Differences in mortality between elderly and younger adult trauma patients: geriatric status increases risk of delayed death

Norwegian survival prediction model in trauma: modelling effects of anatomic injury, acute physiology, age, and co-morbidity

INTRODUCTION

Anatomic injury, physiological derangement, age, and injury mechanism are well-founded predictors of trauma outcome. We aimed to develop and validate the first Scandinavian survival prediction model for trauma.

METHODS

Eligible were patients admitted to Oslo University Hospital Ullevål within 24 h after injury with Injury Severity Score ≥ 10, proximal penetrating injuries or received by a trauma team. The derivation dataset comprised 5363 patients (August 2000 to July 2006); the validation dataset comprised 2517 patients (August 2006 to July 2008). Exclusion because of missing data was < 1%. Outcome was 30-day mortality. Logistic regression analysis incorporated fractional polynomial modelling and interaction effects. Model validation included a calibration plot, Hosmer-Lemeshow test and receiver operating characteristic (ROC) curves.

RESULTS

The new survival prediction model included the anatomic New Injury Severity Score (NISS), Triage Revised Trauma Score (T-RTS, comprising Glascow Coma Scale score, respiratory rate, and systolic blood pressure), age, pre-injury co-morbidity scored according to the American Society of Anesthesiologists Physical Status Classification System (ASA-PS), and an interaction term. Fractional polynomial analysis supported treating NISS and T-RTS as linear functions and age as cubic. Model discrimination between survivors and non-survivors was excellent. Area (95% confidence interval) under the ROC curve was 0.966 (0.959-0.972) in the derivation and 0.946 (0.930-0.962) in the validation dataset. Overall, low mortality and skewed survival probability distribution invalidated model calibration using the Hosmer-Lemeshow test.

CONCLUSIONS

The Norwegian survival prediction model in trauma (NORMIT) is a promising alternative to existing prediction models. External validation of the model in other trauma populations is warranted.

High-energy femur fractures increase morbidity but not mortality in elderly patients

BACKGROUND

Trauma centers are projected to have an increase in the number of elderly patients with high-energy femur fractures. Greater morbidity and mortality have been observed in these patients. Further clarification regarding the impact of high-energy femur fractures is necessary in this population.

QUESTIONS/PURPOSES

Our purpose was to assess the influence of high-energy femur fractures on mortality and morbidity in patients 60 years and older. Specifically, we asked (1) if the presence of a high-energy femur fracture increases in-hospital, 6-month, and 1-year mortality in patients 60 years and older, and (2) if there is a difference in morbidity (number of complications, intensive care unit [ICU] and total hospital length of stay, discharge disposition, accompanying fractures, and surgical intervention) between patients 60 years and older with and without high-energy femur fractures.

METHODS

A retrospective review of 242 patients was performed. Patients with traumatic brain injury or spine injury with a neurologic deficit were excluded. A control group, including patients admitted secondary to high-energy trauma without femur fractures, was matched by gender and Injury Severity Score (ISS). In-hospital mortality, 6-month and 1-year mortality, complications, ICU and total hospital length of stay, discharge disposition, accompanying fractures, surgical intervention, and covariates were recorded. Statistical analyses using Fisher's exact test, ANOVA, Kaplan-Meier estimates, and Cox regression models were performed to show differences in mortality (in-hospital, 6-month, 1-year), complications, length of ICU and total hospital stay, discharge disposition, surgical intervention, and accompanying fractures between elderly patients with and without femur fractures. The average ages of the patients were 72.8 years (± 9 years) in the femur fracture group and 71.8 years (± 9 years) in the control group. Sex, age, ISS, and comorbidities were homogenous between groups.

RESULTS

In-hospital (p = 0.45), 6-month (p = 0.79), and 1-year mortality (p = 0.55) did not differ in patients with and without high-energy femur fractures. Elderly patients with high-energy femur fractures had an increased number of complications (p = 0.029), longer total hospital length of stay (p = 0.039), were discharged more commonly to rehabilitation centers (p < 0.005), had more accompanying long bone fractures (p = 0.002), and were more likely to have surgery (p < 0.001). Average ICU length of stay was similar between the two groups (p = 0.17).

CONCLUSIONS

High-energy femur fractures increased morbidity in patients 60 years and older; however, no increase in mortality was observed in our patients. Concomitant injuries may play a more critical role in this population. Additional studies are necessary to clarify the role of high-energy femur fracture mortality in this age group.

LEVEL OF EVIDENCE

Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Triaging older major trauma patients in the emergency department: an observational study

BACKGROUND

The objective of this study was to compare the triage category assigned to older trauma patients with younger trauma patients upon arrival to the emergency department. The focus was to examine whether older major trauma patients were less likely to be assigned an emergency triage category on arrival to the emergency department after controlling for relevant demographics, injury characteristics and injury severity.

METHODS

This was an observational study using data from the Queensland Trauma Registry. All trauma patients aged 15 years and older who presented to contributing hospitals between 1 January 2005 and 31 December 2009 with an Injury Severity Score (ISS)>15 were included. Logistic regression analysis examined the odds of assignment to emergency (Australasian Triage Scale (ATS) 1 or 2) versus urgent (ATS 3-5) treatment for patients across various age categories after adjustment for relevant demographics, injury characteristics and injury severity.

RESULTS

The study used data on 6923 patients with a median (IQR) age of 43 (26-62) years and a mortality of 11.4% (95% CI 10.7% to 12.2%). Compared with individuals aged 15-34, the adjusted odds of being assigned an ATS category 1 or 2 were 30% lower (OR=0.68, 95% CI 0.57 to 0.81) for individuals aged 55-75 years and were 50% lower (OR=0.46, 95% CI 0.37 to 0.56) for individuals aged 75 years or older.

CONCLUSIONS

Among patients with an ISS>15, older major trauma patients were less likely to be assigned an emergency triage category compared with younger patients. This suggests that the elderly may be undertriaged and provides a potential area of study for reducing mortality and morbidity in older trauma patients.

Octogenarians and motor vehicle collisions: postdischarge mortality is lower than expected

BACKGROUND

Motor vehicle collisions (MVCs) are the second leading cause of injury among octogenarians. Physicians and families lack outcomes-based data to assist in the decision-making process concerning injury treatment in this population. The purpose of this study was to evaluate 1-year postdischarge mortality in octogenarian MVC patients, cause of death, and patterns predictive of mortality.

METHODS

A 10-year retrospective review was conducted of trauma patients 80 years and older who were involved in an MVC and were subsequently discharged alive. Data collected included demographics, injury severity and patterns, hospitalization details, and outcomes. State death database and hospital records were queried to determine cause of death for patients who died within 12 months of hospital discharge. Analyses were conducted to explore if a relationship existed between severity of injury and injury patterns to 12-month postdischarge mortality.

RESULTS

Among the 199 patients included in this study, mean (SD) age and Injury Severity Score (ISS) was 84.2 (3.3) years and 9.3 (8.2), respectively. Twenty-two patients (11.1%) died within 12 months. Among these patients, cause of death was directly related to trauma in nine (40.9%), likely related to trauma in seven (31.8%), and unrelated to trauma in six (27.3%). More severely injured patients (ISS >15, p = 0.0041) and those admitted to the intensive care unit (ICU) (p = 0.0051) were more likely to die within 12 months of discharge. Results indicated a trend toward higher mortality in patients with pneumonia. Rib, hip, and pelvic fractures; spinal injuries; intubation upon hospital arrival; and need for mechanical ventilation were not associated with higher postdischarge mortality rates.

CONCLUSION

The commonly held belief that the majority of octogenarians with MVC-related trauma die within 1 year of hospital discharge is refuted by this study. Only injury severity, ICU admission, and ICU duration were predictive of mortality within 12 months following discharge.

LEVEL OF EVIDENCE

Prognostic study, level III.

Clinical utility of flat inferior vena cava by axial tomography in severely injured elderly patients

BACKGROUND

Flat inferior vena cava (IVC) has been associated with shock and mortality in young trauma patients (age < 55 years). Because of the greater possibility of nonhypovolemic shock in the elderly, we hypothesized that there would be no correlation between IVC ratio and the presence of shock.

