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

Decline in Explanatory Power of Trauma Mortality Models With Age: Varying Contribution of Glasgow Coma Scale, Injury Severity Score, Comorbidities, and Frailty

INTRODUCTION

Adjusting for confounding variables is critical for objective comparison of outcomes. The explanatory power of variables used in adjusted models for injury and their relative utility across age groups has not been well-defined. This study aimed to assess the explanatory power of covariates commonly adjusted in injury research and their relative performance across age groups.

METHODS

Inpatients 18-100 y (2017-2022) were selected from 90 hospital trauma registries. Patients were grouped into sequential 5-y age blocks. Mortality was defined as the proportion of patients "expired + hospice". Dominance analysis was used to determine the average contribution (McFadden's R2) for covariates commonly included in multivariable logistic regressions.

RESULTS

Three hundred seventeen-thousand one hundred thirty-six patients were included (51.1% male, mean age: 63, mean injury severity score [ISS]: 9.8, mean Glasgow Coma Scale: 14.3, 93.5% blunt). Total explanatory power (McFadden's R2) for mortality was highest in youngest age group (52.7% in 18-24 group) and decreased with age, with the lowest R2 (19.6%) in 95-100 group. Regardless of age, the Glasgow Coma Scale was the most important covariate (R2 ranging from 9.0% to 20.4%). At age 18-24 y, ISS was a more dominant contributor than Elixhauser Score, but beyond 55 y, Elixhauser Score became more dominant than ISS.

CONCLUSIONS

The explanatory power of adjustment models including common covariates is limited and varies significantly across age groups, decreasing linearly with age. Adjusting for outcomes using these covariates may limit objective comparisons especially for older adults. Additional research is needed to identify covariates that enhance the explanatory power of adjustment models to allow for more objective comparisons across all ages.

The 2023 WSES guidelines on the management of trauma in elderly and frail patients

BACKGROUND

The trauma mortality rate is higher in the elderly compared with younger patients. Ageing is associated with physiological changes in multiple systems and correlated with frailty. Frailty is a risk factor for mortality in elderly trauma patients. We aim to provide evidence-based guidelines for the management of geriatric trauma patients to improve it and reduce futile procedures.

METHODS

Six working groups of expert acute care and trauma surgeons reviewed extensively the literature according to the topic and the PICO question assigned. Statements and recommendations were assessed according to the GRADE methodology and approved by a consensus of experts in the field at the 10th international congress of the WSES in 2023.

RESULTS

The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage, including drug history, frailty assessment, nutritional status, and early activation of trauma protocol to improve outcomes. Acute trauma pain in the elderly has to be managed in a multimodal analgesic approach, to avoid side effects of opioid use. Antibiotic prophylaxis is recommended in penetrating (abdominal, thoracic) trauma, in severely burned and in open fractures elderly patients to decrease septic complications. Antibiotics are not recommended in blunt trauma in the absence of signs of sepsis and septic shock. Venous thromboembolism prophylaxis with LMWH or UFH should be administrated as soon as possible in high and moderate-risk elderly trauma patients according to the renal function, weight of the patient and bleeding risk. A palliative care team should be involved as soon as possible to discuss the end of life in a multidisciplinary approach considering the patient's directives, family feelings and representatives' desires, and all decisions should be shared.

CONCLUSIONS

The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage based on assessing frailty and early activation of trauma protocol to improve outcomes. Geriatric Intensive Care Units are needed to care for elderly and frail trauma patients in a multidisciplinary approach to decrease mortality and improve outcomes.

Disparity in guideline adherence for prehospital care according to patient age in emergency medical service transport for moderate to severe trauma

OBJECTIVES

The aim of this study was to investigate the association between patient age and guideline adherence for prehospital care in emergency medical services (EMS) for moderate to severe trauma.

METHODS

This was a retrospective observational study that used a nationwide EMS-based trauma database from 2016 to 2019. Adult trauma patients whose injury severity score was greater than or equal to nine were screened, and those with cardiac arrest or without outcome data were excluded. The enrolled patients were categorized into four groups according to patient age: young (<45 years), middle-aged (45-64 years), old (65-84 years), and very old (>84 years). The primary outcome was guideline adherence, which was defined as following all prehospital care components: airway management for level of consciousness below verbal response, oxygen supply for pulse oximetry under 94 %, intravenous fluid administration for systolic blood pressure under 90 mmHg, scene resuscitation time within 10 min, and transport to the trauma center or level 1 emergency department. Multivariable logistic regression was conducted to calculate the adjusted odds ratios (aORs) and 95 % confidence intervals (95 % CIs).

RESULTS

Among the 430,365 EMS-treated trauma patients, 38,580 patients were analyzed-9,573 (24.8 %) in the young group, 15,296 (39.7 %) in the middle-aged group, 9,562 (24.8 %) in the old group, and 4,149 (10.8 %) in the very old group. The main analysis revealed a lower probability of guideline adherence in the old group (aOR 95 % CI = 0.84 (0.76-0.94)) and very old group (aOR 95 % CI = 0.68 (0.58-0.81)) than in the young group.

CONCLUSION

We found disparities in guideline adherence for prehospital care according to patient age at the time of EMS assessment of moderate to severe trauma. Considering this disparity, the prehospital trauma triage and management for older patients needs to be improved and educated to EMS providers.

The effects of Garcinia kola and curcumin on the dorsal root ganglion of the diabetic rat after peripheral nerve transection injury

OBJECTIVE

To test the protective effects of Garcinia kola and curcumin on the ganglion tissues of diabetic rats following the use of autologous vein graft in peripheral nerve transection injury.

METHODS

The sciatic nerve on the right side was transected, and anastomosis was performed between the proximal and distal ends using an autologous vein graft. Curcumin and Garcinia kola seed extract were administered daily by oral gavage. The ganglion tissues were harvested after a 90-day waiting period. Sensory neurons in the dorsal root ganglion at the L4 and L5 levels were used for stereological evaluations. Mean sensory neuron numbers were analyzed using a stereological technique. The size of the light and dark neurons was also estimated, and ultrastructural and immunohistochemical evaluations were performed.

RESULTS

A statistically significant difference in sensory neuron numbers was observed between the groups with and without Garcinia kola and curcumin applications. The immunohistochemical results showed that the s-100 protein is expressed selectively between cell types.

CONCLUSION

The results of this study show that curcumin and Garicinia kola prevented sensory neuron loss in diabetic rats following transection injury to the sciatic nerve.

Effects of Transport to Trauma Centers on Survival Outcomes Among Severe Trauma Patients in Korea: Nationwide Age-Stratified Analysis

BACKGROUND

Previous studies showed that the prognosis for severe trauma patients is better after transport to trauma centers compared to non-trauma centers. However, the benefit from transport to trauma centers may differ according to age group. The aim of this study was to compare the effects of transport to trauma centers on survival outcomes in different age groups among severe trauma patients in Korea.

METHODS

Cross-sectional study using Korean national emergency medical service (EMS) based severe trauma registry in 2018-2019 was conducted. EMS-treated trauma patients whose injury severity score was above or equal to 16, and who were not out-of-hospital cardiac arrest or death on arrival were included. Patients were classified into 3 groups: pediatrics (age < 19), working age (age 19-65), and elderly (age > 65). The primary outcome was in-hospital mortality. Multivariable logistic regression analysis was conducted to evaluate the effect of trauma center transport on outcome after adjusting of age, sex, comorbidity, mechanism of injury, Revised Trauma Score, and Injury Severity Score. All analysis was stratified according to the age group, and subgroup analysis for traumatic brain injury was also conducted.

RESULTS

Overall, total of 10,511 patients were included in the study, and the number of patients in each age group were 488 in pediatrics, 6,812 in working age, and 3,211 in elderly, respectively. The adjusted odds ratio (95% confidence interval [CI]) of trauma center transport on in-hospital mortality from were 0.76 (95% CI, 0.43-1.32) in pediatrics, 0.78 (95% CI, 0.68-0.90) in working age, 0.71(95% CI, 0.60-0.85) in elderly, respectively. In subgroup analysis of traumatic brain injury, the benefit from trauma center transport was observed only in elderly group.

CONCLUSION

We found out trauma centers showed better clinical outcomes for adult and elderly groups, excluding the pediatric group than non-trauma centers. Further research is warranted to evaluate and develop the response system for pediatric severe trauma patients in Korea.

Transfusion futility thresholds and mortality in geriatric trauma: Does frailty matter?

BACKGROUND

Data on massive transfusion (MT) in geriatric trauma patients is lacking. This study aims to determine geriatric transfusion futility thresholds (TT) and TT variations based on frailty.

METHODS

Patients from 2013 to 2018 TQIP database receiving MT were stratified by age and frailty. TTs and outcomes were compared between geriatric and younger adults and among geriatric adults based on frailty status.

RESULTS

The TT was lower for geriatric than younger adults (34 vs 39 units; p ​= ​0.03). There was no difference in TT between the non-frail, frail, and severely frail geriatric adults (37, 30 and 25 units, respectively, p ​> ​0.05). Geriatric adults had higher mortality than younger adults (63.1% vs 45.8%, p < 0.01). Non-frail geriatric adults had the highest mortality (69.4% vs 56.5% vs 56.2%, p < 0.01).

CONCLUSIONS

Geriatric patients have a lower TT than younger adults, irrespective of frailty. This may help improve outcomes and optimize MT utilization.

Head & Neck Trauma in the Geriatric Population

Craniofacial trauma in the geriatric population is increasing as our population ages. Due to loss of bone quality and medical comorbidities, injuries for minor trauma can be severe. A more extensive medical evaluation is usually warranted in this population before proceeding with surgery. In addition, unique surgical considerations exist in the repair of atrophic and edentulous bony fractures. Some quality improvement measures have already been undertaken but more is needed to help standardize care in this vulnerable population.

Epidemiology of major trauma in older adults within Scotland: A national perspective from the Scottish Trauma Audit Group (STAG)

BACKGROUND

Major trauma in older adults (MTOA) poses distinctive health and social care challenges, further underlined by the unique socioeconomic and geographical environment of Scotland. This study provides epidemiological trends of MTOA, to provide insight into areas where further evaluation and research are required.

MATERIALS AND METHODS

Pseudonymised aggregated demographic, injury and outcome data from 2011 to 2020 were obtained from the Scottish Trauma Audit Group (STAG) Database, covering 28 hospitals across Scotland. Only individuals age ≥ 70 with an Injury Severity Score (ISS) > 15 were included.

