Intraoperative position in either the supine or lateral position was not a significant predictor of mortality or ICU admission for the original cohort or the subgroup of Injury Severity Score > or =18. However, for the subgroup of Abbreviated Injury Score chest > or =3, intraoperative positioning in the lateral position had a statistically significant protective effect against ICU admission (P = 0.044).

CONCLUSIONS

For polytrauma patients with femoral shaft fractures, surgical stabilization using IM nails inserted with reaming of the femoral canal in the lateral position is not associated with an increased risk of mortality or ICU admission.

Early postoperative mortality in the elderly: a pilot study

BACKGROUND

As the population ages and as surgical and anaesthetic techniques advance, more elderly people will be referred for surgery. Postoperative mortality and morbidity are certainly associated with increasing age; however the severity of coexisting medical conditions is an equally important risk factor. In the present study we tried to look into the aetiology of early postoperative morbidity of elderly patients following major surgery, in relation to their medical history.

FINDINGS

Fifty patients aged 70 to 95 years of age were enrolled in the study. All patients had undergone major elective orthopedic procedures due to either osteoarthritis of femoral head or femoral neck fracture. Patients were followed up by telephone interview one month following their discharge. 8 out of 50 patients (16%) were reported dead at follow up. For the majority of the patients who died, the cause of death was directly related to their previous medical history.

CONCLUSION

Despite the detailed preoperative evaluation, and the intensive intraoperative and early postoperative anaesthetic care, most patient's deaths were related to their previous medical history.

Major trauma in the elderly

With people living longer and able to undertake more activities, any professional involved in trauma care will inevitably be exposed to older victims of trauma. Increasing numbers of older people are admitted to trauma units, presenting the healthcare professional with challenges including altered physiology, polypharmacy and ethical considerations which may lead to diagnostic and treatment dilemmas. Rib fractures for example are associated with significant morbidity and mortality and optimising analgesia may improve outcomes. There are conflicting views over co-morbidities being associated with mortality, but mortality in UK intensive care units appears to be high in elderly trauma victims. The EAST guidelines provide a thorough management strategy of elderly trauma victims. Old age should not be a sole criterion for limiting or withholding care in trauma patients.

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.

Serum lactate and base deficit as predictors of mortality in normotensive elderly blunt trauma patients

BACKGROUND

Base deficit (BD) and lactate are used as markers of mortality, injury severity, and resource utilization in the general trauma population. No study has defined the role of these markers in the triage and management of the normotensive injured elderly patient.

METHODS

Retrospective cohort study of the trauma registry from a Level I trauma Center during the period of January 1, 2000 through December 31, 2006. Inclusion criteria were age > or = 65 years, initial systolic blood pressure > or = 90 mm Hg; blunt mechanism of trauma. Lactate was categorized as 0 to 2.4 mmol/L (normal), 2.5 to 4.0 mmol/L (moderately elevated), or > 4.0 mmol/L (severely elevated). BD was categorized as > 0 mEq/L (normal), 0 to -6 mEq/L (moderate), or < -6 mEq/L (severe). The primary outcome was inhospital mortality.

RESULTS

Mean lactate was higher in nonsurvivors compared with survivors (2.8 mm/L +/- 1.8 mm/L vs. 2.0 mm/L +/- 1.0 mm/L, p < 0.001). Normal, moderately elevated, and severely elevated lactate was associated with mortality rates of 15% (95% confidence interval [CI] 12-18.8%), 23.4% (95% CI 2-32.4%), and 39.6% (95% CI 26.5-52.8%), respectively. Compared with the normal lactate group, patients in the severely elevated lactate group had 4.2 increased odds of death. BD was more abnormal in nonsurvivors compared with survivors (-2.3 mEq/L +/- 5.2 mEq/L vs. 0.28 mEq/L +/- 1.0 mEq/L, p < 0.001). Normal, moderate, and severe BD were associated with mortality rates of 14% (95% CI 10.3-17.1%), 27% (95% CI 20.1-34.2%), and 40% (95% CI 24.9-54.1%), respectively. Compared with the normal BD group, patients in the severe group had 4.1 increased odds of death.

CONCLUSIONS

Both lactate and BD were associated with significantly increased mortality in normotensive elderly blunt trauma patients. However, because of the high baseline mortality rates in elderly trauma patients, "normal" lactate does not offer complete reassurance to the clinician.