METHODS

We conducted a retrospective cohort study of all severely injured (Injury Severity Score [ISS] ≥ 15), blunt trauma patients 55 years or older from April 2006 to April 2011. Only patients undergoing axial imaging of the IVC within 1 hour of arrival were considered. Anteroposterior and transverse diameter of the IVC were measured 2.5 mm above the renal veins. Transverse-to-anteroposterior IVC ratios of 2, 3, and 4 were analyzed. Hemodynamic (heart rate, blood pressure, systolic blood pressure, shock index, and adjusted shock index [ASI]) and laboratory (hemoglobin, HCO, base excess) markers of shock were reviewed. Correlation among shock markers, IVC ratio, and death was analyzed using multivariate logistic regression. Relationship between shock and IVC ratio was analyzed using logistic regression and χ where appropriate.

RESULTS

A total of 308 patients met the inclusion criteria during the study period. The IVC ratio was greater than 2, greater than 3, and greater than 4 in 180, 85, and 46 patients, respectively. The IVC ratio (analyzed continuously) correlated with mortality (p < 0.05). Ratios of greater than 3 and greater than 4 predicted a 2.0 and 2.2 times mortality increase (95% confidence interval, 1.00-5.00 and 1.00-4.95, respectively). IVC ratio did not correlate with shock (ASI > 50) for any of the ratios studied.

CONCLUSION

As in previous studies with younger injured patients, a flat IVC is predictive of increased mortality risk in the elderly. Presence of a shock state, as defined by ASI, is not correlated with a flat IVC. Moreover, almost one third of patients presenting in shock had a round IVC. This is consistent with our hypothesis that shock in the elderly trauma population may be multifactorial and the risk of nonhypovolemic shock must be considered.

LEVEL OF EVIDENCE

Diagnostic study, level IV.

The changing nature of death on the trauma service

BACKGROUND

Recent innovations in care have improved survival following injury. Coincidentally, the population of elderly injured patients with preexisting comorbidities has increased. We hypothesized that this increase in elderly injured patients may have combined with recent care innovations to alter the causes of death after trauma.

METHODS

We reviewed demographics, injury characteristics, and cause of death of in-hospital deaths of patients admitted to our Level I trauma service from 2000 through 2011. Cause of death was classified as acute hemorrhagic shock; severe traumatic brain injury or high spinal cord injury; complications of preexisting medical condition only (PM); survivable trauma combined with complications of preexisting medical condition (TCoM); multiple-organ failure, sepsis, or adult respiratory distress syndrome (MOF/S/ARDS), or trauma not otherwise categorized (e.g., asphyxiation). Major trauma care advances implemented on our service during the period were identified, and trends in the causes of death were analyzed.

RESULTS

Of the 27,276 admissions, 819 (3%) eligible nonsurvivors were identified for the cause-of-death analyses. Causes of death were severe traumatic brain injury or high spinal cord injury at 44%, acute hemorrhagic shock at 28%, PM at 11%, TCoM at 10%, MOF/S/ARDS at 2%, and trauma not otherwise categorized at 5%. Mean age at death increased across the study interval (range, 47-57 years), while mean Injury Severity Score (ISS) decreased (range, 28-35). There was a significant increase in deaths because of TCoM (3.3-20.9%) and PM (6.7-16.4%), while deaths caused by MOF/S/ARDS decreased from 5% to 0% by 2007. Compared with year 2000, the annual adjusted mortality rate decreased consistently starting in 2009, after the 2002 to 2007 adoption of four major trauma practice guidelines.

CONCLUSION

Mortality caused by preexisting medical conditions has increased, while markedly fewer deaths resulted from the complications of injury. Future improvements in outcomes will require improvement in the management of elderly trauma patients with comorbid conditions.

[Suicide in old age: the underestimated risk. An analysis of 1,894 patients in the Trauma Registry of the German Trauma Society]

BACKGROUND

In Germany, the number of suicides and suicide attempts (n = 9,616) exceeds the number of traffic deaths (n = 4,152) by far. It is unknown how many suicide attempts are treated in trauma centres. Due to a lack of registered suicide attempts in Germany, no data exist about injury patterns, mortality or duration of treatment.

MATERIALS AND METHODS

We prospectively analysed data collected on emergency room patients from the Trauma Registry of the German Trauma Society (TR-DGU) between 1993 and 2009. All patients with an Injury Severity Score (ISS) ≥ 9, age ≥ 18 years and a documented suicide attempt were included in the study. The main target points were epidemiological data, cause of injury and injury patterns, ISS, gender distribution, mortality, duration of treatment and patients' psychiatric medical history.

RESULTS

Of 42,248 patients of the TR-DGU, 1,894 were included in the study; 274 patients were ≥ 65 years old. The most common method was jumping from a height among the group of female patients, whereas the use of firearms predominated in the male group. The average ISS was 31 points in all patient groups. The mortality was highest in patients aged ≥ 65 years. Psychiatric disorders were found predominantly in women.

CONCLUSION

Of all severely injured patients in trauma centres, 5% suffered their injuries as a consequence of a suicidal attempt. In women who survived initially, jumping from a height was the most frequently chosen method. In elderly men the use of firearms dominated. The significant increase of mortality in elderly patients, preexisting depressive conditions and the expected increase in the number of these patients as a consequence of the changed age pyramid should lead to more intensive recognition and treatment of this disease and possibly improved suicide prevention.

Evaluation of the revised trauma and injury severity scores in elderly trauma patients

BACKGROUND

Severity-of-illness scoring systems have primarily been developed for, and validated in, younger trauma patients.

AIMS

We sought to determine the accuracy of the injury severity score (ISS) and the revised trauma score (RTS) in predicting mortality and hospital length of stay (LOS) in trauma patients over the age of 65 treated in our emergency department (ED).

MATERIALS AND METHODS

Using the Illinois Trauma Registry, we identified all patients 65 years and older treated in our level I trauma facility from January 2004 to November 2007. The primary outcome was death; the secondary outcome was overall hospital length of stay (LOS). We measured associations between scores and outcomes with binary logistic and linear regression.

RESULTS

A total of 347 patients, 65 years of age and older were treated in our hospital during the study period. Median age was 76 years (IQR 69-82), with median ISS 13 (IQR 8-17), and median RTS 7.8 (IQR 7.1-7.8). Overall mortality was 24%. A higher value for ISS showed a positive correlation with likelihood of death, which although statistically significant, was numerically small (OR=1.10, 95% CI 1.06 to 1.13, P<0.001). An elevated RTS had an inverse correlation to likelihood of death that was also statistically significant (OR=0.48, 95% CI 0.39 to 0.58, P<0.001). Total hospital LOS increased with increasing ISS, with statistical significance decreasing at the highest levels of ISS, but an increase in RTS not confirming the predicted decrease in total hospital LOS consistently across all ranges of RTS.

CONCLUSIONS

The ISS and the RTS were better predictors of mortality than hypothesized, but had limited correlation with hospital LOS in elderly trauma patients. Although there may be some utility in these scores when applied to the elderly population, caution is warranted if attempting to predict the prognosis of patients.

Dabigatran bleed risk with closed head injuries: are we prepared?

OBJECT

The direct thrombin inhibitor dabigatran has recently been approved in the US as an alternative to warfarin. The lack of guidelines, protocols, and an established specific antidote to reverse the anticoagulation effect of dabigatran potentially increases the rates of morbidity and mortality in patients with closed head injury (CHI). Confronted with this new problem, the authors reviewed their initial clinical experience.

METHODS

The authors retrospectively reviewed all cases of adult patients (age ≥ 18 years) who sustained CHI secondary to ground-level falls and who presented to the authors' provisional regional Level I trauma center between February 2011 and May 2011. The authors divided these patients into 3 groups based on anticoagulant therapy: dabigatran, warfarin, and no anticoagulants.

RESULTS

Between February 2011 and May 2011, CHIs from ground-level falls were sustained by 5 patients while on dabigatran, by 15 patients on warfarin, and by 25 patients who were not on anticoagulants. The treatment of the patients on dabigatran at the authors' institution had great diversity. Repeat CT scans obtained during reversal showed 4 of 5 patients with new or expanded hemorrhages in the dabigatran group, whereas the warfarin group had 3 of 15 (p = 0.03). The overall mortality rate for patients sustaining CHI on dabigatran was 2 (40%) of 5, whereas that of the warfarin group was 0 (0%) of 15 (p = 0.05).

CONCLUSIONS

It is critical for physicians involved in the care of patients with CHI on dabigatran to be aware of an elevated mortality rate if no treatment protocol or guideline is in place. The authors will soon implement a reversal management protocol for patients with CHI on dabigatran at their institution in an attempt to improve efficacy and safety in their treatment approach.