RESULTS

There was an average of 216 annual cases of MTOA, with a 259 % rise in incidence from 2011 to 2020. This was predominantly driven by a rise in low velocity trauma (fall <2 m height; 287 % increase). The proportion of all major trauma attributable to those aged ≥70 rose from 18.5 % in 2011 to 34.6 % in 2020. Death censored median (IQR) acute hospital length of stay was 18 days (9-30). Overall, 30-day survival was 65.3 %, with no improvement seen between 2011 and 2020 (p = 0.50). Independent predictors of improved 30-day survival included Ages 70-79 & 80-89 [compared to reference ≥ 90] (OR 3.12; 95 %CI 2.24,4.31; p < 0.001 and OR 1.66; 95 %CI 1.21,2.29; p = 0.002 respectively), and Extremity injury (OR 1.89; 95 %CI 1.48,2.41; p < 0.001). Head injury (OR 0.72; 95 %CI 0.54,0.96; p = 0.027) and increasing ISS score (OR 0.88, 95 %CI 0.86,0.89; p < 0.001) were associated with lower likelihood of 30-day survival. A further model also including the admission ward (from eSTAG data November 2017 onwards) demonstrated an association with reduced 30-day survival with admission to General Surgery (OR 0.42; 95 %CI 0.19,0.93; p = 0.033), Intensive Care (OR 0.25; 95 %CI 0.10,0.60; p = 0.002) and Medical Specialities (OR 0.33; 95 %CI 0.15,0.73; p = 0.007) compared to the reference (Major Trauma). Exponential Smoothing predictions revealed a further potential 184 % rise in incidence of MTOA from 2021 to 2030 (3657 per 100,000 population at risk to 10,392 per 100,000 population at risk).

CONCLUSION

MTOA is likely to be a rising health care burden, requiring larger quantities of health and social care resource. Urgent preventative strategies are required to reduce low velocity trauma (standing height falls), as well as the high mortality and morbidity of MTOA.

Hospitalization and readmission after single-level fall: a population-based sample

BACKGROUND

Single-level falls (SLFs) in the older US population is a leading cause of hospital admission and rates are increasing. Unscheduled hospital readmission is regarded as a quality-of-care indication and a preventable burden on healthcare systems. We aimed to characterize the predictors of 30-day readmission following admission for SLF injuries among patients 65 years and older.

METHODS

We conducted a retrospective cohort study using the Nationwide Readmission Database from 2018 to 2019. Included patients were 65 and older, admitted emergently following a SLF with a primary injury diagnosis. Hierarchical logit regression was used to model factors associated with readmission within 30 days of discharge.

RESULTS

Of 1,338,905 trauma patients, 65 years or older, 61.3% had a single-level fall as the mechanism of injury. Among fallers, the average age was 81.1 years and 68.5% were female. SLF patients underwent more major therapeutic procedures (56.3% vs. 48.2%), spent over 2 million days in the hospital and incurred total charges of over $28 billion annually. Over 11% of SLF patients were readmitted within 30 days of discharge. Increasing income had a modest effect, where the highest zip code quartile was 9% less likely to be readmitted. Decreasing population density had a protective effect of readmission of 16%, comparing Non-Urban to Large Metropolitan. Transfer to short-term hospital, brain and vascular injuries were independent predictors of 30-day readmission in multivariable analysis (OR 2.50, 1.31, and 1.42, respectively). Palliative care consultation was protective (OR 0.41). The subsequent hospitalizations among those 30-day readmissions were primarily emergent (92.9%), consumed 260,876 hospital days and a total of $2.75 billion annually.

CONCLUSIONS

SLFs exact costs to patients, health systems, and society. Transfer to short-term hospitals at discharge, along with brain and vascular injuries were strong predictors of 30-day readmission and warrant mitigation strategy development with consideration of expanded palliative care consultation.

Reliability and validity of the Chinese version of the trauma-specific frailty index (TSFI) for geriatric trauma patients

BACKGROUND

Pre-traumatic frailty in geriatric trauma patients has caught attention from emergency medical workers and the assessment of it thus become one of the important aspects of risk management. Several tools are available to identify frailty, but limited tools have been validated for geriatric trauma patients in China to assess pre-traumatic frailty.The aim of this study is to translate the Trauma-Specific Frailty Index(TSFI) into Chinese, and to evaluate the reliability and validity of the translated version in geriatric trauma patients.

METHODS

A cross-sectional study was conducted. The TSFI was translated with using the Brislin model, that included forward and backward translation. A total of 184 geriatric trauma patients were recruited by a convenience sampling between October and December 2020 in Hospital of Chengdu University of Traditional Chinese Medicine, Sichuan. Using reliability or internal consistency tests assessed with Cronbach's alpha coefficient, split-half reliability and test-retest reliability. Content validity and construct validity analysis were both performed. Sensitivity, specificity and maximum Youden index(YI) were used to determine the optimal cut-off value. The screening performance was examined by Kappa value.

RESULTS

The total study population included 184 subjects, of which 8 participants were excluded, resulting in a study sample size of 176 elderly trauma patients (the completion rate was 95.7%). The Chinese version of Trauma-Specific Frailty Index(C-TSFI) have 15 items with 5 dimensions. Cronbach's alpha coefficient of the C-TSFI was 0.861, Cronbach's alpha coefficient of dimensions ranged from 0.837 to 0.875, the split-half reliability of the C-TSFI were 0.894 and 0.880 respectively, test-retest reliability ranged from 0.692 to 0.862. The correlation coefficient between items and the C-TSFI ranged from 0.439 to 0.761. The content validity index for items (I-CVI) of the C-TSFI scale was 0.86~1.00, and the scale of content validity index (S-CVI) was 0.93. The area under curve (AUC) of the C-TSFI was 0.932 (95%CI 0.904-0.96, P < 0.05), the maximum YI was 0.725, the sensitivity was 80.2%, the specificity was 92.3%, and the critical value was 0.31. Kappa value was 0.682 (P < 0.05).

CONCLUSIONS

The Chinese version of TSFI could be used as a general assessment tool in geriatric trauma patients, and both its reliability and validity have been demonstrated.

Evaluation and Treatment of Acute Trauma Pain in Older Adults

In the context of an ageing population, the demographic sands of trauma are shifting. Increasingly, trauma units are serving older adults who have sustained injuries in low-energy falls from a standing height. Older age is commonly associated with changes in physiology, as well as an increased prevalence of frailty and multimorbidity, including cardiac, renal and liver disease. These factors can complicate the safe and effective administration of analgesia in the older trauma patient. Trauma services therefore need to adapt to meet this demographic shift and ensure that trauma clinicians are sufficiently skilled in treating pain in complex older people. This article is dedicated to the management of acute trauma pain in older adults. It aims to highlight the notable clinical challenges of managing older trauma patients compared with their younger counterparts. It offers an overview of the evidence and practical opinion on the merits and drawbacks of commonly used analgesics, as well as more novel and emerging analgesic adjuncts. A search of Medline (Ovid, from inception to 7 November 2022) was conducted by a medical librarian to identify relevant articles using keyword and subject heading terms for trauma, pain, older adults and analgesics. Results were limited to articles published in the last 10 years and English language. Relevant articles' references were hand-screened to identify other relevant articles. There is paucity of dedicated high-quality evidence to guide management of trauma-related pain in older adults. Ageing-related changes in physiology, the accumulation of multimorbidity, frailty and the risk of inducing delirium secondary to analgesic medication present a suite of challenges in the older trauma patient. An important nuance of treating pain in older trauma patients is the challenge of balancing iatrogenic adverse effects of analgesia against the harms of undertreated pain, the complications and consequences of which include immobility, pneumonia, sarcopenia, pressure ulcers, long-term functional decline, increased long-term care needs and mortality. In this article, the role of non-opioid agents including short-course non-steroidal anti-inflammatory drugs (NSAIDs) is discussed. Opioid selection and dosing are reviewed for older adults suffering from acute trauma pain in the context of kidney and liver disease. The evidence base and limitations of other adjuncts such as topical and intravenous lidocaine, ketamine and regional anaesthesia in acute geriatric trauma are discussed.

Silver Trauma Review Clinic: a novel model of care to manage non-operative injuries in older patients

BACKGROUND

Increasing numbers of older patients are presenting to the ED following trauma. These patients require multidisciplinary care that the traditional trauma model fails to provide. A Silver Trauma Review Clinic (STRC) was developed in conjunction with the geriatric ED and multidisciplinary services to improve the post-discharge care of patients with non-operative traumatic injuries.We aimed to assess the STRC by reviewing the journey and outcomes of patients who attended the clinic.

METHODS

A retrospective review of electronic chart data was performed on all patients who attended the clinic over the initial 1-year period. Data were collected on patient demographics, medical history, medications, timelines, trauma assessments and further investigations, fracture types, occult injuries, geriatric assessments (Comprehensive Geriatric Assessment, Clinical Frailty Scale, bone health, falls, Orthostatic Hypotension (OH), cognitive screening, mobility), number of reviews and discharge destination.

RESULTS

137 patients were reviewed with a median age of 80 years (IQR 74-86) and 69% were female. The median Clinical Frailty Scale was 3 with a median time from the patient's initial ED presentation to clinic of 15 days (IQR 9.75-21) and median time from initial review to discharge 20 days (IQR 1-35). 71% of presentations were as a result of falls under 2 m. Tertiary survey in the STRC identified previously unrecognised injuries in 24 patients (18%). In total, 56 patients were reviewed with vertebral fractures. 87% of these patients (n=49) were further investigated with a CT or MRI and 95% of patients (n=53) were referred for physiotherapy. Patients attending the STRC had a comprehensive geriatric assessment with abnormal Mini-Cog assessments found in 29%, a new diagnosis of osteoporosis in 43% and orthostatic hypotension diagnosed in 13% of patients. 61% were discharged to primary care and 19% linked into a specialist geriatric clinic.

CONCLUSION

The STRC is a novel approach allowing timely, patient-focused, comprehensive and collaborative trauma care of older patients following non-operative injuries.

Understanding the Impact of Trauma Admissions to Nonsurgical Services

BACKGROUND

The American College of Surgeons Committee on Trauma (ACS COT) delineates trauma center standards, one of which limits the number of injured patients admitted to nonsurgical services. Performance improvement review of nonsurgical admissions (NSAs), particularly those with Injury Severity Score (ISS) > 9, is required.

OBJECTIVE

To examine trauma patients with NSA for appropriateness of admission and any potential clinical effect as a result of NSA.