Aging and animal models of systemic insult: trauma, burn, and sepsis

In the acute-care setting, it is widely accepted that elderly patients have increased morbidity and mortality compared with young healthy patients. The reasons for this, however, are largely unknown. Although animal modeling has helped improve treatment strategies for young patients, there are a scarce number of studies attempting to understand the mechanisms of systemic insults such as trauma, burn, and sepsis in aged individuals. This review aims to highlight the relevance of using animals to study the pathogenesis of these insults in the aged and, despite the deficiency of information, to summarize what is currently known in this field.

Trauma

In terms of cost and years of potential lives lost, injury arguably remains the most important public health problem facing the United States. Care of traumatically injured patients depends on early surgical intervention and avoiding delays in the diagnosis of injuries that threaten life and limb. In the critical care phase, successful outcomes after injury depend almost solely on diligence, attention to detail, and surveillance for iatrogenic infections and complications.

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.

Defining the "older" crash victim: the relationship between age and serious injury in motor vehicle crashes

OBJECTIVE

Age is often used as a predictor of injury and mortality in motor vehicle crashes (MVCs), however, the age that defines an "older" occupant in terms of injury-risk remains unclear, as do specific injury patterns associated with increasing age. The objective of this study was to evaluate the relationship between age and serious injury (including injury patterns) for occupants involved in MVCs.

METHODS

This was a retrospective cohort study using a national population-based cohort of adult front-seat occupants involved in MVCs and included in the National Automotive Sampling System Crashworthiness Data System database from 1995 to 2006. The primary outcome was serious injury, defined as an abbreviated injury scale (AIS) score >/=3 in any body region. Anatomic injury patterns were also assessed by age.

RESULTS

One hundred thousand one hundred and fifty-six adult front-seat occupants were included in the analysis, of which 14,128 (2%) were seriously injured. Age was a strong predictor of serious injury using a variety of different age covariates (categorical, continuous, and polynomial) in multivariable regression models (p<0.0001 for all). There was evidence of a strong non-linear relationship between age and serious injury (p<0.001 for comparison of non-linear to linear representation of age). There was no age that clearly defined an "older" occupant by injury risk, as the odds of injury increased with increasing age across all age groups. The proportion of serious head and extremity injuries gradually increased with increasing age, while serious chest injuries markedly increased after 60 years.

CONCLUSIONS

Age is a strong predictor of serious injury from motor vehicle trauma, the risk of which increases in non-linear fashion as age increases. There is no specific age that clearly defines an "older" occupant by injury risk.

Risk factors for surgical site infection after surgery for esophageal perforation

Esophageal perforations carry a high potential for morbidity and mortality. The prognosis depends on rapid and precise diagnosis and management. Surgical site infections (SSIs) are very common following the surgical treatment of esophageal lesions. We aimed identify significant risk factors for SSI after surgery for esophageal perforation via an historical cohort study including patients who underwent surgical management of esophageal perforation. The predictive variables were analyzed by bivariate analysis and multiple logistic regression. Eighty-one patients were studied during a 10-year period ending in 2004. The mean age was 42.6 years. In 44% of the patients the time interval between the perforation and surgery was up to 6 h and in 30% it was > 24 h. Associated lesions occurred in other cavities; 17% in the chest, 5% in the abdomen, 5% in the extremities, 4% in the spinal column and bone marrow and 2% in the face. There were grade I lesions in eight cases (10%), grade II in 64 cases (79%) and grade III in nine cases (11%). The mean time of surgery procedure was 117.2 min. The mean SSI was 7.99. SSIs occurred in 33 patients (41%). The risk factors for SSI following surgical management of esophageal perforation were: age > or = 50 years, time delay to treatment > 24 h, associated lesion in another cavity and Injury Severity Score > or = 15.

Isolated cervical spine fractures in the elderly: a deadly injury

BACKGROUND

Traumatic injury in the elderly is an increasing problem and studies have shown that elderly patients (>/=65 years old) with cervical spine fractures and spinal cord injury (SCI) carry a mortality rate of 21% to 30%. However, little has been described with regard to outcomes for elderly patients with isolated cervical spine fractures (ICSF).

HYPOTHESIS

Outcomes for elderly patients with ICSF will be similar to elderly patients with cervical fractures and associated traumatic injuries (ATI) or SCI.