A simple clinical risk nomogram to predict mortality-associated geriatric complications in severely injured geriatric patients

BACKGROUND

This study aimed to (1) identify inpatient complications associated with the greatest differential mortality risk between young and old patients with traumatic injury and (2) identify older patients at elevated risk for mortality-associated complications.

METHODS

Secondary analysis of more than 280,000 patients hospitalized for traumatic injury in 2001 to 2005 collected by the National Trauma Data Bank was performed. Predictor variables include 21 hospital complications. We used each complication to predict odds of hospital mortality, stratified by old (65+ years) versus young (18-64 years) age, controlling for age, sex, and preexisting condition count. We defined mortality-associated geriatric complications (MGCs) as complications associated with more than two times risk of mortality in older patients compared with younger patients. We then used age, comorbidity, and sex to predict development of MGCs or death.

RESULTS

We defined seven infectious and six noninfectious complications as MGCs (adjusted relative risk reduction for death associated with old age [aRRR] with 95% confidence interval [CI]): abscess (aRRR, 4.1; 95% CI, 3.6-4.5), wound infection (aRRR, 3.5; 95% CI, 3.2-3.9), empyema (aRRR, 3.4; 95% CI, 3.1, 3.8), urinary tract infection (aRRR, 3.3; 95% 3.0-3.6), pneumonia (aRRR, 3.1; 95% CI, 2.8-3.5), bacteremia (aRRR, 2.8; 95% CI, 2.6-3.0), aspiration pneumonia (aRRR, 2.6; 95% CI, 2.2-3.0), reduction/fixation failure (aRRR, 3.6; 95% CI, 3.3-3.9), pressure ulcer (aRRR, 3.3; 95% CI, 3.1-3.6), deep venous thrombosis (aRRR, 3.2; 95% CI, 2.9-3.6), pneumothorax (aRRR, 3.1; 95% CI, 2.5-3.7), and compartment syndrome (aRRR, 2.2; 95% CI, 1.5-2.9). We developed a graphical nomogram based on sex, age, and number of preexisting conditions to predict risk of MGCs (c statistic, 0.74).

CONCLUSION

Older patients at risk for MGC development should be considered for targeted interventions to improve quality of care.

LEVEL OF EVIDENCE

Prognostic/epidemiologic study, level III.

Classification of comorbidity in trauma: the reliability of pre-injury ASA physical status classification

BACKGROUND

Pre-injury comorbidities can influence the outcomes of severely injured patients. Pre-injury comorbidity status, graded according to the American Society of Anesthesiologists Physical Status (ASA-PS) classification system, is an independent predictor of survival in trauma patients and is recommended as a comorbidity score in the Utstein Trauma Template for Uniform Reporting of Data. Little is known about the reliability of pre-injury ASA-PS scores. The objective of this study was to examine whether the pre-injury ASA-PS system was a reliable scale for grading comorbidity in trauma patients.

METHODS

Nineteen Norwegian trauma registry coders were invited to participate in a reliability study in which 50 real but anonymised patient medical records were distributed. Reliability was analysed using quadratic weighted kappa (κ(w)) analysis with 95% CI as the primary outcome measure and unweighted kappa (κ) analysis, which included unknown values, as a secondary outcome measure.

RESULTS

Fifteen of the invitees responded to the invitation, and ten participated. We found moderate (κ(w)=0.77 [95% CI: 0.64-0.87]) to substantial (κ(w)=0.95 [95% CI: 0.89-0.99]) rater-against-reference standard reliability using κ(w) and fair (κ=0.46 [95% CI: 0.29-0.64]) to substantial (κ=0.83 [95% CI: 0.68-0.94]) reliability using κ. The inter-rater reliability ranged from moderate (κ(w)=0.66 [95% CI: 0.45-0.81]) to substantial (κ(w)=0.96 [95% CI: 0.88-1.00]) for κ(w) and from slight (κ=0.36 [95% CI: 0.21-0.54]) to moderate (κ=0.75 [95% CI: 0.62-0.89]) for κ.

CONCLUSIONS

The rater-against-reference standard reliability varied from moderate to substantial for the primary outcome measure and from fair to substantial for the secondary outcome measure. The study findings indicate that the pre-injury ASA-PS scale is a reliable score for classifying comorbidity in trauma patients.

Defining geriatric trauma: when does age make a difference?

BACKGROUND

Injured elderly patients experience high rates of undertriage to trauma centers (TCs) whereas debate continues regarding the age defining a geriatric trauma patient. We sought to identify when mortality risk increases in injured patients as the result of age alone to determine whether TC care was associated with improved outcomes for these patients and to estimate the added admissions burden to TCs using an age threshold for triage.

METHODS

We performed a retrospective cohort study of injured patients treated at TCs and non-TCs in Pennsylvania from April 1, 2001, to March 31, 2005. Patients were included if they were between 19 and 100 years of age and had sustained minimal injury (Injury Severity Score < 9). The primary outcome was in-hospital mortality. We analyzed age as a predictor of mortality by using the fractional polynomial method.

RESULTS

A total of 104,015 patients were included. Mortality risk significantly increased at 57 years (odds ratio 5.58; 95% confidence interval 1.07-29.0; P = .04) relative to 19-year-old patients. TC care was associated with a decreased mortality risk compared with non-TC care (odds ratio 0.83; 95% confidence interval 0.69-0.99; P = .04). Using an age of 70 as a threshold for mandatory triage, we estimated TCs could expect an annual increase of approximately one additional admission per day.

CONCLUSION

Age is a significant risk factor for mortality in trauma patients, and TC care improves outcomes even in older, minimally injured patients. An age threshold should be considered as a criterion for TC triage. Use of the clinically relevant age of 70 as this threshold would not impose a substantial increase on annual TC admissions.

High-energy skeletal trauma in the elderly

Despite the increasing prevalence of high-energy skeletal trauma in the elderly (i.e., sixty years or older), there is a lack of prospective data regarding best care for these injuries.Elderly patients with multiple injuries are often undertriaged to trauma centers and underresuscitated.Aggressive early resuscitation can improve outcomes in elderly patients who have sustained skeletal trauma.Comanagement by orthopaedic surgeons and geriatricians of elderly patients with skeletal trauma can lead to a lower length of hospital stay, lower readmission rates, shorter time to operation, lower complication rates, and lower mortality.

Injury patterns of seniors in traffic accidents: A technical and medical analysis

AIM: To investigate the actual injury situation of seniors in traffic accidents and to evaluate the different injury patterns.

METHODS: Injury data, environmental circumstances and crash circumstances of accidents were collected shortly after the accident event at the scene. With these data, a technical and medical analysis was performed, including Injury Severity Score, Abbreviated Injury Scale and Maximum Abbreviated Injury Scale. The method of data collection is named the German In-Depth Accident Study and can be seen as representative.

RESULTS: A total of 4430 injured seniors in traffic accidents were evaluated. The incidence of sustaining severe injuries to extremities, head and maxillofacial region was significantly higher in the group of elderly people compared to a younger age (P < 0.05). The number of accident-related injuries was higher in the group of seniors compared to other groups.

CONCLUSION: Seniors are more likely to be involved in traffic injuries and to sustain serious to severe injuries compared to other groups.

Geriatric trauma: demographics, injuries, and mortality

OBJECTIVES

To identify injuries that elderly sustain during high-energy trauma and determine which are associated with mortality.

DESIGN

Retrospective review of prospectively collected database.

SETTING

Academic trauma center.

PATIENTS

Patients selected from database of all trauma admissions from January 2004 through June 2009. Study population consisted of patients directly admitted from scene of injury who sustained high-energy trauma with at least one orthopaedic injury and were 65 years or older (n = 597).

INTERVENTION

Review of demographics, trauma markers, injuries, and disposition statuses.

MAIN OUTCOME MEASUREMENTS

Statistical analysis using χ test, Student t test, and logistic regression analysis.

RESULTS

The most common fractures were of the rib, distal radius, pelvic ring, facial bones, proximal humerus, clavicle, ankle, and sacrum. The injuries associated with the highest mortality rates were fractures of the cervical spine with neurological deficit (47%), at the C2 level (44%), and of the proximal femur (25%), pelvic ring (25%), clavicle (24%), and distal humerus (24%). The fractures significantly associated with mortality were fractures of the clavicle (P = 0.001), foot joints (P = 0.001), proximal humerus or shaft and head of the humerus (P = 0.002), sacroiliac joint (P = 0.004), and distal ulna (P = 0.002).