METHODS

All trauma patients presenting to our ACS COT-verified level 1 trauma center in Southern California (05/2021-04/2022) were retrospectively screened. Nonsurgical admissions with ISS > 9 were included without exclusions. Appropriateness and clinical impact of NSA were assessed by the Trauma Medical Director (TMD) and Associate TMD.

RESULTS

Forty patients met study criteria, with a mean age of 54 years (range 5 d-99 y). The mean ISS was 19 (range 10-30). Nonsurgical admissions most commonly sustained traumatic brain injury (TBI) (n = 27, 68%) after ground level falls (GLF) (n = 32, 80%). All NSAs were evaluated by ≥1 surgical service, commonly neurosurgery (n = 33, 83%) and trauma surgery (n = 13, 33%). Sixteen patients (40%) died, 75% (n = 12) of which were secondary to catastrophic TBI. Upon detailed review, all NSAs were deemed appropriate and without potential clinical impact.

CONCLUSIONS

All NSAs in this study were appropriate admissions without clinical effect from lack of surgical admission. Nonsurgical admissions were typically elderly patients with head injuries after GLF. With the anticipated increase in geriatric trauma due to our aging population, NSA with surgical consultation may be an important way to manage trauma admissions without compromising care of injured patients.

Built environment influence on the incidence of elderly pedestrian collisions in a medium-large city in southern Brazil: a spatial analysis

Trauma disproportionately affects vulnerable road users, especially the elderly. We analyzed the spatial distribution of elderly pedestrians struck by vehicles in the urban area of Maringa city, from 2014 to 2018. Hotspots were obtained by kernel density estimation and wavelet analysis. The relationship between spatial relative risks (RR) of elderly run-overs and the built environment was assessed through Qualitative Comparative Analysis (QCA). Incidents were more frequent in the central and southeast regions of the city, where the RR was up to 2.58 times higher. The QCA test found a significant association between elderly pedestrian victims and the presence of traffic lights, medical centers/hospitals, roundabouts and schools. There is an association between higher risk of elderly pedestrians collisions and specific elements of built environments in Maringa, providing fundamental data to help guide public policies to improve urban mobility aimed at protecting vulnerable road users and planning an age-friendly city.

Geriatric spine fractures - Demography, changing trends, challenges and special considerations: A narrative review

The aim of this manuscript was to summarize the demography and changing trends of geriatric spinal injuries and to enumerate the challenges and special considerations in the care of geriatric spinal injuries. PubMed, Scopus and Embase databases were searched for literature on geriatric spine fractures using MeSH terms 'aged', 'aged, 80 and over', 'elderly', 'spinal fracture/epidemiology', spinal fracture/therapy∗' and keywords pertaining to the same. The search results were screened for appropriate articles and reviewed. There is a high community prevalence of elderly vertebral fractures ranging from 18% to as high as 51%. The proportion of older patients among the spinal injured is rising as well. There is a higher chance of missing spinal injuries in the elderly and clinical guidelines may not be applicable to this patient group. Classification and surgical treatment are different from younger adult counterparts as the elderly osteoporotic spine behaves differently biomechanically. There is a high incidence of respiratory complications both for surgically and conservatively managed groups. Older age generally is associated with a higher complication rate including mortality.

Identifying Quality Indicators for the Care of Hospitalized Injured Older Adults: A Scoping Review of the Literature

OBJECTIVES

Older adults represent more than 50% of trauma admissions in many high-income countries. Furthermore, they are at increased risk for complications, resulting in worse health outcomes than younger adults and a significant health care utilization burden. Quality indicators (QIs) are used to assess the quality of care in trauma systems, but few QIs reflect responses to older patients' specific needs. We aimed to (1) identify QIs used to assess acute hospital care for injured older patients, (2) assess support for identified QIs and, (3) identify gaps in existing QIs.

DESIGN

Scoping review of the scientific and gray literature.

METHODS

Selection and data extraction were performed by 2 independent reviewers. The level of support was assessed by the number of sources reporting QIs and whether they were developed according to scientific evidence, expert consensus, and patients' perspectives.

RESULTS

Of 10,855 identified studies, 167 were eligible. Among 257 different QIs identified, 52% were hip fracture specific. Gaps were identified for head injuries, rib, and pelvic ring fractures. Although 61% of QIs assessed care processes, 21% and 18% focused on structures and outcomes, respectively. Although most QIs were based on literature reviews and/or expert consensus, patients' perspective was rarely accounted for. The 15 QIs with the highest level of support included minimum time between emergency department arrival and ward admission, minimum time to surgery for fractures, assessment by a geriatrician, orthogeriatric review for hip fracture patients, delirium screening, prompt and appropriate analgesia, early mobilizations, and physiotherapy.

CONCLUSION AND IMPLICATIONS

Multiple QIs were identified, but their level of support was limited, and important gaps were identified. Future work should focus on achieving consensus for a set of QIs to assess the quality of trauma care to older adults. Such QIs could be used for quality improvement and ultimately improve outcomes for injured older adults.

Frailty Identification in Prehospital Care: A Scoping Review of the Literature

The proportion of older adults is increasing worldwide. Frailty assessment in prehospital care was suggested to improve triage decisions and paramedics' judgment. This study aimed to assess the scope and nature of available evidence around frailty identification in prehospital care. A systematic search of the literature was performed using MEDLINE, SCOPUS, CINHAL, and Web of Science to identify relevant articles published from January 2022 downwards. A list of indexed terms and their associated alternatives were pre-determined. Of the 71 identified and reviewed articles after removing duplicates, six articles were included in the review. Due to the heterogeneity of the included articles, the findings were described narratively. The findings of this review showed that the available evidence is limited and heterogenic. Two themes emerged from the findings of the included articles: 1) Paramedics' Perceptions about Frailty Assessment in Prehospital Care and 2) Frailty Scores for Application in Prehospital Care. Paramedics recognised frailty assessment in pre-hospital care to be feasible and important. They highlighted the need for a simple and clear frailty score that could be used and mentioned to other healthcare professionals when handing over patients. Six frailty scores were reported to be used in prehospital care. The evidence around each frailty score is very limited. Overall, frailty assessment in prehospital care was shown to be important and feasible. Different frailty scores have been assessed for use in prehospital care. Further research investigating frailty identification in prehospital care is needed.

The Significance of the Treatment for Elderly Severe Trauma Patients Who Required Intensive Care

Purpose Elderly trauma patients have a higher risk of severe disability and death, and this outcome burden in elderly trauma patients must be addressed in countries in which the population is aging. The clarification of the unique clinical features of elderly people who have experienced trauma is important. The purpose of this study is to evaluate the significance of the treatment for elderly severe trauma patients based on the prognosis and total hospital cost. Methods Trauma patients transferred to our emergency department (ED) and admitted to our intensive care unit (ICU) directly or through emergency surgery between January 2013 and December 2019 were examined. We divided patients into three groups: <65 years old (Group Y); 65-79 years old (Group M); and ≥80 years old (Group E). We compared the pre- and post-trauma American Society of Anesthesiology Physical Status (ASA-PS) score and the Katz Activities of Daily Living (ADL) questionnaire at arrival among the three groups. In addition, the duration of ICU and hospital stays, hospital mortality, and total treatment costs were compared. Results There were 1,652 patients admitted to ICU through the ED from January 2013 to December 2019. Of those patients, 197 trauma patients were analyzed. There was no significant difference in injury severity scores between the groups. Significant differences in both the ASA-PS and Katz-ADL scores in posttrauma status were observed among the three groups (posttrauma ASA-PS, 2.0 (2.0, 2.8) in Group Y, 3.0 (2.0, 3.0) in Group M, 3.0 (3.0, 3.0) in Group E, p < 0.001*, posttrauma Katz-ADL, 10.0 (3.3, 12.0) in Group Y, 5.5 (2.0, 10.0) in Group M, 2.0 (0.5, 4.0) in Group E, p < 0.001). The duration of both ICU and hospital stay was significantly longer in Group E compared to the other groups (ICU stay, 4.0 (3.0, 6.5) days in Group Y, 4.0 (3.0, 9.8) days in Group M, 6.5 (3.0, 15.3) days, p = 0.006, hospital stay, 16.9 (8.6, 33.0) days in Group Y, 26.7 (12.0, 51.8) days in Group M, 32.5 (12.8, 51.5) days in Group E, p = 0.005). ICU and hospital mortality were highest in Group E compared with the other groups, but the differences were not significant. Finally, the total hospital cost in Group E was significantly higher than the other groups. Conclusions In elderly trauma patients who required intensive care, PS and ADL in posttrauma status were worse, ICU and hospital stays were longer, and ICU and hospital mortality were higher compared with younger patients. In addition, medical costs were greater in elderly patients. It is supposed that the therapeutic effect observed in young trauma patients cannot be expected in elderly trauma patients.

Comparing Comorbidity Polypharmacy Score and Charlson Comorbidity Index in predicting outcomes in older trauma patients

BACKGROUND

The Charlson Comorbidity Index (CCI) and Comorbidity Polypharmacy Score (CPS) may potentially risk-stratify older trauma patients more accurately than traditional trauma severity scores. We aim to evaluate if CCI or CPS are better predictors of mortality and discharge venue in such patients.

METHODS

We conducted a retrospective study using registry data from two tertiary trauma centres. Patients aged 65 years and above who presented to the emergency departments (EDs) between January 2011 and December 2015 with traumatic injuries were included. Charts were reviewed for demographics, injury mechanism and severity, discharge outcomes, and types of comorbidities and medications used. Primary outcome was overall mortality; secondary outcomes included ED disposition and hospital discharge venue. Discriminatory power of the score(s) were compared using area under the receiver operating characteristic (AUROC) curve.

RESULTS

There were 2,750 patients, with overall female predominance (56.7%, 1,560/2,750) and median age of 78 years (interquartile range [IQR] 72 to 84 years). Median CCI score was 1 (IQR 0 to 2) and median CPS was 8 (IQR 4 to 12). Overall mortality was 9.4% (259/2,750). Every 1-point increase in CCI score resulted in increased odds of death by 16% (adjusted odds ratio 1.16, 95% confidence interval 1.07 to 1.26, p<0.001). Addition of CCI to the Injury Severity Score (ISS) increased the discriminatory power for mortality (AUROC for ISS = 0.832; AUROC for ISS with CCI = 0.843). Every 1-point increase in CCI was significantly associated with decreased odds of admission to a rehab facility by 8%. CPS did not predict mortality and discharge venue.

CONCLUSION

CCI, but not CPS, was a predictor of mortality. A higher CCI was associated with decreased odds of discharge to a subacute facility, likely related to underlying rehabilitation potential. Further studies should be undertaken to explore an integrated scoring system that considers injury severity, comorbidities, and polypharmacy.