METHODS

A 9-year retrospective analysis was performed on all patients >/=65 years old admitted to a level I trauma center with any cervical spine fracture. Primary outcomes were defined as favorable (discharge to home or rehabilitation hospital) or unfavorable (death, discharge to a long-term acute care facility, or a skilled nursing facility). ICSF was defined as those fractures without ATI or SCI. Long-term mortality data were gathered using the Social Security Death Index.

RESULTS

A total of 177 patients with mean age of 78 +/- 1 and Injury Severity Score of 17 +/- 1 were evaluated. Fifty-six percent were men and falls were the most common mechanism (62%). An unfavorable outcome was seen in 56% of the study population with a mortality rate of 25%. ATIs were seen in 57% of the population and 22% had SCI. Patients with SCI had a significantly higher mortality compared with patients without SCI (38% vs. 22%, p = 0.032). However, there was no difference in unfavorable outcomes. Patients with ICSF had no differences in unfavorable outcomes compared with patients with SCI or ATI. Long-term survival analysis after discharge (mean = 2.8 years) demonstrated that patients with a favorable outcome had a significantly improved survival compared with patients with unfavorable outcomes (p < 0.001).

CONCLUSION

ICSFs were associated with an unfavorable outcome in the elderly population regardless of ATI or SCI. These unfavorable outcomes were also associated with long-term mortality. Strategies to reduce morbidity and mortality in this devastating injury will be essential to improve outcomes and maximize resource utilization.

Cerebral endothelial damage after severe head injury

We demonstrate that in head injuries the degree of cerebral endothelial activation or injury depends on the type of brain injury and the patients age, and that in severe head injuries measuring the serum levels of thrombomodulin (TM) and von Willebrand factor (vWF) is useful in evaluating cerebral endothelial injury and activation. The values of vWF in the cases of focal brain injury were significantly higher than in the cases of diffuse axonal injury. The serum levels of TM in focal brain injuries were higher than in diffuse axonal injuries, but the differences were not statistically significant. In patients with delayed traumatic intracerebral hematoma (DTICH), vWF levels were much higher than in patients without DTICH. The values of TM and vWF in elderly patients were significantly higher than in younger patients. These findings indicate that: 1) the degree of endothelial activation in focal brain injury is significantly higher than in diffuse brain injury; 2) the degree of cerebral endothelial injury in patients with DTICH is much higher than in those without DTICH; and 3) the degree of cerebral endothelial activation and injury in elderly head injury patients is significantly higher than in younger patients.

Cerebral endothelial injury in elderly patients with severe head injury measured by serum thrombomodulin and von Willebrand factor

Elevated serum levels of thrombomodulin (TM) and von Willebrand factor (vWf) are good indicators of injury and activation of cerebral endothelium in patients with severe simple head injury. The present study evaluated cerebral endothelial injury or activation as the serum levels of TM and vWf in elderly and younger patients with similar brain trauma, to evaluate the primary parenchymal injury of the brain. Patients with head injury were classified into the young group (16-30 years), the middle-aged group (31-65 years), and the elderly group (over 66 years). There was no difference in Glasgow Coma Scale on admission between the three groups. The serum levels of TM and vWf at 2 hours after injury were significantly higher in the elderly group than in the other groups. However, the serum levels of TM and vWf were not significantly different at 3 and 7 days after injury. Cerebral endothelial activation and injury were significantly higher in elderly patients just after head injury than in younger patients, which suggests that greater sensitivity to endothelial injury and activation may be important in the worse outcome after head injury in elderly patients compared with younger patients.

Multiple Trauma in Young and Elderly: Are There Any Differences?

BACKGROUND

Old age is considered a risk factor; however, its effect on the prognosis of injured elderly patients remains uncertain.

AIM

To find the effect of old age on final outcome of elderly patients withmultiple trauma and to determine whether a different therapeutic approach is needed.

METHODS

All patients with at least two injured body regions, as defined by the ISS, of grade 4 in AIS, were included.

RESULTS

We studied 165 patients up to 64 years (Y) of age and 56 patients older than 65 years (E) in a 10-year period. On presentation 21.2% of Y and 25% of E, were hypovolemic (p = NS). No significant difference in number of injuries/patient was noted between Y and E patients, hemodynamically stable (HS) and unstable (HU) - (3.0 vs. 2.9 and 3.9 vs. 3.6). An increased relative frequency of chest and abdomen injuries was noted in Y and E, who died or were HU on presentation. A higher relative frequency of long bone and pelvis fractures was noted in the E. The ISS was not different among HS and HU, Y and E. Hospitalization in ICU was more common in E than in Y (69.6 vs. 47.3%), but there was no difference in the final outcome: overall mortality was 10.3% in Y versus 16.1% in E (p = NS), mortality in HU was 42.9% in Y versus 50% in E (p = NS). ISS was not associated with mortality in either group.