CONCLUSIONS

Elderly patients present with significantly worse injuries, remain in the hospital longer, require greater use of resources after discharge, and die at 3 times the rate of the younger population. Although the high mortality rates associated with cervical spine, hip, and pelvic ring fractures were not unexpected, the injuries that were statistically associated with mortality were unexpected. Injuries such as clavicle fracture were statistically associated with mortality. As our population ages and becomes more active, the demographic may gain in clinical importance.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Preinjury beta blocker usage does not affect the heart rate response to initial trauma resuscitation

BACKGROUND

The effect of preinjury beta blockade on heart rate during initial trauma resuscitation is unclear. We hypothesized that preinjury beta blockade does not affect the heart rate response to initial trauma resuscitation.

METHODS

A case-control study of patients admitted to a level I trauma center was conducted. Medical records were reviewed for demographics, medications, injury information, and hemodynamic profiles. Logistic regression identified correlations between preinjury beta blockade and hemodynamics during initial trauma resuscitation and in-hospital mortality.

RESULTS

There were 76 deaths (cases) and 304 survivors (controls). Mean pre-resuscitation heart rate was 83 in patients on beta blocker and 89 in patients not on beta blocker (p=0.007). Mean post-resuscitation heart rate was 80 in patients on beta blocker and 85 in patients not on beta blocker (p=0.02). Tachycardia was present in 14.3% with preinjury beta blocker and 29.7% without (p=0.009). Bradycardia was present in 7.1% with preinjury beta blocker and 2.3% without (p=0.035). Of all patients who presented with an abnormal heart rate, 46% of patients on beta blocker attained a normal heart rate after resuscitation vs. 53% of patients not on beta blocker (p=not significant).

CONCLUSION

Preinjury beta blockade is associated with a slower presenting heart rate, more bradycardia, less tachycardia, but no difference in mortality or ability to achieve a normal heart rate with resuscitation.

Comorbidity-polypharmacy scoring facilitates outcome prediction in older trauma patients

OBJECTIVES

To determine the association between comorbidity-polypharmacy score (CPS) and clinical outcomes in a large sample of older trauma patients, focusing on outcome prognostication.

DESIGN

The CPS combines number of preinjury medications and comorbidities to more objectively quantify the severity of comorbid conditions.

SETTING

An urban tertiary care level 1 trauma center in the Midwest.

PARTICIPANTS

Trauma patients aged 45 and older.

METHODS

Participants were stratified into four groups according to CPS ranges. Survival analyses were performed using Kaplan-Meier/Mantel-Cox testing. Factors influencing mortality, complications, and survivor discharge destination were evaluated using analysis of covariance and multivariate logistic regression.

RESULTS

Records for 469 individuals (mean age 62.1, mean injury severity score 9.3) were reviewed. Higher CPS is associated with greater mortality, complications, longer hospital and intensive care unit stay, and need for discharge to a facility. Higher CPS is associated with lower 90-day survival (Mantel-Cox, P < .001). Mortality was independently associated with older age (odds ratio (OR) = 1.06 per year), higher injury severity score (OR = 1.19 per point), and higher CPS (OR = 1.11 per point) in multivariate analysis (all P < .01). Complications and need for discharge to a facility were independently associated with older age and higher injury severity score and CPS.

CONCLUSION

CPS can be readily determined in the era of medication reconciliation. Trauma patients with CPS of 15 or greater are at greater risk of poor clinical outcomes. CPS constitutes a useful adjunct to currently available injury severity scoring tools as a predictor of morbidity, mortality, hospital resource utilization, and postdischarge disposition in older trauma patients.

Motor vehicle collision-related emergency department visits by older adults in the United States

OBJECTIVES

Motor vehicle collisions (MVCs) are the second most common cause of nonfatal injury among U.S. adults age 65 years and older. However, the frequency of emergency department (ED) visits, disposition, pain locations, and pain severity for older adults experiencing MVCs have not previously been described. The authors sought to determine these characteristics using information from two nationally representative data sets.

METHODS

Data from the 2008 Healthcare Cost and Utilization Project Nationwide Emergency Department Sample (NEDS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS) were used to estimate MVC-related ED visits and ED disposition for patients 65 years and older. NHAMCS data from 2004 through 2008 were used to further characterize MVC-related ED visits.

RESULTS

  In 2008, the NEDS contained 28,445,564 patient visits, of which 760,356 (2.7%) were due to MVCs. The NHAMCS contained 34,134 patient visits, of which 1,038 (3.0%) were due to MVCs. National estimates of MVC-related ED visits by patients 65 years and older in 2008 are 226,000 (95% confidence interval [CI]=210,000 to 240,000) for NEDS and 270,000 (95% CI=185,000 to 355,000) for NHAMCS. Most older adults with MVC-related ED visits were sent home from the ED (proportion discharged NEDS 78%, 95% CI=78% to 79%; NHAMCS 77%, 95% CI=66% to 86%). During the years 2004 through 2008, of MVC-related ED visits by older adults not resulting in hospital admission, moderate or severe pain was reported in 61% (95% CI=52% to 70%) of those with recorded pain scores. Older patients sent home after MVC-related ED visits were less likely than younger patients to receive analgesics (35%, 95% CI=26% to 43% vs. 47%, 95% CI=44% to 50%) during their ED evaluations or as discharge prescriptions (52%, 95% CI=41% to 62% vs. 65%, 95% CI=61% to 68%).

CONCLUSIONS

In 2008, adults age 65 years or older made more than 200,000 MVC-related ED visits. Approximately 80% of these visits were discharged home from the ED, but the majority of discharged patients reported moderate or severe pain. Further studies of pain and functional outcomes in this population are needed.

Mild Traumatic Brain Injury among the Geriatric Population

Mild traumatic brain injury (TBI) is an unfortunately common occurrence in the elderly. With the growing population of older adults in the United States and globally, strategies that reduce the risk of becoming injured need to be developed, and diagnostic tools and treatments that may benefit this group need to be explored. Particular attention needs to be given to polypharmacy, drug interactions, the use of anticoagulants, safety issues in the living environment, elder abuse, and alcohol consumption. Low-mechanism falls should prompt health care providers to consider the possibility of head injury in elderly patients. Early and tailored management of our seniors following a mild TBI can provide them with the best possible quality of life. This review will discuss the current literature on mild TBI in the older adult, address gaps in research, and discuss the implications for future care of the older TBI patient.

Hemodynamic responses and serum nitrite concentration during uncontrolled hemorrhagic shock in normotensive and hypertensive rats

BACKGROUND

We evaluated the effect of hypertension on hemodynamic responses and serum nitrite concentrations in normotensive (NT) and deoxycorticosteron acetate (DOCA)-Salt hypertensive (HT) rats.

METHODS

Uncontrolled hemorrhagic shock was induced in NT and HT rats (n=7 each) by preliminary bleed of 25 ml/kg followed by a 75% tail amputation. The mean arterial pressure (MAP), heart rate and serum nitrite were measured pre-hemorrhage and during hemorrhage.

RESULTS

Changes in time-averaged MAP after hemorrhage were significantly greater in HT group than NT. After resuscitation, the HT rats failed to restore MAP to baseline level. Serum nitrite level in both groups was significantly increased during shock period. Survival rate of HT animals was lower than NT group, although it was not statistically significant.

CONCLUSIONS

Marked reduction of MAP and less improvement after resuscitation suggested the less adaptation of cardiovascular system in HT animals which may interfere with management of these subjects during uncontrolled hemorrhagic shock.

Comorbidity-polypharmacy score: a novel adjunct in post-emergency department trauma triage

OBJECTIVE

Post-emergency department triage of older trauma patients continues to be challenging, as morbidity and mortality for any given level of injury severity tend to increase with age. The comorbidity-polypharmacy score (CPS) combines the number of pre-injury medications with the number of comorbidities to estimate the severity of comorbid conditions. This retrospective study examines the relationship between CPS and triage accuracy for older (≥45y) patients admitted for traumatic injury.

METHODS

Patients aged 45y and older presenting to level 1 trauma center from 2005 to 2008 were included. Basic data included patient demographics, injury severity score, morbidity and mortality, and functional outcome measures. CPS was calculated by adding total numbers of comorbid conditions and pre-injury medications. Patients were divided into three triage groups: undertriage (UT), appropriate triage (AT), and overtriage (OT). UT criteria included initial admission to the floor or step-down unit followed by an unplanned transfer to intensive care unit (ICU) within 24h of admission. OT was defined as initial ICU admission for <1d without stated need for ICU level of care (i.e., lack of evidence for tracheal intubation or mechanical ventilation, injury-related hemorrhage, or other traditional ICU indications, such as intracranial bleeding). All other patients were presumed to be correctly triaged. The three triage groups were then analyzed looking for contributors to mistriage.