Age as a Barrier to Surgical Stabilization of Rib Fractures in Patients with Flail Chest

INTRODUCTION

Although randomized trials demonstrate a benefit to surgical stabilization of rib fractures (SSRF), SSRF is rarely performed. We hypothesized older patients were less likely to receive SSRF nationally.

METHODS

The 2016 National Inpatient Sample was used to identify adults with flail chest. Comorbidities and receipt of SSRF were categorized by ICD-10 code. Univariable testing and Multivariable regression were performed to determine the association of demographic characteristics and comorbidities to receipt of SSRF.

RESULTS

1021 patients with flail chest were identified, including 244 (23.9%) who received SSRF. Patients ≥70 years were less likely to receive SSRF. (<70 yrs 201/774 [26.0%] vs ≥70 43/247 [17.4%], P = .006) and had higher risk of death (<70 yrs 39/774 [5.0%] vs ≥70 33/247 [13.4%], P < .001) In multivariable modeling, only age ≥70 years was associated with SSRF (OR .591, P = .005).

CONCLUSION

Despite guideline-based support of SSRF in flail chest, SSRF is performed in <25% of patients. Age ≥70 years is associated with lower rate of SSRF and higher risk of death. Future study should examine barriers to SSRF in older patients.

Development of Imaging Criteria for Geriatric Blunt Trauma Patients

INTRODUCTION

Current decision tools to guide trauma computed tomography (CT) imaging were not validated for use in older patients. We hypothesized that specific clinical variables would be predictive of injury and could be used to guide imaging in this population to minimize risk of missed injury.

METHODS

Blunt trauma patients aged 65 y and more admitted to a Level 1 trauma center intensive care unit from January 2018 to November 2020 were reviewed for histories, physical examination findings, and demographic information known at the time of presentation. Injuries were defined using the patient's final abbreviated injury score codes, obtained from the trauma registry. Abbreviated injury score codes were categorized by corresponding CT body region: Head, Face, Chest, C-Spine, Abdomen/Pelvis, or T/L-Spine. Variable groupings strongly predictive of injury were tested to identify models with high sensitivity and a negative predictive value.

RESULTS

We included 608 patients. Median age was 77 y (interquartile range, 70-84.5) and 55% were male. Ground-level fall was the most common injury mechanism. The most commonly injured CT body regions were Head (52%) and Chest (42%). Variable groupings predictive of injury were identified in all body regions. We identified models with 97.8% sensitivity for Head and 98.8% for Face injuries. Sensitivities more than 90% were reached for all except C-Spine and Abdomen/Pelvis.

CONCLUSIONS

Decision aids to guide imaging for older trauma patients are needed to improve consistency and quality of care. We have identified groupings of clinical variables that are predictive of injury to guide CT imaging after geriatric blunt trauma. Further study is needed to refine and validate these models.

The effect of Ramadan on elderly patients presenting to the emergency department

Background Patients visiting the emergency department (ED) may show variations by certain time periods such as Ramadan. We wished to ascertain whether Ramadan affects the ED presentations, clinical conditions and outcomes of patients aged 65 years or older. Methods . Patients aged 65 years or older who presented to ED in Ramadan and in the following month in 2018 were reviewed retrospectively. Results . A total of 1947 patients were enrolled, of whom 958 presented in Ramadan and 989 in the following month. The patients who presented in Ramadan most commonly (23.8%) presented between 8 p.m. and 11.59 p.m.; patients who presented in the following month most commonly (24%) presented between 8 a.m. and 11.59 a.m. (p=0.26). Complaints concerning the central nervous system (CNS) were more common in the month after Ramadan (p<0.0001). Diagnoses related to the cardiovascular system were more commonly made in Ramadan (p=0.037), whereas those related to CNS, otorhinolaryngology and oncology were more commonly made in the following month (p=0.0005, p=0.024 and p=0.003, respectively). No significant difference was found between the two groups with respect to outcomes (p=0.36). Compared to patients who presented in Ramadan, those that presented in the following month had a significantly longer ED stay (p=0.036). Conclusion . Our study detected no significant difference between the two groups with respect to the time of presentation and ED outcomes. Patients who presented in Ramadan had a lower incidence of CNS complaints; a higher incidence of cardiovascular diagnoses; lower incidences of CNS, oncological and otorhinolaryngological diagnoses and a significantly shorter length of ED stay.

Case volume and rate are associated with outcomes in geriatric trauma: A case for geriatric trauma centers?

BACKGROUND

Increased morbidity and mortality in geriatric trauma patients are usually due to decreased physiologic reserve and increased comorbidities. It is unclear whether geriatric trauma case volume and rates correlate with survival. We hypothesized that geriatric patients would have increased survival when treated in high-case volume and rate trauma centers.

METHODS

A retrospective cohort study was conducted using the Trauma Quality Improvement Program database between 2015 and 2019. Geriatric trauma patients (≥65 years) with severe injury (Injury Severity Score ≥16) were included. Geriatric case volume (GCV) was defined as the mean annual number of treated geriatric trauma patients, while geriatric case rate (GCR) was the mean annual number of elderly trauma patients divided by all trauma patients in each center. Trauma centers were classified into low-, medium-, and high-volume and rate facilities based on GCV and GCR. The association of GCV and GCR with in-hospital mortality and complication rates was assessed using the generalized additive model (GAM) and multivariate generalized linear mixed model adjusted for patient characteristics (age, sex, Injury Severity Score, Revised Trauma Score, and Modified Frailty Index) as fixed-effect variables and hospital characteristics as random effect variables.

RESULTS

A total of 164,818 geriatric trauma patients from 812 hospitals were included in the analysis. The GAM plots showed that the adjusted odds of in-hospital mortality decreased as GCV and the GCR increased. The generalized linear mixed model revealed that both high GCV and high GCR hospitals had lower mortality rates than low GCV and GCR hospitals (adjusted odds ratio [95% confidence interval], high GCV and high GCR centers; 0.82 [0.72-0.92] and 0.81 [0.73-0.90], respectively).

CONCLUSION

Both high geriatric trauma volume and rates were associated with decreased mortality of geriatric trauma patients. Consolidation of care for elderly patients with severe injury in specialized high-volume centers may be considered.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Recording adverse events following orthopaedic trauma: Financial implications and validation of an adverse event assessment form in an Irish regional trauma unit

BACKGROUND

In Ireland, funding of orthopaedic trauma is based on an activity-based funding (ABF) model. Clinically similar cases are split into diagnostic-related groups (DRG), with base funding per DRG provided. Increased complexity of cases (length of stay; complications incurred; occurrence of adverse events) attracts additional remuneration to the base funding. In our institution these adverse events are recorded via retrospective chart-abstraction methods by administrative staff. Incidences which are not included from this review affect both follow up with family physicians and patient care; as well as skewing budgetary decisions that impact fiscal viability of the service. The aim of this study was to compare a prospectively implemented adverse events form with the current national retrospective chart abstraction method. Our outcomes in terms of pay-by-results financial implications.

METHODS

An adverse events database adapted from a similar validated model was used to prospectively record complications in 216 patients admitted via the orthopaedic trauma service. Data was contemporaneously collected via a GDPR compliant secure medical messaging platform. Results were compared with the same cohort using an existing data abstraction method. Both data sets were coded in accordance with current standards for case funding.

RESULTS

Overall, 49 adverse events were recorded during the study through prospective charting of adverse events, compared with 26 events documented by customary method (p<0.01).Anaemia requiring blood transfusion n = 11 22.4%) was the most common complication, followed by delirium n = 6 (12%), acute kidney injury n = 6 (12%), and pneumonia n = 5 (10.2%). Missed appropriate funding through conventional methods totalled €40,293 .

CONCLUSION

This pilot study demonstrates the ability to improve capture of adverse events through use of a well-designed assessment form. Proper perioperative data handling is a critical aspect of financial subsidies, enabling optimal allocation of funds.

Adherence to the TQIP Palliative Care Guidelines Among Patients With Serious Illness at a Level I Trauma Center in the US

Importance

The American College of Surgeons Trauma Quality Improvement Program (TQIP) guidelines encourage trauma service clinicians to deliver palliative care in parallel with life-sustaining treatment and recommend goals of care (GOC) discussions within 72 hours of admission for patients with serious illness.

Objective

To measure adherence to TQIP guidelines-recommended GOC discussions for trauma patients with serious illness, treated at a level I trauma center in the US.

Design, Setting, and Participants

This retrospective cohort study included 674 adults admitted to a trauma service center for 3 or more days between December 2019 and June 2020. The medical records of 486 patients who met the criteria for serious illness using a consensus definition adapted to the National Trauma Data Bank were reviewed for the presence of a GOC discussion. Patients were divided into 2 cohorts based on admission before or after the guidelines were incorporated into the institutional practice guidelines on March 1, 2020.

Main Outcomes and Measures

The primary outcomes were GOC completion within 72 hours of admission and during the overall hospitalization. Patient and clinical factors associated with GOC completion were assessed. Other palliative care processes measured included palliative care consultation, prior advance care planning document, and do-not-resuscitate code status. Additional end-of-life processes (ie, comfort care and inpatient hospice) were measured in a subset with inpatient mortality.

Results

Of 674 patients meeting the review criteria, 486 (72.1%) met at least 1 definition of serious illness (mean [SD] age, 60.9 [21.3] years; mean [SD] Injury Severity Score, 16.9 [12.3]). Of these patients, 328 (67.5%) were male and 266 (54.7%) were White. Among the seriously ill patients, 92 (18.9%) had evidence of GOC completion within 72 hours of admission and 124 (25.5%) during the overall hospitalization. No differences were observed between patients admitted before and after institutional guideline publication in GOC completion within 72 hours (19.0% [47 of 248 patients] vs 18.9% [45 of 238]; P = .99) or during the overall hospitalization (26.2% [65 of 248 patients] vs 24.8% [59 of 238]; P = .72). After adjusting for age, GOC completion was found to be associated with the presence of mechanical ventilation (odds ratio [OR], 6.42; 95% CI, 3.49-11.81) and meeting multiple serious illness criteria (OR, 4.07; 95% CI, 2.25-7.38).

Conclusions and Relevance

The findings of this cohort study suggest that, despite the presence of national guidelines, GOC discussions for patients with serious illness were documented infrequently. This study suggests a need for system-level interventions to ensure best practices and may inform strategies to measure and improve trauma service quality in palliative care.