CONCLUSIONS

Old age has no influence on final outcome of E multi trauma patients; hence, the therapeutic approach of these patients should be the same in Y.

Geriatric Trauma

Elderly trauma patients present unique challenges and face more significant obstacles to recovery than younger patients. Despite overall higher mortality, longer length of stay, increased resource use, and higher rates of discharge to rehabilitation, most elderly trauma patients return to independent or preinjury functional status. Critical to improving these outcomes is an understanding that although similar trauma principles apply to the elderly, these patients require more aggressive evaluation and resuscitation. This article reviews the recent developments in the literature regarding care of the elderly trauma patient.

Introducing a clinical pathway in fluid management

Following the publication of the National Confidential Enquiry into Perioperative Death's (NCEPOD) report, Extremes of Age (NCEPOD 1999), several recommendations were made relating to the management of patients admitted via Accident and Emergency (A&E) with fractured necks of femur (NOF). An audit was carried out relating fluid management in the elderly. A multidisciplinary clinical pathway for patients with fractured NOF was produced. The audit was repeated in 2002, 2003 and 2005 to obtain data as to whether the pathway had improved the management of patients admitted with fractured NOF Comparing audit data between 2000 and 2005 there were significant reductions in the incidence of perioperative hypotension and an increase in the percentage of patients who were prescribed and received intravenous fluids (p<0.05). A protocol-based pathway produced as a result of a recommendation from NCEPOD has greatly improved the fluid management of patients admitted to a general hospital with fractures.

Are Patients With Self-Inflicted Injuries More Likely to Die?

BACKGROUND

Suicide represents one of the leading causes of trauma in industrialized countries. However, when compared with unintentional injury and assault, the outcome of self-inflicted injury has not been well described.

METHODS

All patients admitted to a French academic trauma center from January 2002 to December 2004 and listed in a trauma data bank were included in a prospective analysis. Variables including mortality, circumstances (unintentional vs. assault vs. self-inflicted), and mechanism of injury were recorded.

RESULTS

About 1,004 continuous trauma patients were analyzed: 151 (15%) with self-inflicted injuries, 761 (76%) with unintentional injuries, and 91 (9%) with injuries from assault. When compared with patients suffering from unintentional injuries and assault, self-inflicted injury patients presented more frequently after a fall from height (94 of 151 vs. 133 of 759 and 0 of 91, p < 0.05) and with a severe head injury (47 of 151 vs. 172 of 752 and 10 of 91, p < 0.05). They also had a more severe injury (Injury Severity Score, 28 +/- 21 vs. 22 +/- 16 and 12 +/- 10; p < 0.05), a lower probability of survival (Trauma Related Injury Severity Score, 0.71 +/- 0.37 vs. 0.83 +/- 0.28 and 0.92 +/- 0.19; p < 0.05), and survival rate (70% vs. 85% and 93%, p < 0.05). In multivariate analysis, Trauma Related Injury Severity Score (odds ratio, 0.54; 95% confidence interval, 0.45-0.59; p < 0.001), age (odds ratio, 1.17; confidence interval, 1.02-1.34; p < 0.05), and mechanism of trauma (p = 0.01) were independently correlated with the final mortality rate.

CONCLUSIONS

Self-inflicted injury patients presented with a higher mortality rate that was related to increased injury severity. The circumstances surrounding the trauma were not independently associated with an increased odds ratio of death after major trauma.

Trauma team activation: simplified criteria safely reduces overtriage

BACKGROUND

Our current trauma triage system uses patient and scene variables within a 3-tiered trauma response system. Our purpose was to evaluate the accuracy of the current system and to identify the most reliable variables for trauma triage.

METHODS

This was a retrospective review at a level II trauma center. Multivariate logistic regression was used to identify independent predictors of the need for any urgent emergency department procedure or operative intervention. The current triage system was analyzed and compared with a proposed simplified system.