RESULTS

Charts for 711 patients were evaluated (mean age, 63.5y; 55.7% male; mean ISS, 9.02). Of those, 11 (1.55%) met criteria for UT and 14 (1.97%) for OT. The remaining 686 patients had no evidence of mistriage. The three groups were similar in terms of injury severity and GCS. The groups were significantly different with respect to CPS, with UT CPSs (14.9±6.80) being nearly three times higher than OT CPSs (5.14±3.48). There were more similarities between AT and OT groups, with the UT group being characterized by greater number of complications and lower functional outcomes at discharge (all, P<0.05). The UT group had significantly higher mortality (27%) than the AT and OT groups (6% and 0%, respectively).

CONCLUSIONS

In the era of medication reconciliation, CPS is easy to obtain and calculate in patients who are not critically injured. This study suggests that CPS may be a promising adjunct in identifying older trauma patients who are more likely to be undertriaged. The significance of our findings is especially important when considering that injury severity in the UT group was similar to that in the other groups. Further evaluation of CPS as a triage tool in acute trauma is warranted.

Evaluating age in the field triage of injured persons

STUDY OBJECTIVE

We evaluate trauma undertriage by age group, the association between age and serious injury after accounting for other field triage criteria and confounders, and the potential effect of a mandatory age triage criterion for field triage.

METHODS

This was a retrospective cohort study of injured children and adults transported by 48 emergency medical services (EMS) agencies to 105 hospitals in 6 regions of the western United States from 2006 through 2008. We used probabilistic linkage to match EMS records to hospital records, including trauma registries, state discharge databases, and emergency department databases. The primary outcome measure was serious injury, as measured by an Injury Severity Score greater than or equal to 16. We assessed undertriage (Injury Severity Score ≥16 and triage-negative or transport to a nontrauma center) by age decile and used multivariable logistic regression models to estimate the association (linear and nonlinear) between age and Injury Severity Score greater than or equal to 16, adjusted for important confounders. We also evaluated the potential influence of age on triage efficiency and trauma center volume.

RESULTS

Injured patients (260,027) were evaluated and transported by EMS during the 3-year study period. Undertriage increased for patients older than 60 years, reaching approximately 60% for those older than 90 years. There was a strong nonlinear association between age and Injury Severity Score greater than or equal to 16. For patients not meeting other triage criteria, the probability of serious injury was most notable after 60 years. A mandatory age triage criterion would have decreased undertriage at the expense of overtriage, with 1 patient with Injury Severity Score greater than or equal to 16 identified for every 60 to 65 additional patients transported to major trauma centers.

CONCLUSION

Trauma undertriage increases in patients older than 60 years. Although the probability of serious injury increases among triage-negative patients with increasing age, the use of a mandatory age triage criterion appears inefficient for improving field triage.

Utilization and costs of health care after geriatric traumatic brain injury

Despite the growing number of older adults experiencing traumatic brain injury (TBI), little information exists regarding their utilization and cost of health care services. Identifying patterns in the type of care received and determining their costs is an important first step toward understanding the return on investment and potential areas for improvement. We performed a health care utilization and cost analysis using the National Study on the Costs and Outcomes of Trauma (NSCOT) dataset. Subjects were persons 55-84 years of age with TBI treated in 69 U.S. hospitals located in 14 states (n=414, weighted n=1038). Health outcomes, health care utilization, and 1-year costs of care following TBI in 2005 U.S. dollars were estimated from hospital bills, patient surveys, medical records, and Medicare claims data. The subjects were further analyzed in three subgroups (55-64, 65-74, and 75-84 years of age). Unadjusted cost models were built, followed by a second set of models adjusting for demographic and pre-injury health status. Those in the oldest category (75-84 years) had significantly higher numbers of re-hospitalizations, home health care visits, and hours per week of unpaid care, and significantly lower numbers of physician and mental health professional visits than younger age groups (age 55-64 and 65-74 years). Significant age-related differences were seen in all health outcomes tested at 12 months post-injury except for incidence of depressive symptoms. One-year total treatment costs did not differ significantly across age categories for brain-injured older adults in either the unadjusted or adjusted models. The unadjusted total mean 1-year cost of care was $77,872 in persons aged 55-64 years, $76,903 in persons aged 65-74 years, and $72,733 in persons aged 75-84 years. There were significant differences in cost drivers among the age groups. In the unadjusted model index hospitalization costs and inpatient rehabilitation costs were significantly lower in the oldest age category, while outpatient care costs and nursing home stays were lower in the younger age categories. In the adjusted model, in addition to these cost drivers, re-hospitalization costs were significantly higher among those 75-84 years of age, and receipt of informal care from friends and family was significantly different, being lowest among those aged 65-74 years, and highest among those aged 75-84 years. Identifying variations in care that these patients are receiving and determining the costs versus benefits is an important next step in understanding potential areas for improvement.

Severely injured geriatric population: morbidity, mortality, and risk factors

BACKGROUND

With an increasing life expectancy and more active elderly population, management of geriatric trauma patients continues to evolve. The aim was to describe the mechanism and injuries of severely injured geriatric patients and to identify risk factors associated with mortality.

METHODS

The Trauma Registry at a Canadian Level I trauma center was queried for all trauma patients older than 65 years and injury severity score >15 from 2004 to 2006, resulting in a retrospective chart review of 276 patients. The data were subsequently analyzed using univariate and multivariate analysis.

RESULTS

Average age was 81.5 years (mean injury severity score of 25). Most common comorbid illness was hypertension (57.3%) and most frequent mechanism of injury was falls (72.3%). The overall mortality was comparable with the US National Trauma Data Bank (26.8% vs. 32.0%, confidence interval, 0.00-0.10). Geriatric patients requiring intubation, blood transfusions, or suffering from head, C-spine, or chest trauma had an increased likelihood of death. In-hospital respiratory, gastrointestinal, or infectious complications also had higher likelihood of death.

CONCLUSIONS

Falls continue to be the most frequent mechanism of injury in severely injured geriatric patients. Risk factors associated with a higher likelihood of death are identified. More research is needed to better understand this important and increasing group of trauma patients.

Development of statewide geriatric patients trauma triage criteria

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Diurnal variation in mortality in older nocturnal fallers

BACKGROUND

The prevalence of older trauma patients is rising in Westernised populations. Age has an independent adverse affect on survival from injury. Factors contributing to this increased mortality are incompletely understood.

OBJECTIVE

To examine the independent effects of age, time and mechanism of injury on survival from trauma at 30 days.

METHODS

We analysed prospectively collected data from the Trauma Audit and Research Network database. Isolated femoral neck and pubic rami fractures are not included in this data set. Univariate and multivariate regression analyses were undertaken. Independent effects of age, time of injury and mechanism of injury on survival following trauma were evaluated.

RESULTS

A total of 137,521 trauma patients were included in the study. Trauma victims aged over 65 years had increased odds of death of 9.58 (95% CI: 8.78-10.45), adjusting for known confounders of outcome. Analysis of two-way interactions of age and time of arrival to hospital, revealed patients ≥65 years had a higher odds of death if they presented between midnight and 8 a.m., compared with 08:00-16:00 h; OR = 1.5, (95% CI: 1.29-1.73). Further analysis of this older group, examining the interaction of time and mechanism of injury, revealed a doubling of the odds of death in patients injured following a fall <2 m, when they presented between midnight and 8 a.m.; OR = 2.1, (95% CI: 1.32-3.30). This diurnal variation in mortality was exclusive to older fallers.

CONCLUSIONS

Age over 65 years has an independent detrimental affect on survival from trauma. A distinct diurnal variation in mortality from injury occurs in older patients injured as a result of a low velocity fall.

[Out-of-hospital management of elderly patients for trauma injury]

Elderly patients should benefit from maximum care in cases of serious trauma, starting with pre-hospital care. A proper evaluation of the gravity of the trauma is an essential element in the management. The elderly are at risk of "under-triage", which can result in inappropriate hospital admission and delayed trauma care. Particular attention must be paid to "common" trauma, because such trauma is often associated with a potentially serious outcome in elderly patients. The Vittel criteria offer an important tool to estimate the level of gravity and to help in patient triage. The kinetic of the accident is important in identifying serious trauma. Emergency medical services with physicians on board must be the norm in cases of severe trauma, irrespective of the age of the patient. The literature clearly indicates the benefit of an aggressive strategy in elderly trauma patients, thus justifying direct admission in a trauma center in cases of real or potentially serious trauma. There is no difference in pre-hospital care management between elderly and younger trauma patients. Analgesia must be a priority. When a self-assessment of pain intensity is impossible, specific scales for pain can be used, such as Algoplus(®). Morphine titration is the recommended strategy for analgesia in the pre-hospital setting and the same protocol must be used for both the elderly and younger patients. Locoregional anaesthesia should be used when possible in this setting, in particular the ilio-facial block. Age is not a criterion for a non-resuscitation order in trauma patients. The decisions of limitation of therapeutic, if they were not anticipated, will be discussed after admission, according to the principles of the current legislation.