Long-term health and mobility of older adults following traumatic injury: a qualitative longitudinal study

PURPOSE

The aim of this study was to explore older adults' experiences of and approaches to managing their long-term health and mobility after traumatic injury.

METHODS

A longitudinal qualitative study was undertaken with older adults following traumatic injury in Victoria, Australia. Fifteen participants (≥65 years) were interviewed at three years post-injury (n = 15), and re-interviewed at four (n = 14) and five years (n = 12) post-injury. Using a framework approach, a longitudinal thematic analysis was performed.

RESULTS

Older age at the time of injury was identified by participants as a key factor influencing their recovery. Many participants reported actively attempting to regain their strength and fitness in the first five years following injury. However, their age, injury impacts, other health conditions, and weight gain made it difficult to achieve recovery goals. Many older adults reported a decline in their physical function over time. While these experiences and persistent disability constrained or changed the quality of social relationships, community participation, and independence, several participants described adapting to their functional limitations, and managing their secondary conditions over time.

CONCLUSION

In our cohort, the intertwined combination of ageing, injury, and comorbid conditions negatively affected health and mobility, reinforcing the need for preventative strategies.Implications for rehabilitationOlder adults recovering from traumatic injury may benefit from specialised care pathways that offer long-term and tailored therapies, with programs and services specific to their needs and goals.An integrated service approach by injury insurers, health care, primary care, disability, and aged care could more clearly identify and effectively address the individual needs and goals of older adults with complex conditions.Health and social services that work with people with injuries to develop personalised coping strategies can reduce anxiety related to uncertainty about the future, promote well-being, and support participation in valued activities.

Epidemiology and outcomes of older trauma patients in Singapore: A multicentre study

BACKGROUND

An ageing population has caused rising trauma cases amongst older patients. Multiple comorbidities, polypharmacy and limited reserves predispose them to poorer outcomes following a traumatic event. The Comorbidity Polypharmacy Score (CPS) has been found to predict outcomes and mortality in older trauma patients, but has not been studied in Asians.

AIM

We aim to describe the epidemiological characteristics of older trauma patients and explore the association of CPS on clinical outcomes.

METHODS

We conducted a retrospective observational study using data from the trauma registries of 2 tertiary trauma centres. Patients aged 45 years and above attending the emergency departments (EDs) from January 2011 to December 2015 with traumatic injuries (Injury Severity Score [ISS] of 9 and above) were included. Demographics, clinical data including number of comorbidities and medications used were collected to calculate the CPS. Outcomes of mortality, ED disposition and hospital discharge venue were examined.

RESULTS

There were 4,522 patients (median age 70 years; males 53.8%), with majority sustaining Tier 2 injuries (ISS 9 to 15; 68.9%). Falls were the predominant mechanism for those aged above 60 years and above (76%). Median CPS was 6 (interquartile range [IQR] 1 to 11). Amongst patients 75 years and older, 56% comprised the moderate to morbid CPS groups (CPS ≥ 8). Overall mortality was 8.4%; patients above 75 years had longer median length of stay (10 versus 7.1-8.9 days in other ages). Male gender (adjusted odds ratio [aOR] 1.51; 95% confidence interval [CI] 1.12-2.02), increasing age (aOR 1.04; 95% CI 1.03-1.05), injury to abdomen (aOR 3.24; 95% CI 1.93-5.45) and severe CPS category (aOR 1.88; 95% CI 1.23-2.89) were associated with increased odds of death. Increasing age and moderate CPS category increased odds of discharge to a rehabilitation (aOR for age 1.03, 95% CI 1.02-1.04; aOR for moderate CPS 1.72, 95% CI 1.43-2.07) or long-term care facility (aOR for age 1.05, 95% CI 1.03-1.06; aOR for CPS 1.60, 95% CI 1.10-2.32).

CONCLUSION

CPS predicted mortality and discharge to a rehabilitation or care facility in this urban, ageing Asian population. Its use may aid future trauma research and needs assessments in such patients.

Health care utilization and outcomes in older adults after Traumatic Brain Injury: A CENTER-TBI study

INTRODUCTION

The incidence of Traumatic Brain Injury (TBI) is increasingly common in older adults aged ≥65 years, forming a growing public health problem. However, older adults are underrepresented in TBI research. Therefore, we aimed to provide an overview of health-care utilization, and of six-month outcomes after TBI and their determinants in older adults who sustained a TBI.

METHODS

We used data from the prospective multi-center Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. In-hospital and post-hospital health care utilization and outcomes were described for patients aged ≥65 years. Ordinal and linear regression analyses were performed to identify determinants of the Glasgow Outcome Scale Extended (GOSE), health-related quality of life (HRQoL), and mental health symptoms six-months post-injury.

RESULTS

Of 1254 older patients, 45% were admitted to an ICU with a mean length of stay of 9 days. Nearly 30% of the patients received inpatient rehabilitation. In total, 554/1254 older patients completed the six-month follow-up questionnaires. The mortality rate was 9% after mild and 60% after moderate/severe TBI, and full recovery based on GOSE was reported for 44% of patients after mild and 6% after moderate/severe TBI. Higher age and increased injury severity were primarily associated with functional impairment, while pre-injury systemic disease, psychiatric conditions and lower educational level were associated with functional impairment, lower generic and disease-specific HRQoL and mental health symptoms.

CONCLUSION

The rate of impairment and disability following TBI in older adults is substantial, and poorer outcomes across domains are associated with worse preinjury health. Nonetheless, a considerable number of patients fully or partially returns to their preinjury functioning. There should not be pessimism about outcomes in older adults who survive.

COVID-19 and the injured patient: A multicenter review

Introduction

Coronavirus disease 2019 (COVID-19) has been shown to affect outcomes among surgical patients. We hypothesized that COVID-19 would be linked to higher mortality and longer length of stay of trauma patients regardless of the injury severity score (ISS).

Methods

We performed a retrospective analysis of trauma registries from two level 1 trauma centers (suburban and urban) from March 1, 2019, to June 30, 2019, and March 1, 2020, to June 30, 2020, comparing baseline characteristics and cumulative adverse events. Data collected included ISS, demographics, and comorbidities. The primary outcome was time from hospitalization to in-hospital death. Outcomes during the height of the first New York COVID-19 wave were also compared with the same time frame in the prior year. Kaplan–Meier method with log-rank test and Cox proportional hazard models were used to compare outcomes.

Results

There were 1180 trauma patients admitted during the study period from March 2020 to June 2020. Of these, 596 were never tested for COVID-19 and were excluded from the analysis. A total of 148 COVID+ patients and 436 COVID− patients composed the 2020 cohort for analysis. Compared with the 2019 cohort, the 2020 cohort was older with more associated comorbidities, more adverse events, but lower ISS. Higher rates of historical hypertension, diabetes, neurologic events, and coagulopathy were found among COVID+ patients compared with COVID− patients. D-dimer and ferritin were unreliable indicators of COVID-19 severity; however, C-reactive protein levels were higher in COVID+ relative to COVID− patients. Patients who were COVID+ had a lower median ISS compared with COVID− patients, and COVID+ patients had higher rates of mortality and longer length of stay.

Conclusions

COVID+ trauma patients admitted to our two level 1 trauma centers had increased morbidity and mortality compared with admitted COVID− trauma patients despite age and lower ISS. C-reactive protein may play a role in monitoring COVID-19 activity in trauma patients. A better understanding of the physiological impact of COVID-19 on injured patients warrants further investigation.

The public health burden of geriatric trauma: Analysis of 2,688,008 hospitalizations from Centers for Medicare and Medicaid Services inpatient claims

BACKGROUND

Geriatric trauma care (GTC) represents an increasing proportion of injury care, but associated public health research on outcomes and expenditures is limited. The purpose of this study was to describe GTC characteristics, location, diagnoses, and expenditures.

METHODS

Patients at short-term nonfederal hospitals, 65 years or older, with ≥1 injury International Classification of Diseases, Tenth Revision, were selected from 2016 to 2019 Centers for Medicare and Medicaid Services Inpatient Standard Analytical Files. Trauma center levels were linked to Inpatient Standard Analytical Files data via American Hospital Association Hospital ID and fuzzy string matching. Demographics, care location, diagnoses, and expenditures were compared across groups.

RESULTS

A total of 2,688,008 hospitalizations (62% female; 90% White; 71% falls; mean Injury Severity Score, 6.5) from 3,286 hospitals were included, comprising 8.5% of all Medicare inpatient hospitalizations. Level I centers encompassed 7.2% of the institutions (n = 236) but 21.2% of hospitalizations, while nontrauma centers represented 58.5% of institutions (n = 1,923) and 37.7% of hospitalizations. Compared with nontrauma centers, patients at Level I centers had higher Elixhauser scores (9.0 vs. 8.8) and Injury Severity Score (7.4 vs. 6.0; p < 0.0001). The most frequent primary diagnosis at all centers was hip/femur fracture (28.3%), followed by traumatic brain injury (10.1%). Expenditures totaled $32.9 billion for trauma-related hospitalizations, or 9.1% of total Medicare hospitalization expenditures and approximately 1.1% of the annual Medicare budget. The overall mortality rate was 3.5%.

CONCLUSION

Geriatric trauma care accounts for 8.5% of all inpatient GTC and a similar percentage of expenditures, the most common injury being hip/femur fractures. The largest proportion of GTC occurs at nontrauma centers, emphasizing their vital role in trauma care. Public health prevention programs and GTC guidelines should be implemented by all hospitals, not just trauma centers. Further research is required to determine the optimal role of trauma systems in GTC, establish data-driven triage guidelines, and define the impact of trauma centers and nontrauma centers on GTC mortality.

LEVEL OF EVIDENCE

Therapeutic/care management, Level III.

Preoperative and Postoperative Cognitive Assessment in Geriatric Patients Following Acute Traumatic Injuries: Towards Improving Geriatric Trauma Outcomes

INTRODUCTION

A growing percentage of the US population is over the age of 65, and geriatrics account for a large portion of trauma admissions, expected to reach nearly 40% by 2050. Cognitive status is important for operative management, especially in elderly populations. This study aims to investigate preoperative and postoperative cognitive function assessment tools in geriatric patients following acute trauma and associated outcomes, including functional status, postdischarge disposition, mortality, and hospital length of stay (H-LOS).

METHODS

A literature search was conducted using Medline/PubMed, Google Scholar, Embase, JAMA Networks, and Cochrane databases for studies investigating the use of cognitive assessment tools for geriatric patients with acute trauma. The last literature search was conducted on November 13, 2021.