RESULTS

There were 1495 consecutive trauma admissions identified, the majority (88%) were blunt mechanism. Urgent emergency department interventions were required in 11%, and 4% required emergent surgery. Logistic regression demonstrated that prehospital Glasgow Coma Score <14 (odds ratio [OR] 9.7), hypotension (OR 3.3), altered respiratory effort (OR 4.6), and penetrating truncal injury (OR 10.8) independently predicted the need for urgent intervention (all P < .01). The current system undertriaged only 1% but overtriaged 51% of patients. A simplified triage system using these 4 variables significantly decreased overtriage and reliably identified patients with severe injury.

CONCLUSIONS

A simplified triage system using only highly predictive variables can safely decrease the high rate of overtriage of trauma patients.

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.

Predictive effect of out-of-hospital time in outcomes of severely injured young adult and elderly patients

INTRODUCTION

The importance of accessing care within the first hour after injury has been a fundamental tenet of trauma system planning for 30 years. However, the scientific basis for this belief either has been missing or largely derived from case series from trauma centers. This study sought to determine the correlation between prehospital times and outcomes among severely injured elderly patients.

METHODS

This is a cross-sectional, observational study. All adults (> or = 18 years of age) with acute trauma as defined by The International Classification of Diseases Ninth Edition, Clinical Modification diagnostic codes and E-codes were included. Poisonings, single system burns, and late effects of injury were excluded. Chi-square and Student's t-test were used for significance testing. To assess the predictive effects of prehospital time and outcomes, three independent logistic regression models were constructed for both young and elderly groups, with hospital length of stay, mortality, and complications as individual dependent variables. Statistical significance was set at the 0.05 level.

RESULTS

Of 41,041 cases, 37,276 were > or = 18 years of age. Of the 1,866 with an Injury Severity Score (ISS) > 15, 1,205 were young and 661 elderly. Logistic regression results showed that prehospital time correlated significantly with hospital length of stay (p = 0.001) and complications (p = 0.016), but not with mortality (p = 0.264) among young patients, whereas in the elderly group pre-hospital time had no significant predictive effect for length of stay, complications, or mortality (p = 0.512, p = 0.512, and p = 0.954 respectively).

CONCLUSION

This population-based study has demonstrated that prehospital time correlates with length of stay and complications in young patients. In elderly patients, prehospital time failed to show correlation with any outcomes measured.

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.

The impact of associated diseases on the etiology, course and mortality in geriatric trauma patients

OBJECTIVES

To determine the impact of accompanying medical illnesses on the cause, course, mortality and morbidity of a geriatric trauma population.

METHODS

This prospective and observational study was carried out in a university hospital that is a level 1 trauma center between January 2002 and January 2003 with a total of 55 patient aged over 65 years. All consecutive patients presented with trauma and having an Abbreviated Injury Severity Scale (AIS) score greater than 20 points were recruited. All patients and relatives were requested to give information on the accompanying diseases. The raw data were analyzed as to the effect of these factors on the findings relating to trauma severity, vital signs, course, short-term mortality and morbidity.

RESULTS

The most common mechanism of trauma was pedestrians hit by cars (33%) in the young elderly group; 81.2% of the sample had an associated disease and 40% of these patients had a complaint related to the disease. The rates of admission to the intensive care units and mortality were higher in patients with higher total Abbreviated Injury Scale scores (P=0.007, P=0.003). Patients with pulmonary disease or myocardial infarction had a significantly higher mortality rate than those without.

CONCLUSION

Although not an essential factor in the cause per se, the diseases often encountered in the geriatric trauma population have a significant role on the course and mortality.

Critical care challenges in orthopedic surgery patients

OBJECTIVES

To review common and life-threatening complications resulting in intensive care unit admission for patients undergoing orthopedic surgery procedures. To identify specific diagnostic techniques and treatment modalities that may improve the outcome of critically ill orthopedic surgery patients.

DESIGN

A review of the current literature regarding the care of orthopedic surgery patients was performed.

RESULTS

Orthopedic surgery patients are vulnerable to a number of complications, particularly pulmonary complications related to scoliosis surgery, embolic complications of joint arthroplasty, and complications related to the use of opioids and sedatives in an elderly population. They also are susceptible to transfusion-related complications such as transfusion-related acute lung injury and transfusion-associated circulatory overload. Specific strategies for management of these complex patients are identified.