Neurological outcomes of neurosurgical operations for multiple trauma elderly patients in Hong Kong

Background:

We aimed to investigate neurological outcomes in elderly patients with multiple trauma, and to review their clinical outcomes following neurosurgical operations.

Patients and Methods:

The study was conducted in a regional trauma center in Hong Kong. We collected prospective data on consecutive trauma patients from January 2001 to December 2008. Patients with multiple trauma (as defined by Injury Severity Score of 15 or more), with both head injury and extracranial injury, were included for analysis.

Results:

Age over 65 years, admission Glasgow Coma Scale (GCS), and Injury Severity Score were significantly poor prognostic factors in logistic regression analysis. Eleven (32%) of the 34 patients aged over 65 who underwent neurosurgical operations attained favorable neurological outcomes (GCS 4-5) at 6 months.

Conclusions:

Age was an important prognostic factor in multiple trauma patients requiring neurosurgical operations. Future randomized controlled clinical trials should be designed to recruit elderly patients (such as age between 65 and 75 years) at clinical equipoise for traumatic hematoma (such as subdural hematoma or traumatic intracerebral hematoma) evacuation and assess the quality of life, neurological, and cognitive outcomes.

The validity of the Canadian Triage and Acuity Scale in predicting resource utilization and the need for immediate life-saving interventions in elderly emergency department patients

Background

We evaluated the validity of the Canadian Triage and Acuity Scale (CTAS) in elderly emergency department (ED) patients. In particular, we examined the sensitivity and specificity of the CTAS for identifying elderly patients who received an immediate life-saving intervention in the ED.

Methods

We reviewed the medical records of consecutive patients who were 65 years of age or older and presented to a single academic ED within a three-month period. The CTAS triage scores were compared to actual patient course, including disposition, discharge outcome and resource utilization. We calculated the sensitivity and specificity of the CTAS triage for identifying patients who received an immediate intervention.

Results

Of the 1903 consecutive patients who were ≥ 65 years of age, 113 (5.9%) had a CTAS level of 1, 174 (9.1%) had a CTAS level of 2, 1154 (60.6%) had a CTAS level of 3, 347 (18.2%) had a CTAS level of 4, and 115 (6.0%) had a CTAS level of 5. As a patient's triage score increased, the severity (such as mortality and intensive care unit admission) and resource utilization increased significantly. Ninety-four of the patients received a life-saving intervention within an hour following their arrival to the ED. The CTAS scores for these patients were 1, 2 and 3 for 46, 46 and 2 patients, respectively. The sensitivity and specificity of a CTAS score of ≤ 2 for identifying patients for receiving an immediate intervention were 97.9% and 89.2%, respectively.

Conclusions

The CTAS is a triage tool with high validity for elderly patients, and it is an especially useful tool for categorizing severity and for recognizing elderly patients who require immediate life-saving intervention.

Renal Insufficiency Predicts Mortality in Geriatric Patients Undergoing Emergent General Surgery

Clinical predictors of perioperative mortality in geriatric patients undergoing emergent general surgery have not been well described. The purpose of this study was to determine the incidence of postoperative morbidity and mortality in geriatric patients and factors associated with mortality. A retrospective review of patients 65 years of age or older undergoing emergent general surgery at a public teaching hospital was performed over a 7-year period. Data collected included demographics, comorbidities, laboratory studies, perioperative morbidities, and mortality. Descriptive statistics and predictors of morbidity and mortality are described. The mean age was 74 years. Indications for surgery included small bowel obstruction (24%), diverticulitis (20%), perforated viscous (16%), and large bowel obstruction (9%). The overall complication rate was 41 per cent with six cardiac complications (14%) and seven perioperative (16%) deaths. Mean admission serum creatinine was significantly higher in patients who died (3.6 vs 1.5 mg/dL, P = 0.004). Mortality for patients with an admission serum creatinine greater than 2.0 mg/dL was 42 per cent (5 of 12) compared with 3 per cent (2 of 32) for those 2.0 mg/dL or less (OR, 10.7; CI, 1.7 to 67; P = 0.01). Morbidity and mortality in geriatric patients undergoing emergency surgery remains high with the most significant predictor of mortality being the presence of renal insufficiency on admission.

Modification of Glasgow Coma Scale criteria for injured elders

OBJECTIVES

An abnormal field Glasgow Coma Scale (GCS) score of ≤13 has been used in our emergency medical services (EMS) system to prompt transport to a trauma center. For elders, Ohio has recently adopted a GCS of ≤14 to prompt EMS transport to a trauma center, as older patients respond differently to trauma and may benefit from a different GCS threshold. This study sought to determine if a field GCS of 14 is an appropriate cutoff to initiate transport to a trauma center among injured elders.

METHODS

This was a retrospective, observational statewide analysis of injured patients ≥16 years old captured by the Ohio Trauma Registry from 2002 to 2007. Outcomes studied included mortality, traumatic brain injury (TBI), neurosurgical intervention, and endotracheal intubation (ETI). Multiple imputation was performed to account for missing data. Age-stratified sensitivity and specificity for proposed GCS cutoffs of 13 and 14 were calculated. A series of multivariate logistic regression models was then constructed using each outcome as a dependent variable. Independent variables included age, GCS score, sex, blood pressure, injury type, nontrauma center, race, ethnicity, and Injury Severity Score (ISS). Two separate analyses were performed. For each age group, odds ratios (ORs) of each outcome were calculated both for the decrease in GCS from 15 to 14 and for the decrease from 14 to 13. The group of elders with GCS 14 was then compared to adults with GCS 13.

RESULTS

A total of 52,412 study patients were identified. For a GCS cutoff of 13, sensitivity among elders for each outcome was >20% less than sensitivity for adults, and specificity was 5% to 10% greater. Increasing the GCS cutoff for elders to 14 resulted in improved sensitivity for all outcomes (approximately 10%), with a decline in specificity to values near that of adults with GCS 13. In the multivariate models for elders, mortality increased with a decrease in GCS both from 15 to 14 (OR = 1.40, 95% confidence interval [CI] = 1.07 to 1.83) and from GCS 14 to 13 (OR = 2.34, 95% CI = 1.57 to 3.52). In adults, mortality did not increase with the drop from GCS 15 to 14 (OR = 1.22, 95% CI = 0.88 to 1.71) or from GCS 14 to 13 (OR = 1.45, 95% CI = 0.91 to 2.30). When comparing elders with GCS 14 to adults with GCS 13, elders had greater odds of mortality (OR = 4.68, 95% CI = 2.90 to 7.54) and TBI (OR = 1.84, 95% CI = 1.45 to 2.34).

CONCLUSIONS

Changing the EMS trauma triage cutoff for elders from GCS 13 to GCS 14 results in improved sensitivity for clinically relevant outcomes. In injured elders, the decline in GCS from 15 to 14 is associated with increased mortality, a finding not observed in younger adults. Elders with GCS 14 have greater odds of mortality and TBI than adults with GCS 13. These results support recent changes in EMS trauma triage guidelines for elders adopted in Ohio.

Gunshot injuries in the elderly: patterns and outcomes. A national trauma databank analysis

BACKGROUND

Trauma in the elderly (≥ 55 years) accounts for a significant proportion of admissions to trauma centers. Our understanding of the epidemiology and outcomes associated with penetrating injury in this age segment of the population, however, is severely limited. The aim of the present study therefore was to investigate the incidence and type of injuries sustained by elderly patients from firearms and the impact of age on outcomes.

METHODS

This was a 5-year National Trauma Databank (NTDB) study. Injury demographics, mortality rates, and lengths of stay in the Intensive Care Unit (ICU) and the hospital were analyzed. Elderly patients ≥ 55 years old were assigned to one of three categorical strata: 55-64 years old, 65-74 years old, and ≥ 75 years old.