RESULTS

Ten studies were included in this review, of which five focused on preoperative cognitive assessment and five focused on postoperative. The evidence suggests patients with preoperative cognitive impairment had worse functional status, mortality, and postdischarge disposition along with increased LOS. Acute trauma patients with postoperative cognitive impairment also had worse functional status, mortality, and adverse postdischarge disposition.

CONCLUSIONS

Preoperative and postoperative cognitive impairment is common in geriatric patients with acute trauma and is associated with worse outcomes, including decreased functional status, increased LOS, and adverse discharge disposition. Cognitive assessment tools such as MMSE, MoCA, and CAM are fast and effective at detecting cognitive impairment in the acute trauma setting and allow clinicians to address preoperative or postoperative cognitive impairments to improve patient outcomes.

Research priorities for prehospital care of older patients with injuries: scoping review

BACKGROUND AND OBJECTIVE

There is increasing recognition of the importance of prehospital trauma care for older patients, but little systematic research to guide practice. We aimed to review the published evidence on prehospital trauma care for older patients, determine the scope of existing research and identify research gaps in the literature.

METHODS

We undertook a systematic scoping review guided by the Arksey and O'Malley framework and reported in line with the PRISMA-ScR checklist. A systematic search was conducted of Scopus, CINAHL, MEDLINE, PubMed and Cochrane library databases to identify articles published between 2001 and 2021. Study selection criteria were applied independently by two reviewers. Data were extracted, charted and summarised from eligible articles. A data-charting form was then developed to facilitate thematic analysis. Narrative synthesis then involved identifying major themes and subthemes from the data.

RESULTS

We identified and reviewed 65 studies, and included 25. We identified five categories: 'field triage', 'ageing impacts', 'decision-making', 'paramedic' awareness' and 'paramedic's behaviour'. Undertriage and overtriage (sensitivity and specificity) were commonly cited as poorly investigated field-triage subthemes. Ageing-related physiologic changes, comorbidities and polypharmacy were the most widely researched. Inaccurate decision-making and poor early identification of major injuries were identified as potentially influencing patient outcomes.

CONCLUSION

This is the first study reviewing the published evidence on prehospital trauma care for older patients and identifying research priorities for future research. Field-triage tools, paramedics' knowledge about injuries in the older population, and understanding of paramedics' negative behaviours towards older patients were identified as key research priorities.

A multicenter cohort study on the association between prehospital immobilization and functional outcome of patients following spinal injury in Asia

Prehospital spinal immobilization is a widely used procedure in the emergency medical service (EMS) system worldwide, while the incidence of patients with spinal injury (SI) is relatively low, and unnecessary prehospital spinal immobilization is associated with patient complications. This study aimed to determine the association between prehospital spine immobilization and favorable functional outcomes at hospital discharge among trauma patients with SI. We conducted a retrospective cohort study using the Pan-Asia Trauma Outcomes Study (PATOS) registry data from January 1, 2016, to November 30, 2018. A total of 759 patients with SI were enrolled from 43,752 trauma patients in the PATOS registry during the study period. The subjects had a median age of 58 years (Q1–Q3, 41–72), and 438 (57.7%) patients had prehospital spine immobilization. Overall, prehospital spinal immobilization was not associated with favorable functional outcomes at discharge in multivariable logistic regression (aOR 1.06; 95% CI 0.62–1.81, p = 0.826). However, in the subgroup of cervical SI, prehospital spinal immobilization was associated with favorable functional outcomes at discharge (aOR 3.14; 95% CI 1.04–9.50; p = 0.043). Therefore, we suggest that paramedics should be more careful when determining the presence of a cervical SI and should apply full spine immobilization if possible.

Factors Influencing Geriatric Orthopaedic Trauma Mortality

INTRODUCTION

This study aimed to: (1) evaluate the independent risk factors related to survival and mortality and (2) predict survival in geriatric orthopaedic trauma patients admitted to our institution's ICU as a Level 1 or 2 trauma activation.

METHODS

A retrospective review was performed on patients age >60, over a 10 year period, who were involved in a multi-trauma with orthopaedic injuries. Variables evaluated include: sex, age, Injury Severity Score (ISS), mechanism of injury, number and type of orthopaedic injury, anticoagulant use, comorbidities, length of stay in intensive care unit (ICU), type of ICU, ventilator use, vasopressors use, incidence of multiple organ dysfunction syndrome (MODS), number of surgeries, and 1-month and 6-month mortality. A Kaplan-Meier estimator and Cox proportional hazards analysis were used to predict and assess survival probability.

RESULTS

174 patients were included, with an average mortality of 47.7%. Deceased patients had a significantly greater age, ISS, vasopressor usage, ICU stay, incidence of MODF, incidence of genitourinary disease, anticoagulant usage, ventilator usage, number of orthopaedic surgeries, and orthopaedic injuries. The relative risk for mortality within the first month was significantly associated with increased age, ISS, high-energy trauma, length of ICU stay, MODS, psychiatric disease, and anticoagulant use. Patients with an ISS ≤30 were significantly more likely to survive than patients with an ISS of >30. Greater age, ISS, length of ICU stay, incidence of MODS, anticoagulant, and ventilator use were significantly predictive of lower survival rates. Mechanism of injury, number of orthopaedic surgeries and orthopaedic injuries, and type of orthopaedic injury were not found to be predictive of survival.

CONCLUSIONS

An ISS >30 at admission is strongly predictive of a lower probability of survival. Genitourinary disease was associated with increased mortality. Low age, ISS, length of stay in ICU, incidence of MODS, anticoagulant use, and ventilator use, are significantly predictive of survival. Number of orthopaedic surgeries, orthopaedic injuries, and type of orthopaedic injury were not found to be predictive of survival. These indications help us to better understand factors predictive of death among geriatric orthopaedic trauma patients, and improve the way we can diagnose and care for them.

Comprehensive comparison between geriatric and nongeriatric patients with trauma

The incidence of geriatric trauma is increasing due to the growing elderly population. Healthcare providers require a global perspective to differentiate critical factors that might alter patients' prognosis.We retrospectively reviewed all adult patients admitted to a trauma center during a 4-year period. We identified 655 adult trauma patients aged from 18 to 64 (nongeriatric group) and 273 trauma patients ≥65 years (geriatric group). Clinical data were collected and compared between the 2 groups.The geriatric group had a higher incidence of trauma and higher Injury Severity Scores than did the nongeriatric group. Fewer geriatric patients underwent surgical treatment (all patients: geriatric vs nongeriatric: 65.9% vs 70.7%; patients with severe trauma: geriatric vs nongeriatric: 27.6% vs 44.5%). Regarding prognosis, the geriatric group exhibited higher mortality rate and less need for long-term care (geriatric vs nongeriatric: mortality: 5.5% vs 1.8%; long-term care: 2.2% vs 5.0%).We observed that geriatric patients had higher trauma incidence and higher trauma mortality rate. Aging is a definite predictor of poor outcomes for trauma patients. Limited physiological reserves and preference for less aggressive treatment might be the main reasons for poor outcomes in elderly individuals.

The patient's voice matters: The impact of advance directives on elderly trauma patients

BACKGROUND

Geriatric trauma rates are increasing, yet trauma centers often struggle to provide autonomy regarding decision making to these patients. Advance care planning can assist with this process. Currently, there are limited data on the impact of advance directives (ADs) in elderly trauma patients. The purpose of this study was to evaluate the prevalence of preinjury AD in geriatric trauma patients and its impact on outcomes, with the hypothesis that ADs would not be associated with an increase in mortality.

METHODS

A multicenter retrospective review was conducted on patients older than 65 years with traumatic injury between 2017 and 2019. Three Level I trauma centers and one Level II trauma center were included. Exclusion criteria were readmission, burn injury, transfer to another facility, discharge from emergency department, and mortality prior to being admitted.

RESULTS

There were 6,135 patients identified; 751 (12.2%) had a preinjury AD. Patients in the AD+ group were older (86 vs. 77 years, p < 0.0001), more likely to be women (67.0% vs. 54.8%, p < 0.0001), and had more comorbidities. Hospital length of stay and ventilator days were similar. In-hospital mortality occurred in 236 patients, and 75.4% of them underwent withdrawal of care (WOC). The mortality rate was higher in AD+ group (10.5% vs. 2.9%, p < 0.0001). No difference was seen in the rate of AD between the WOC+ and WOC- group (31.5% vs. 39.6%, p = 0.251). A preinjury AD was identified as an independent predictor of mortality, but not a predictor of WOC.

CONCLUSION

Despite a high WOC rate in patients older than 65 years, most patients did not have an AD prior to injury. As the elderly trauma population grows, advance care planning should be better integrated into geriatric care to encourage a patient-centered approach to end-of-life care.

LEVEL OF EVIDENCE

Prognostic and epidemiological, level IV.

Geriatric Trauma in a High-Volume Trauma Centre in Cape Town: How Do We Compare?

BACKGROUND

Little is known about the injury profile of older persons from low-and-middle-income countries, such as South Africa, where violence is prevalent. This study aimed to identify common mechanisms of injury (MOI), severity, complications, and outcomes in elderly patients admitted to a referral trauma centre in Cape Town.

METHODS

A retrospective review was performed of all patients ≥60 years presenting at Tygerberg hospital trauma centre over an eight-month period. Descriptive statistics were computed for all variables of interest, and the relationship between the MOI, injury severity score (ISS), complications, and outcomes were assessed.

RESULTS

Of the total 7,635 trauma cases admitted, patients ≥60 years accounted for 4% (n = 275). The most frequent MOI was low falls (58%). Of these 11% of injuries were intentionally inflicted. Among them 35% of the patients experienced complications. The ISS was positively associated with the number of complications (p < 0.01). The mortality rate was 6.5%. An ISS of ≥10 was associated with increased mortality (p < 0.01). The number of complications was positively associated with mortality (p < 0.01).

CONCLUSIONS

In contrast to high-income countries (HICs), the cohort of elderly patients admitted to the trauma centre made up a relatively small portion of the total admissions. Compared to HICs, intentionally inflicted injuries and preventable MOI were common in our sample, underscoring the importance of addressing causative factors. Notably, the ISS was strongly associated with the number of complications and an ISS ≥10 was associated with mortality, highlighting the utility of the ISS in identifying elderly trauma patients most at risk of negative outcomes.

Elderly trauma associated with high-risk recreational activity: A population-based study, United States, 2010 through 2016

BACKGROUND

Understanding trends in prevalence and etiology is critical to public health strategies for prevention and management of injury related to high-risk recreation in elderly Americans.