CONCLUSIONS

Orthopedic surgery patients represent a significant and growing proportion of patients in intensive care units. They develop unique complications, and management of these complications requires understanding of preoperative co-morbidities, intraoperative management, and early recognition and treatment of postoperative complications. Prevention and early identification of these complications are the most efficacious routes to improving outcomes in this patient population.

Trauma case management: improving patient outcomes

BACKGROUND

The purpose of the study was to measure the effect of trauma case management (TCM) on patient outcomes, using practice-specific outcome variables such as in-hospital complication rates, length of stay, resource use and allied health service intervention rates.

METHODS

TCM was provided 7 days a week to all trauma patient admissions. Data from 754 patients were collected over 14 months. These data were compared with 777 matched patients from the previous 14 months.

RESULTS

TCM greatly improved time to allied health intervention (p<0.0001). Results demonstrated a decrease in the occurrence of deep vein thrombosis (p<0.038) and a trend towards decreased patient morbidity, unplanned admissions to the intensive care unit and operating suite. A reduced hospital stay LOS, particularly in the paediatric and 45-64 years age group was noted. Six thousand six hundred twenty-one fewer pathology tests were performed and the total number of bed days was 483 days less than predicted from the control group.

CONCLUSION

The introduction of TCM improved the efficiency and effectiveness of trauma patient care in our institution. This initiative demonstrates that TCM results in improvements to quality of care, trauma patient morbidity, financial performance and resource use.

Rib fractures: Relationship with pneumonia and mortality*

OBJECTIVE

In single-institution studies, age is a risk factor for mortality after rib fracture. Sample size has limited the assessment of other risk factors. We used a national database to analyze suspected risk factors contributing to pneumonia and mortality in patients sustaining rib fractures.

DESIGN

: Database analysis.

PATIENTS

All patients with rib fractures discharged from hospitals submitting information to the Nationwide Inpatient Sample database.

INTERVENTIONS

The 1999 Nationwide Inpatient Sample was queried for all patients with rib fracture. Age, gender, number of rib fractures, Injury Severity Score, comorbidities, pneumonia, and mortality were abstracted from the database. Comorbidities were scored according to Elixhauser. Multivariate analysis identified independent risk factors for mortality and pneumonia.

MEASUREMENTS AND MAIN RESULTS

We identified 23,426 patients; 17,308 patients had a primary diagnosis of trauma and were included in the analysis. Mean age was 56. Mean Injury Severity Score was 13.1. The number of comorbidities ranged from 0 to 9. Overall mortality was 4%. Six percent of patients had pneumonia. In a multivariate model, age and Injury Severity Score were significantly associated with both mortality and pneumonia. Comorbidity score was associated with pneumonia and mortality only in patients with isolated thoracic trauma. Pneumonia was associated with mortality only in patients with isolated thoracic trauma.

CONCLUSIONS

In a model controlling for multiple known risk factors, age and Injury Severity Score were the only important predictors of mortality in patients with rib fractures and multiple-system injury. Pneumonia was significantly associated with mortality only in patients with isolated thoracic trauma.

Severe occupational injuries among older workers: Demographic factors, time of injury, place and mechanism of injury, length of stay, and cost data

Between 2002 and 2012, the number of individuals > 55 years of age in the workforce is projected to climb by approximately 50%. Few studies have substantiated that severe occupational injury to older workers is a significant problem. To identify the variables related to traumatic injuries of older workers, data were abstracted retrospectively from a regional trauma center database, including demographic and injury characteristics, length of hospital and intensive care unit (ICU) stay, and cost. The results showed that older workers had higher fatality rates than younger workers. As age increased, the Injury Severity Score also increased. Most injuries were the result of falls, with orthopedic injuries being the most common type of injury. Patients spent an average of 6 days in the ICU at a cost of > 4920 US dollars/day. By identifying the characteristics associated with older workers' severe occupational injuries, further research and better industry programs targeting this group can be implemented.

Outcome From Serious Injury in Older Adults

PURPOSE

To analyze the research published in peer-reviewed journals between 1996 and 2005 about factors affecting the physical outcomes of older adults after serious traumatic injury.

ORGANIZING CONSTRUCT

Twenty-seven primary research studies published in the last 10 years pertained to in-hospital and long-term outcomes of serious injury among older adults. Research specific to isolated hip injury, traumatic brain injury, and burn trauma was excluded.