RESULTS

During the study period, 98,242 patients were admitted for firearm-related injuries, and 3,190 (3.2%) of them were ≥ 55 years old. Within the elderly age segment of the population, 1,676 patients (52.5%) were 55-64 years of age, 727 (22.8%) were 65-74 years of age, and 787 (24.7%) were ≥ 75 years old. The incidence of severe trauma [Injury Severity Score (ISS) ≥ 16] in the elderly age strata was 43.3, 46.8, and 57.6%, respectively (p < 0.001). Patients ≥ 75 years old were significantly more likely than patients 55-74 years old to suffer self-inflicted injuries. The most commonly encountered injury in elderly patients was gunshot wounds to the head, which increased in a stepwise fashion with advancing age (25.8, 31.6, and 39.4% respectively; p < 0.001). The crude mortality rate in all patients sustaining gunshot wounds increased progressively with age. Within the elderly age segment, mortality ranged from 28.5% in the age stratum 55-64 years, to 55.4% in the stratum ≥ 75 years (adjusted p < 0.001). Intensive care unit and hospital length of stay increased with advancing age but peaked and remained stable among the elderly age groups. An admission Glasgow Coma Score (GCS) ≤ 8, an ISS ≥ 16, hypotension on admission, age, self-inflicted injury, and injury sustained by assault were factors independently associated with death in patients ≥ 55 years.

CONCLUSIONS

Injury from firearms is not uncommon in the elderly patient population and is primarily a result of self-inflicted gunshot wounds to the head. These patients sustain a high burden of injury and a high rate of mortality, which increases with advancing age.

Multiple trauma in the elderly: new management perspectives

Multiple trauma in the elderly is increasing with the aging population. In contrast to their younger counterparts, elderly patients experience significantly higher mortality rates and complications after major trauma. Diminished physiological reserve and the existence of multiple medical comorbidities present additional challenges to management. As such, a different approach is required to care for the elderly trauma patient.

Withdrawal of life sustaining therapy after traumatic injury

Background: Each year, traumatic injury accounts for large number of patient admissions and deaths in the US. Injuries have tremendous public health implications, and controlling and treating traumatised patients is an essential part of any health delivery system. Nonetheless, traumatised patients whose terminal hospitalisation ends in the intensive care unit (ICU) are a particular demographic group that has not been well studied.

Methods: Here, we review demographic trends, critical care unit utilisation and outcomes for trauma patients. Based on the available data, we discuss issues related to specific patient groups (such as the elderly), management of end-of-life patients in the ICU, views of medical professionals relative to end-of-life care and costs associated and with care of terminally ill patients. In this context, we also review and discuss recent data on withdrawal of life-sustaining therapies for trauma patients.

Conclusions: We conclude that it is difficult for physicians, patients and their families to recognise when care should focus on comfort rather than aggressive interventions that prolong dying. This is particularly difficult in situations of trauma, where unexpected injury causes profound disability. Nonetheless, the challenges pertain to trauma patients as they do to all critically ill patients, where providing an ethical and dignified death can be as heroic as aggressive measures to save life. More studies are needed to determine how we can best meet the needs of terminally ill trauma patients and their families.

Factors associated with trauma center use for elderly patients with trauma: a statewide analysis, 1999-2008

OBJECTIVES

To estimate the likelihood of trauma center admission for injured elderly patients with trauma, determine trends in trauma center admissions, and identify factors associated with trauma center use for elderly patients with trauma.

DESIGN

Retrospective analysis.

SETTING

Acute care hospitals in California.

PATIENTS

All patients hospitalized for acute traumatic injuries during the period from January 1, 1999, to December 31, 2008 (n = 430,081). Patients who had scheduled admissions for nonacute or minor trauma were excluded.

MAIN OUTCOME MEASURE

Likelihood of admission to level I or II trauma center was calculated according to age categories after adjusting for patient and system factors.

RESULTS

Of 430,081 patients admitted to California acute care hospitals for trauma-related diagnoses, 27% were older than 65 years. After adjusting for demographic, clinical, and system factors, compared with trauma patients aged 18-25 years, the odds of admission to a trauma center decreased with increasing age; patients aged 26-45 years had lower odds (odds ratio [OR], 0.75; 95% confidence interval [CI], 0.71-0.80) of being admitted to a trauma center for their injuries than did patients 46-65 years of age (OR, 0.57; 95% CI, 0.54-0.60), patients 66-85 years of age (OR, 0.35; 95% CI, 0.30-0.41), and patients older than 85 years (OR, 0.30; 95% CI, 0.25-0.36). Similar patterns were found when stratifying the analysis by trauma type and severity. Living more than 50 miles away from a trauma center (OR, 0.03; 95% CI, 0.01-0.06) and lack of county trauma center (OR, 0.17; 95% CI, 0.09-0.35) were also predictors of not receiving trauma care.

CONCLUSION

Age and likelihood of admission to a trauma center for injured patients were observed to be inversely proportional after controlling for other factors. System-level factors play a major role in determining which injured patients receive trauma care.

Emergency department crystalloid resuscitation of 1.5 L or more is associated with increased mortality in elderly and nonelderly trauma patients

BACKGROUND

Recent evidence suggests a survival advantage in trauma patients who receive controlled or hypotensive resuscitation volumes. This study examines the threshold crystalloid volume that is an independent risk factor for mortality after trauma.

METHODS

This study analyzed prospectively collected data from a Level I Trauma Center between January 2000 and December 2008. Demographics and outcomes were compared in elderly (≥70 years) and nonelderly (<70 years) trauma patients who received crystalloid fluid in the emergency department (ED) to determine a threshold volume that was an independent predictor for mortality.

RESULTS

A total of 3,137 patients who received crystalloid resuscitation in the ED were compared. Overall mortality was 5.2%. Mortality among the elderly population was 17.3% (41 deaths), whereas mortality in the nonelderly population was 4% (116 deaths). After multivariate logistic regression analysis, fluid volumes of 1.5 L or more were significantly associated with mortality in both elderly (odds ratio [OR]: 2.89, confidence interval [CI] [1.13-7.41], p=0.027) and nonelderly patients (OR: 2.09, CI [1.31-3.33], p=0.002). Fluid volumes up to 1 L were not associated with significantly increased mortality. At 3 L, mortality was especially pronounced in the elderly (OR: 8.61, CI [1.55-47.75] p=0.014), when compared with the nonelderly (OR=2.69, CI [1.53-4.73], p=0.0006).

CONCLUSION

ED volume replacement of 1.5 L or more was an independent risk factor for mortality. High-volume resuscitations were associated with high-mortality particularly in the elderly trauma patient. Our finding supports the notion that excessive fluid resuscitation should be avoided in the ED and when required, operative intervention or intensive care admission should be considered.

The impact of country and culture on end-of-life care for injured patients: results from an international survey

BACKGROUND

Up to 20% of all trauma patients admitted to an intensive care unit die from their injuries. End-of-life decision making is a variable process that involves prognosis, predicted functional outcomes, personal beliefs, institutional resources, societal norms, and clinician experience. The goal of this study was to better understand end-of-life processes after major injury by comparing clinician viewpoints from various countries and cultures.

METHODS

A clinician-based, 38-question international survey was used to characterize the impacts of medical, religious, social, and system factors on end-of-life care after trauma.

RESULTS

A total of 419 clinicians from the United States (49%), Canada (19%), South Africa (11%), Europe (9%), Asia (8%), and Australasia (4%) completed the survey. In America, the admitting surgeon guided most end-of-life decisions (51%), when compared with all other countries (0-27%). The practice structure of American respondents also varied from other regions. Formal medical futility laws are rarely available (14-38%). Ethical consultation services are often accessible (29-98%), but rarely used (0-29%), and typically unhelpful (<30%). End-of-life decision making for patients with traumatic brain injuries varied extensively across regions with regard to the impact of patient age, Glasgow Coma Scale score, and clinician philosophy. Similar differences were observed for spinal cord injuries (age and functional level). The availability and use of "donation after cardiac death" also varied substantially between countries.

CONCLUSIONS

In this unique study, geographic differences in religion, practice composition, decision-maker viewpoint, and institutional resources resulted in significant variation in end-of-life care after injury. These disparities reflect competing concepts (patient autonomy, distributive justice, and religion).

Patients with pelvic fractures due to falls: A paradigm that contributed to autopsy-based audit of trauma in Greece

BACKGROUND

Evaluation of the pelvic fractures (PFx) population in auditing effective components of trauma care is the subject of this study.