METHODS

The National Emergency Department Sample from 2010 through 2016 was queried for patients with a principal diagnosis of trauma (ICD-9 codes 800.0-959.9) and who were 55 years and older. High-risk recreation was determined from e-codes a priori. Primary outcome measures were mortality and total hospital charges.

RESULTS

Of the 29,491,352 patient cohort, 458,599 (1.56%) engaged in high-risk activity, including those age 85 and older. High-risk cases were younger (median age 61 vs 70) and majority male (71.87% vs 39.24%). The most frequent activities were pedal cycling (45.81%), motorcycling (29.08%), and off-road vehicles (9.13%). Brain injuries (8.82% vs 3.88%), rib/sternal fractures (13.35% vs 3.53%), and cardiopulmonary injury (5.25% vs 0.57%) were more common among high-risk cases. Mortality (0.75% vs 0.40%) and total median hospital charges ($3,360 vs $2,312) were also higher for high-risk admissions, where the odds of mortality increased exponentially per year of age (odds ratio, 1.06; 99.5% CI, 1.05-1.08). High-risk recreation was associated with more than $1 billion in total hospital charges and more than 100 deaths among elderly Americans per year.

CONCLUSION

Morbidity, mortality, and resource utilization due to high-risk recreation extend into the ninth decade of life. The patterns of injury described here offer opportunities for targeted injury prevention education to minimize risk among this growing segment of the United States population.

Location of Injury and Other Factors Associated With Increased Survival Among Severely Injured Geriatric Trauma Patients

BACKGROUND

Patients with a Trauma Injury Severity Score (TRISS) < .5 are termed "unexpected survivors." There is scarce information published on this subset of geriatric patients whose survival is an anomaly.

METHODS

This is a retrospective case-control study examining all geriatric patients (age ≥65) not expected to survive (TRISS<.5) in the Pennsylvania Trauma Outcome Study (PTOS) database from 2013 to 2017. Primary outcome was survival to discharge. We selected 10 clinically important variables for logistic regression analysis as possible factors that may improve survival.

RESULTS

1336 patients were included, 395 (29.6%) were unexpected survivors. Factors that improved survival odds are the following: Place of injury: street/highway (AOR:0.51; 95% CI: .36-.73, P < .001) and residential institution (AOR:0.46; 95% CI: .21-.98, P = .043); and presence of Benzodiazepines (AOR:0.49; 95% CI: .31-.77, P = .002) or ethanol (AOR:0.57; 95% CI: .34-.97, P = .040). Factors that decreased survival odds are the following: Hypotension (AOR: 8.59; 95% CI: 4.33-17.01, P < .001) and hypothermia (AOR: 1.58; 95% CI: 1.10-2.28, P = .014). Gender, race/ethnicity, blood transfusion in first 24 hours, shift of presentation to Emergency Department, place of injury (farm, industrial, recreational, or public building), use of Tetrahydrocannabinol, amphetamines or opioids, and level of trauma activation did not impact survival.

DISCUSSION

Location of injury (street/highway and residential institution) and ethanol or benzodiazepine use led to a significant increased survival in severely injured geriatric patients. Hypotension and hypothermia led to decreased survival. Future studies should determine possible reasons these factors lead to survival (and identify additional factors) to focus efforts in these areas to improve outcomes in geriatric trauma.

Failure to Rescue in Geriatric Trauma: The Impact of Any Complication Increases with Age and Injury Severity in Elderly Trauma Patients

INTRODUCTION

The interaction of increasing age, Injury Severity Score (ISS), and complications is not well described in geriatric trauma patients. We hypothesized that failure to rescue rate from any complication worsens with age and injury severity.

METHODS

The National Trauma Data Bank (NTDB) was queried for injured patients aged 65 years or older from January 1, 2013 through December 31, 2016. Demographics and injury characteristics were used to compare groups. Mortality rates were calculated across subgroups of age and ISS, and captured with heatmaps. Multivariable logistic regression was performed to identify independent predictors of mortality.

RESULTS

614,496 geriatric trauma patients were included; 151,880 (24.7%) experienced a complication. Those with complications tended to be older, female, non-white, have non-blunt mechanism, higher ISS, and hypotension on arrival. Overall mortality was highest (19%) in the oldest (≥86 years old) and most severely injured (ISS ≥ 25) patients, with constant age increasing across each ISS group was associated with a 157% increase in overall mortality (P < .001, 95% CI: 148-167%). Holding ISS stable, increasing age group was associated with a 48% increase in overall mortality (P < .001, 95% CI: 44-52%). After controlling for standard demographic variables at presentation, the existence of any complication was an independent predictor of overall mortality in geriatric patients (OR: 2.3; 95% CI: 2.2-2.4).

CONCLUSIONS

Any complication was an independent risk factor for mortality, and scaled with increasing age and ISS in geriatric patients. Differences in failure to rescue between populations may reflect critical differences in physiologic vulnerability that could represent targets for interventions.

A biomimetic shock model on the effect of endothelial aging on vascular barrier properties

BACKGROUND

Aging is characterized by a decline in cellular function, which has an adverse effect on the biologic response to injury. Both aging and trauma/hemorrhagic shock (T/HS) increase oxidative stress which impairs the vascular endothelium (EC) and glycocalyx (EG). The additive effect of aging on EC and EG damage following T/HS are unknown. This was studied in an in vitro model.

METHODS

Confluent endothelial cell monolayers from primary aortic endothelial cells from 10-week-old mice ("young" cells) or primary aortic cells from 65-week-old mice ("aged" cells) were established in microfluidic devices (MFDs) and perfused at constant shear conditions overnight. Mouse endothelial cell monolayers were then exposed to hypoxia/reoxygenation alone and/or epinephrine or norepinephrine. Endothelial glycocalyx degradation was indexed as well as subsequent endothelial injury/activation.

RESULTS

Aged endothelial cells showed increase glycocalyx shedding and subsequent loss of glycocalyx thickness. This lead to a more pronounced level of EC injury/activation compared with young endothelial cells. Although exposure to biomimetic shock conditions exacerbated both endothelial glycocalyx shedding and endothelial injury in both aged and young endothelial cells, the effect was significantly more pronounced in aged cells.

CONCLUSION

Advanced age is associated with worse outcomes in severely injured trauma patients. Our study demonstrates that there is increased EG shedding and a diminished EG layer in aged compared to "young" endothelial cell layers. Biomimetic shock conditions lead to an even greater impairment of the endothelial glycocalyx in aged versus young endothelial cell monolayers. It appears that these effects are a consequence of aging related oxidative stress at both baseline and shock conditions. This exacerbates shock-induced endotheliopathy and may contribute to untoward effects on patient outcomes in this population.

Cost-Effectiveness of Multifactorial Interventions in Preventing Falls among Elderly Population: A Systematic Review

Objective:

To review the cost-effectiveness of multifactorial interventions to prevent falls in elderly people.

Methods:

In this systematic review, the databases including PubMed via MEDLINE, Web of Science, Embase, Scopus, Cochrane Library and Google Scholar (from 1st January 2000 to 30^th February) were used. All pre-reviewed articles related to cost-effectiveness analysis of multifactorial interventions to prevent falls in elderly were included in this paper and congresses abstracts were excluded. Descriptive statistics were used for quantitative data and content-analysis method to analyze qualitative data.

Results:

Out of the 456 articles, 19 were finally included in the study. Eighteen articles were conducted in High-Income Countries (HICs) and 16 were at the community level. Medical visits consultation and education were the most common interventions. Most studies were cost-effectiveness and using the Randomized Control Trial (RCT) methods. A fall of prevention costs ranged from $ 272 to $ 987. Incremental Cost-Effectiveness Ratio (ICER) interventions also ranged from the US $ 120,667 to the US $ 4280.9.

Conclusion:

The results show that despite the high effectiveness of multifactorial interventions to prevent elderly falls, the cost of the interventions are high and they are not very cost-effective. It would be better to design and implement multifactorial interventions with low cost and high effectiveness that are appropriate for each country.

Unplanned Readmissions to the Intensive Care Unit Among Geriatric Trauma Patients

BACKGROUND

Unplanned readmission/bounceback to the intensive care unit (ICUBB) is a prevalent issue in the medical community. The geriatric population is incompletely studied in regard to ICUBB. We sought to determine if ICUBB in older patients was associated with higher risk of mortality. We hypothesized that, of those who were older, those with ICUBB would have higher mortality compared to those with no ICUBB. Further, we hypothesized that of those with ICUBB, older age would lead to higher mortality.

METHODS

The Pennsylvania Trauma Outcome Study database was retrospectively queried from 2003 to 2018 for all trauma patients of age ≥40 years. Those with advance directives were excluded. Adjusted analysis in the form of logistic regressions controlling for demographic and injury covariates and clustering by facility were used to assess the adjusted impact of ICUBB and age on mortality.

RESULTS

363,778 patients were aged ≥40 years. When comparing mortalities between the age 40 and 49 years group and those in older groups, a dramatic increase in mortality was observed between those in each respective age category with ICUBB vs non-ICUBB. This trend was most prominent in those in the 90+ years age group (ICUBB: AOR: 34.78, P < .001; non-ICUBB: AOR: 9.08, P < .001). A second model only including patients who had ICUBB found that patients of age ≥65 years had significantly higher odds of mortality (AOR: 4.10, P < .001) when compared to their younger counterparts (age <65 years).

DISCUSSION

An ICUBB seems to exacerbate mortality rates as age increases. This profound increase in mortality calls for strategies to be developed, especially in the older population, to attempt to mitigate the factors leading to ICUBB.

Surgical Management of Facial Fractures in Geriatric Patients

ABSTRACT

Facial fractures comprise a substantial part of traumatology. Due to aging of the population, over the last 20 years, there has been a pattern of redistribution of these fractures with a higher incidence at an older age. The aim of this study was to retrospectively analyze the epidemiology, pattern, and surgical management of facial fractures in geriatric patients presenting at a single tertiary trauma center.This study included patients aged ≥70 years who presented with facial bone fractures between 2008 and 2017 and were treated with surgical interventions. Parameters such as age, sex, American Society of Anesthesiologists classification, Glasgow Coma Scale score, fracture type, fracture mechanism, concomitant injuries, duration of hospitalization, and postoperative complications were evaluated.A total of 300 patients were included: 118 men (39.3%) and 182 women (60.7%). The mean age was 78.8 years. An orbital floor fracture was the most common injury (35.1%). The most common cause of fracture was a fall at home (67%). A total of 113 patients (37.7%) had 162 concomitant injuries, 35 patients (11.7%) suffered from polytrauma, and 7 patients developed postoperative complications. The average length of stay was 1.67 days in the intensive care unit and 5.50 days in the standard ward. Polytrauma, pre-existing medical conditions, and oral anticoagulation had a significant impact on the duration of hospitalization.Facial fractures are common in combination with other injuries. Women are more often affected than men, and falling at home is the most common cause of facial injuries. Postoperative complications are rare.