METHODS

An integrative review of research published between January 1996 and January 2005 was carried out to examine the relationship between older age and outcome from severe injury. MEDLINE, BIOSIS previews, CINAHL, and PsycINFO databases were searched using the MeSH terms: injury, serious injury, trauma and multiple trauma, and crossed with type, severity, medical/surgical management, complication, outcome, mortality, morbidity, survival, disability, quality of life, functional status, functional recovery, function, and placement.

FINDINGS

Older adults in these studies had higher short- and long-term mortality than did younger adults. The relationship between older age and poorer outcome persisted when adjusting for injury severity, number of injuries, comorbidities, and complications. At the same time, injury severity, number of injuries, complications, and gender each independently correlated with increased mortality among older adults. The body of research is limited by overreliance on retrospective data and heterogeneity in definitional criteria for the older adult population.

CONCLUSIONS

Additional research is needed to clarify the contributory effect of variables such as psychosocial sequelae and physiologic resilience on injury outcome. The field of geriatric trauma would benefit from further population-based prospective investigation of the determinants of injury outcome in older adults in order to guide interventions and acute care treatment.

Who has life-sustaining therapy withdrawn after injury?

BACKGROUND

Trauma scoring systems have been developed to help surgeons predict who will die after injury. However, some patients may not actually die of their injuries but may undergo withdrawal of life-sustaining therapy (WLST). The goal of this study was to determine which factors were associated with WLST among older patients who died. We hypothesized that patients with comorbid illnesses, higher injury severity scores (ISS), complications, and existing advanced directives (AD) would be more likely to have WLST and that patients having WLST would receive more medication for symptom relief in the 24 hours before death.

METHODS

Data were collected via a retrospective chart review of patients age 55 years and older admitted to the intensive care unit after injury who subsequently died. In addition to demographic and injury information, documentation of family discussions regarding care wishes and formal ADs were evaluated. Patients dying despite curative attempts were compared with those who died after WLST by Student's t test and chi test where appropriate.

RESULTS

In a 3-year period, of 330 patients age 55 and older admitted to the intensive care unit, 66 (20%) died. Complete records were available for 64 patients. More than half of those who died (n = 35, 54.7%) had WLST. ADs were available for 15 patients (23.4%), and 11 (17.2%) patients had expressed to their families desires to not undergo aggressive curative care. Family discussions were documented for 50 (78%) cases. Comorbid illnesses were present in 46 (71.9%) patients and 35 (54.7%) developed at least one complication. Among people with ADs, 73% had WLST versus 49% of people without ADs (p = 0.09). WLST was independent of comorbid illnesses (p = 0.3), complications (p = 0.8), age (p = 0.5), and ISS (p = 0.2). Patients for whom there was documentation of a family discussion were more likely to have WLST than those without (91.4% versus 62.1%, p = 0.005). Morphine and benzodiazepine dosing in the 24 hours preceding death were greater in the WLST group than the curative therapy group (p = 0.02 and p = 0.05, respectively).

CONCLUSIONS

Expected associations with WLST such as age, ISS, comorbidities, and complications were not present in this population. Although trends may exist regarding patient wishes and ADs, larger studies are needed to corroborate these findings. Given the percentage of patients having supportive care withdrawn, trauma registries and scoring systems should include WLST.

Mortality in severely injured elderly trauma patients--when does age become a risk factor?

Age is a well-known risk factor in trauma patients. The aim of the present study was to define the age-dependent cut-off for increasing mortality in multiple injured patients. Pre-existing medical conditions in older age and impaired age-dependent physiologic reserve contributing to a worse outcome in multiple injured elderly patients are discussed as reasons for increased mortality. A retrospective clinical study of a statewide trauma data set from 1993 through 2000 included 5375 patients with an Injury Severity Score (ISS) > or = 16 who were stratified by age. The ISS and Abbreviated Injury Score (AIS) quantified the injury severity. Outcome measures were mortality, shock, multiple organ failure, and severe head injury. Mortality in this series increased beginning at age 56 years, and that increase was independent of the ISS. The mortality rate increased from 7.3% (patients 46-55 years of age) to 13.0% (patients ages 56-65 years) in patients with ISS 16-24; from 23.8% to 32.1% in those with ISS 25-50; and from 62.2% to 82.1% in those with ISS 51-75 (P < or = 0.05). Severe traumatic brain injury (sTBI) was the most frequent cause of death, with a significant peak in patients older than 75 years. The incidence of lethal multiple organ failure increased significantly beginning at age 56 years (P < or = 0.05), but it showed no further increase in patients aged 76 years or older. In contrast, the incidence of lethal shock showed a significant increase from age 76 years (P < or = 0.05), but not at age 56 years. However, from age 56 years, mortality increased significantly in patients who sustained multiple trauma-an increase that was independent of trauma severity.