METHODS

A retrospective, case-control, autopsy-based study compared a population with PFx to a control-group using a template with trauma outcome variables, which included demographics, ICD-9, intention, mechanisms, toxicology, Abbreviated Injury Scale (AIS-90), Injury Severity Score (ISS), causes of haemorrhage, comorbidity, survival time, pre-hospital response, in hospital data, location of death, and preventable deaths.

RESULTS

Of 970 consecutive patients with fatal falls, 209 (21.5%) had PFx and constituted the PFx-group while 761 (78.5%) formed the control-group.Multivariate analysis showed that gender, age, intention, and height of fall were risk factors for PFx. A 300% higher odds of a psychiatric history was found in the PFx-group compared to the control-group (p < 0.001).The median ISS was 50 (17-75) for the PFx-group and 26 (1-75) for the control-group (p < 0.0001). There were no patients with an ISS less than 16 in the PFx group.Associated injuries were significantly more common in the PFx-group than in the control-group. Potentially preventable deaths (ISS < 75) constituted 78% (n = 163) of the PFx-group. The most common AIS3-5 injuries in the potentially preventable subset of patients were the lower extremities in 133 (81.6%), thorax in 130 (79.7%), abdomen/pelvic contents in 99 (60.7%), head in 95 (58.3%) and the spine in 26 (15.9%) patients.A subset of 126 (60.3%) potentially preventable deaths in the PFx-group had at least one AIS-90 code other than the PFx, denoting major haemorrhage. Deaths directly attributed to PFx were limited to 6 (2.9%).The median survival time was 30 minutes for the PFx-group and 20 hours for the control-group (p < 0.001). For a one-group increment in the ISS-groups, the survival rates over the post-traumatic time intervals were reduced by 57% (p < 0.0001).Pre-hospital mortality was significantly higher in the PFx-group i.e. 70.3% of the PFx-group versus 42.7% of the control-group (p < 0.001).

CONCLUSIONS

The PFx-group shared common causative risk factors, high severity and multiplicity of injuries that define the PFx-group as a paradigm of injury for audit. This reduced sample of autopsies substantially contributed to the audit of functional, infrastructural, management and prevention issues requiring transformation to reduce mortality.

Ground level falls are associated with significant mortality in elderly patients

BACKGROUND

Falls from height are considered to be high risk for multisystem injury. Ground-level falls (GLF) are often deemed a low-energy mechanism of injury (MOI) and not a recommended triage criterion for trauma team activation. We hypothesize that in elderly patients, a GLF may represent a high-risk group for injury and concurrent comorbidities that warrant trauma service evaluation and should be triaged appropriately.

METHODS

This is a retrospective study based on the National Trauma Data Bank. All patients with MOI consistent with GLF were identified. Demographics, type and severity of injuries, and outcomes were analyzed.

RESULTS

We identified 57,302 patients with GLF. The group had 34% men, with mean age of 68 years ± 17 years and injury severity score of 8 ± 5. Overall mortality was 3.2%. There were 32,320 elderly patients (older than 70 years). The mortality in the elderly was significantly higher than the nonelderly (4.4% vs. 1.6%, p < 0.0001). The elderly were more likely to sustain long-bone fracture (54.5% vs. 35.9%, p < 0.0001), pelvic fracture (7.6% vs. 2.4%, p < 0.0001), and intracranial injury (10.6% vs. 8.7%, p<0.0001). Multivariate analysis showed that Glasgow Coma Scale (GCS) score <15 (odds ratio, 4.98) and older than 70 years (odds ratio, 2.75) were significant predictors of mortality inpatients after GLF.

CONCLUSIONS

Patients older than 70 years and with GCS score <15 represent a group with significant inhospital mortality.

Trends in the accuracy of older person trauma triage from 2004 to 2008

BACKGROUND

Older injured persons are frequently undertriaged, increasing the risk for preventable mortality and morbidity in an already-vulnerable population. Changes made in 2006 to the American College of Surgeons Committee on Trauma (ACS-COT) Field Triage Decision Scheme might improve triage accuracy for this population.

OBJECTIVE

This study examined triage accuracy before and after the 2006 revisions.

METHODS

This secondary analysis of 2004, 2007, and 2008 data from the National Automotive Sampling System Crashworthiness Data System included persons aged 55 years and older who were transported to a hospital and had a maximum injury severity of uninjured or an Abbreviated Injury Scale score of 1 to 5. Trauma center and non-trauma center admission was a proxy for triage accuracy. Frequencies, means, standard deviations, sensitivities, specificities, positive predictive values (PPVs), and negative predictive values (NPVs) were calculated.

RESULTS

Although triage accuracy has improved from 2004 to 2008, the undertriage rate still remains higher than the ACS-COT target of 5-10%. Overtriage rates have remained slightly above or within an acceptable range, suggesting that gains in triage accuracy have not unduly overburdened trauma centers. Both PPV and NPV have improved since 2004.

CONCLUSIONS

There is a positive trend in triage accuracy for older injured persons since 2004. Ongoing funding, continued trauma system development with more training emphasis on scene evaluation of older adults, and the use of the ACS-COT triage decision scheme are essential for further improvement of triage accuracy. More research is needed to identify and validate additional triage criteria that are sensitive to severe injuries in older persons.

Global differences in causes, management, and survival after severe trauma: the recombinant activated factor VII phase 3 trauma trial

BACKGROUND

Little is known about international variation in mortality after severe trauma. This study examines variation in mortality, injury severity, and case management among countries from a recent prospective multinational trauma trial.

METHODS

This trauma trial was a prospective, randomized, double-blinded, multicenter comparison of recombinant activated factor VII versus placebo in severely injured bleeding trauma patients. Differences in baseline patient characteristics, case management, and clinical outcomes were examined for the 11 countries recruiting most patients. Between-country differences in mortality were examined using regression analysis adjusting for case mix and case management differences. Global predictors of mortality were also identified using multivariate regression analysis.

RESULTS

Significant differences were observed between countries in unadjusted mortality rates at 24 hours (p = 0.025) and 90 days (p < 0.0001). When adjusting for differences in case mix and case management, the between country differences in mortality at 24 hours and 90 days remained significant. Consistent independent predictors of 24-hour, 24-hour to 90-day, and 90-day mortality were admission lactate >or=5 mmol/L (odds ratio: 9.06, 3.56, and 5.39, respectively) and adherence to clinical management guidelines (odds ratio: 4.92, 5.90, and 3.26, respectively). On average, the damage control surgery guideline was less well adhered to than the RBC transfusion and ventilator guidelines. There was statistically significant variation between countries with respect to adherence to the RBC transfusion guideline.

CONCLUSIONS

Considering international variation in mortality when designing or interpreting results from multinational trauma studies is important. Significant differences in mortality persisted between patients from different countries after case mix and case management adjustment. Adherence to clinical guidelines was associated with improved survival. Stratification, case mix adjustment, and use of guidelines on damage control surgery, transfusion, and ventilation may mitigate country-driven variation in mortality.

Identifying life-threatening shock in the older injured patient: an analysis of the National Trauma Data Bank

OBJECTIVE

Reliance on traditional vital signs (TVS), particularly in older patients, to identify life-threatening shock after injury may be unreliable. Shock index (SI), defined as heart rate divided by systolic blood pressure (SBP), may be a better indicator of early shock after injury than TVS. Multiplying age by SI (age x SI) may be better in older injured patients. We hypothesized that age x SI would be a better predictor of 48-hour mortality in old patients (age, >55 years) compared with TVS, whereas for young patients (age, <or=55 years), SI would be a better predictor than TVS.

METHODS

Version 8.1 of the National Trauma Data Bank was queried for incidents of blunt, non-neurologic injury occurring during 2007, to patients aged 18 to 81 years. Areas under the receiver operating characteristic curves (AUC) were compared for TVS, SI, and age x SI in young and old patients for predicting 48-hour mortality.

RESULTS

A total of 189,574 incidents were identified. Overall 48-hour mortality was 1.18%. For young patients, there was no difference between SBP (AUC, 0.654) and SI (AUC, 0.655) for predicting 48-hour mortality. For old patients, age x SI (AUC, 0.693) was a better predictor of 48-hour mortality compared with heart rate (AUC, 0.626; p < 0.0001), SBP (AUC, 0.657; p < 0.0002), or SI (AUC, 0.684; p < 0.008).

CONCLUSION

TVS are inadequate predictors of shock after non-neurologic blunt injury. Using SI in the young and age x SI in old to identify patients at risk for early mortality after blunt injury could result in earlier definitive treatment.