CT as a first-line modality in elderly patients with stable blunt chest trauma

PURPOSE

Blunt thoracic injuries are common among elderly patients and may be a common cause of morbidity and death from blunt trauma injuries. We aimed to examine the impact of chest CT on the diagnosis and change of management plan in elderly patients with stable blunt chest trauma. We hypothesized that chest CT may play an important role in providing optimal management to this subgroup of trauma patients.

METHODS

A retrospective analysis was performed on all the admitted adult blunt trauma patients between January 2014 and December 2018. Stable blunt chest trauma patients with abbreviated injury severity (AIS) < 3 for extra-thoracic injuries confirmed with chest X-ray (CXR) and chest CT on admission or during hospitalization were included in the study. The AIS is an international scale for grading the severity of anatomic injury following blunt trauma. Primary outcome variables were occult injuries, change in management, need for surgical procedures, missed injuries, readmission rate, intensive care unit (ICU) and length of hospital stay.

RESULTS

There are 473 patients with blunt chest trauma included in the study. The study patients were divided into two groups according to the age range: group 1: 289 patients were included and aged 18-64 years; group 2: 184 patients were included and aged 65-99 years . Elderly patients in group 2 more often required ICU admission (11.4% vs. 5.2%), had a longer length of ICU stay (days) (median 11 vs. 6, p = 0.01), and the length of hospital stay (days) (median 14 vs. 6, p = 0.04). Injuries identified on chest CT has led to a change of management in 4.4% of young patients in group 1 and in 10.9% of elderly patients in group 2 with initially normal CXR. Chest CT resulted in a change of management in 12.8% of young patients in group 1 and in 25.7% of elderly patients in group 2 with initially abnormal CXR.

CONCLUSION

Chest CT led to a change of management in a substantial proportion of elderly patients. Therefore, we recommend chest CT as a first-line imaging modality in patients aged over 65 years with isolated blunt chest trauma.

Pattern of trauma in elderly patients seen at the trauma centre of national hospital Abuja, Nigeria

Introduction

The global population is aging, creating challenges for health systems. The mean age of patients with major trauma has increased over time, posing some challenges for trauma system designs. Elderly trauma patients are said to have higher mortality rates and longer hospital and intensive care unit stays. This study is aimed at assessing the pattern of injuries in elderly population in a dedicated trauma centre of a developing economy.

Methods

This is a retrospective study of all patients aged 60 years and above seen in the trauma centre of a West African tertiary hospital over a three year period from January 2017 to December 2019. Relevant parameters including Sociodemographic data, injury pattern and injury scores were derived from the trauma registry. Data analysis was done using statistical package for social sciences (SPSS) version 24. Results were presented using tables and a figure.

Results

A total of 183 patients aged 60 years and above were enrolled out of 4549 general trauma patients, representing 4% of the trauma patient population seen. Male to female ratio was 2.3 with the mean age of 65 ± 6.3. The most frequent mechanisms of injury were motor vehicular crash (MVC) (48.4%), followed by falls (16.5%). More proportion of females (21.8%) were significantly found to suffer falls compared to their males (14.2%) counterparts (p < 0.05). Traumatic brain injury was the commonest diagnosis accounting for 24.3% of cases. The predominant revised trauma scores (RTS) and injury severity scores (ISS) were 12 and 1–15 respectively, with overall mortality of 6.1%.

Conclusion

The proportion of elderly trauma patients studied in this centre is low. MVC is still the leading mechanism of injury in our elderly trauma population. The mortality rate is however low in this study, in line with the low trauma and severity scores. Preventive measures for MVC should be strongly encouraged to reduce the incidence of elderly trauma patients in this part of the world.

Elderly trauma mortality in a resource-limited setting: A benchmark for process improvement

INTRODUCTION

As life expectancy improves globally, the burden of elderly trauma continues to increase. Sub-Saharan Africa is projected to have the most rapid growth in its elderly demographic. Consequently, we sought to examine the trends in characteristics and outcomes of elderly trauma in a tertiary care hospital in Malawi.

METHODS

We performed a retrospective analysis of adult patients in the trauma registry at Kamuzu Central Hospital (KCH) in Lilongwe, Malawi from 2011-2017. Patients were categorized into elderly (≥ 65 years) and non-elderly (18-64 years). Bivariate analysis compared the characteristics and outcomes of elderly vs. non-elderly patients. The elderly population was then examined over the study period. Poisson regression modeling was used to determine the risk of mortality among elderly patients over time.

RESULTS

Of 63,699 adult trauma patients, 1,925 (3.0%) were aged ≥ 65 years. Among the elderly, the most common mechanism of injury was falls (n = 725 [37.7%]) whereas vehicle or bike collisions were more common in the non-elderly (n = 15,967 [25.9%]). Fractures and dislocations were more prevalent in the elderly (n = 808 [42.0%] vs. 9,133 [14.8%], p < 0.001). In-hospital crude mortality for the elderly was double the non-elderly group (4.8% vs. 2.4%, p < 0.001). Elderly transfers, surgeries, and length of stay significantly increased over the study period but mortality remained relatively unchanged. When adjusted for injury severity and transfer status, there was no significant difference in risk of in-hospital mortality over time.

CONCLUSION

At KCH, the proportion of elderly trauma patients is slowly increasing. Although healthcare resource utilization has increased over time, the overall trend in mortality has not improved. As the quality of care for the most vulnerable populations is a benchmark for the success of a trauma program, further work is needed to improve the trend in outcomes of the elderly trauma population in Malawi.

A retrospective cohort study of 27,049 polytraumatized patients age 60 and above: identifying changes over 16 years

Aim

In this study, we establish an overview of changes we observed in demographics of older severe trauma patients from 2002 to 2017.

Findings

Trauma mechanism, as well as injury pattern, changed over time. We found length of stay and mortality decreased despite an increase in patient age.

Message

We ascribe this observation mainly to increased use of diagnostic tools and improved treatment algorithms and underline the importance of the implementation of specialized geriatric trauma centers allowing interdisciplinary care.

Purpose

The number of severely injured patients exceeding the age of 60 has shown a steep increase within the last decades. These patients present with numerous co-morbidities, polypharmacy, and increased frailty requiring an adjusted treatment approach. In this study, we establish an overview of changes we observed in demographics of older severe trauma patients from 2002 to 2017.

Methods

A descriptive analysis of the data from the TraumaRegister DGU^® (TR-DGU) was performed. Patients admitted to a level one trauma center in Germany, Austria and Switzerland between 2002 and 2017, aged 60 years or older and with an injury severity score (ISS) over 15 were included. Patients were stratified into subgroups based on the admission: 2002–2005 (1), 2006–2009 (2), 2010–2013 (3) and 2014–2017 (4). Trauma and patient characteristics, diagnostics, treatment and outcome were compared.

Results

In total 27,049 patients with an average age of 73.9 years met the inclusion criteria. The majority were males (64%), and the mean ISS was 27.4. The proportion of patients 60 years or older [(23% (1) to 40% (4)] rose considerably over time. Trauma mechanisms changed over time and more specifically low falls (< 3 m) rose from 17.6% (1) to 40.1% (4). Altered injury patterns were also identified. Length-of-stay decreased from 28.9 (1) to 19.5 days (4) and the length-of-stay on ICU decreased from 17.1 (1) to 12.7 days (4). Mortality decreased from 40.5% (1) to 31.8% (4).

Conclusion

Length of stay and mortality decreased despite an increase in patient age. We ascribe this observation mainly to increased use of diagnostic tools, improved treatment algorithms, and the implementation of specialized trauma centers for older patients allowing interdisciplinary care.

Impact of anticoagulation and antiplatelet drugs on surgery rates and mortality in trauma patients

Preinjury anticoagulation therapy (AT) is associated with a higher risk for major bleeding. We aimed to evaluated the influence of preinjury anticoagulant medication on the clinical course after moderate and severe trauma. Patients in the TraumaRegister DGU ≥ 55 years who received AT were matched with patients not receiving AT. Pairs were grouped according to the drug used: Antiplatelet drugs (APD), vitamin K antagonists (VKA) and direct oral anticoagulants (DOAC). The primary end points were early (< 24 h) and total in-hospital mortality. Secondary endpoints included emergency surgical procedure rates and surgery rates. The APD group matched 1759 pairs, the VKA group 677 pairs, and the DOAC group 437 pairs. Surgery rates were statistically significant higher in the AT groups compared to controls (APD group: 51.8% vs. 47.8%, p = 0.015; VKA group: 52.4% vs. 44.8%, p = 0.005; DOAC group: 52.6% vs. 41.0%, p = 0.001). Patients on VKA had higher total in-hospital mortality (23.9% vs. 19.5%, p = 0.026), whereas APD patients showed a significantly higher early mortality compared to controls (5.3% vs. 3.5%, p = 0.011). Standard operating procedures should be developed to avoid lethal under-triage. Further studies should focus on detailed information about complications, secondary surgical procedures and preventable risk factors in relation to mortality.

Challenges in the PREHOSPITAL emergency management of geriatric trauma patients - a scoping review

BACKGROUND

Despite a widely acknowledged increase in older people presenting with traumatic injury in western populations there remains a lack of research into the optimal prehospital management of this vulnerable patient group. Research into this cohort faces many uniqu1e challenges, such as inconsistent definitions, variable physiology, non-linear presentation and multi-morbidity. This scoping review sought to summarise the main challenges in providing prehospital care to older trauma patients to improve the care for this vulnerable group.

METHODS AND FINDINGS

A scoping review was performed searching Google Scholar, PubMed and Medline from 2000 until 2020 for literature in English addressing the management of older trauma patients in both the prehospital arena and Emergency Department. A thematic analysis and narrative synthesis was conducted on the included 131 studies. Age-threshold was confirmed by a descriptive analysis from all included studies. The majority of the studies assessed triage and found that recognition and undertriage presented a significant challenge, with adverse effects on mortality. We identified six key challenges in the prehospital field that were summarised in this review.

CONCLUSIONS

Trauma in older people is common and challenges prehospital care providers in numerous ways that are difficult to address. Undertriage and the potential for age bias remain prevalent. In this Scoping Review, we identified and discussed six major challenges that are unique to the prehospital environment. More high-quality evidence is needed to investigate this issue further.