Microstructural insight into pedestrian pelvic fracture as assessed by high-resolution computed tomography

Pelvic and femoral neck bone surface strains were recorded in five full-body human cadaver vehicle-pedestrian impacts. Impacts were performed at 40 km/h using automotive front ends constructed to represent those used in previously reported finite element simulations. While experimental kinematics and bone strains closely matched model predictions, observed pelvic fractures did not consistently agree with the model, and could not be solely explained by vehicle geometry. In an attempt to reconcile injury outcome with factors apart from vehicle design, a proxy measure of subject skeletal health was assessed by high-resolution quantitative computed tomography (HRqCT) of the femoral neck. The incidence of hip/pelvis fracture was found to be consistent with low volumetric bone mineral density and low trabecular bone density. This finding lends quantitative support to the notion that healthy trabecular architecture is crucial in withstanding non-physiological impact loads. Furthermore, it is recommended that injury criteria used to assess vehicle safety with regard to pedestrians consider the increased susceptibility of elderly victims to pelvic fracture.

Allogenic Blood Transfusion in the First 24 Hours after Trauma Is Associated with Increased Systemic Inflammatory Response Syndrome (SIRS) and Death

BACKGROUND

Previous studies have documented that blood transfusion incites a substantial inflammatory response with the systemic release of cytokines. Furthermore, blood transfusion is a significant independent predictor of multiple organ failure in trauma. The objective of this study was to assess the risk of systemic inflammatory response syndrome (SIRS) and intensive care unit (ICU) admission, length of stay (LOS), and mortality in trauma patients who require blood transfusion.

METHODS

Prospective data were collected on 9,539 trauma patients admitted to the R. Adams Cowley Shock Trauma Center over a 30-month period from January, 1997 to July, 1999. Complete SIRS data were available on 7,602 patients. Patients were stratified by age, gender, race, Glasgow coma scale (GCS), and injury severity score (ISS). A systemic inflammatory response to a wide variety of severe clinical insults (SIRS) was defined as a SIRS score of > or =2, as calculated on admission. Blood transfusion was assessed as an independent predictor of SIRS, ICU admission and length of stay, and mortality.

RESULTS

The mean age of the study cohort was 37 +/- 17 years; the mean ISS was 9 +/- 9 points. Seventy-one percent of the patients were male, and 85% sustained blunt trauma. Blood transfusion within the first 24 h was administered to 954 patients, comprising 10% of the study cohort. Transfused patients were significantly older (43 +/- 20 vs. 36 +/- 16 years, p < 0.00001), had higher ISS (22 +/- 12 vs. 8 +/- 7 points, p < 0.00001), and lower GCS (12 +/- 4 vs. 14 +/- 2 points, p < 0.00001) than non-transfused patients. Blood transfusion and increased total volume of blood transfusion was associated with SIRS. Blood transfusion was also a significant independent predictor of SIRS, ICU admission, and mortality in trauma patients by multinomial logistic regression analysis. Trauma patients who received blood transfusion had a two- to nearly sixfold increase in SIRS (p < 0.0001) and more than a fourfold increase in ICU admission (OR 4.62, 95% CI 3.84-5.55, p < 0.0001) and mortality (OR 4.23, 95% CI 3.07-5.84, p < 0.0001) compared to those that were not transfused. Linear regression analysis revealed that transfusion was an independent predictor of ICU LOS (Coef. 5.20, SE 0.43, p < 0.0001). Transfused patients had significantly longer ICU LOS (16.8 +/- 14.9 vs. 9.9 +/- 10.6 days, p < 0.00001) and hospital LOS (14.5 +/- 15.5 vs. 2.5 +/- 5.3 days, p < 0.00001) compared to non-transfused patients.

CONCLUSIONS

Blood transfusion within the first 24 h was an independent predictor of mortality, SIRS, ICU admission, and ICU LOS in trauma patients. The use of blood substitutes and alternative agents to increase serum hemoglobin concentration in the post-injury period warrants further investigation.