When the trauma patient is elderly

Polytrauma in the Geriatric Population: Analysis of Outcomes for Surgically Treated Multiple Fractures with a Minimum 2 Years of Follow-Up

INTRODUCTION

This study analyzed the clinical and radiological outcomes of geriatric polytrauma patients who had multiple fractures surgically treated and a minimum of 2 years of follow-up.

METHODS

Eighty-six geriatric patients with polytrauma and multiple fractures which were surgically treated in orthopedics and who had a minimum of 2 years of follow-up were retrospectively analyzed. Patients' demographic characteristics, comorbidities, and follow-up time were recorded. The mechanism of injury, fracture type and location, Injury Severity Score (ISS), American Society of Anesthesiologists (ASA) score, duration of hospital stay, complications, and 1-year mortality were also recorded. Fracture union, implant failure, and refractures/misalignment were analyzed from radiographs.

RESULTS

There were 34 (39.5%) male and 52 (60.5%) female patients. Mean age was 73.5 years with an average follow-up time of 32.9 months. Patients had more low-energy traumas and more lower extremity, comminuted fractures. On the contrary, high-energy traumas and femur/pelvic fracture surgeries had higher associated mortality. The mean ISS score was 26.3. The most common ASA score was ASA 3 (75.8%). The most common clinical and radiological complications were prolonged wound drainage and implant failure. The total 1-year mortality rate was 22.1%. Patients with high ASA scores and patients with lower extremity fractures (femoral/pelvic fractures) also had significantly increased mortality rates. No significant relation was detected between mortality and ISS, fracture type, number of fractures, and duration of hospital stay.

CONCLUSION

Orthopedic surgeons must be alert about the possible complications of femoral fractures and comminuted fractures including pelvic girdle. Surgically treated, multifractured patients with high-energy trauma, advanced age, and high ASA scores are also at risk for mortality regardless of the ISS, comorbidities, and duration of hospital stay. Pulmonary thromboemboli must be kept in mind as a significant complication for 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.

The Impact of Obesity on Outcomes in Geriatric Blunt Trauma

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

Epidemiology of Road Traffic Injuries among Elderly People; A Systematic Review and Meta-Analysis

Objective:

To systematically review the epidemiological patterns and interventions for prevention of road traffic injuries (RTIs) among elderly.

Methods:

Searching keywords including: accident, trauma, road injury, road traffic injuries, aging, old, elder, strategy, intervention, road traffic crash prevention and traffic accident in databases including, Google scholar, SID, IranMedex, PubMed and Scopus. English and non-Persian articles, articles presented in congresses, articles that considered elderly people to have age under than 60 years were excluded. The reporting quality of articles was assessed by two experts using Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) check list.

Results:

RTIs compromised 23.6% of total injuries among elderly. The most frequent injuries were about car accidents (51.4%). Pedestrian injuries composed 48.1% of the RTIs. Head and neck (32.1%) were most injured body parts. There was a significant difference between elderly and non-elderly people in terms of RTIs associated mortality (Odd=2.57 [1.2-5.4 CI 95%]). Overall 25 main domains of intervention and 73 subordinate domains were extracted in five categories (human, road and environment, tools and cars, medical, legal and political issues).

Conclusion:

According to the notable prevalence and fatality of RTIs, lack of sufficient studies and valid evidence of the present study can provide an appropriate evidence for better interventions for RTIs prevention among elderly.

Polytrauma in the elderly: a review

Although the field of geriatric trauma is – ironically – young, care for the elderly trauma patient is increasingly recognised as an important challenge, considering the worldwide trend towards increasing longevity.

Increasing age is associated with physiological changes and resulting comorbidities that present multiple challenges to the treating physician.

Even though polytrauma is less likely with increasing age, lower-energy trauma can also result in life-threatening injuries due to the reduced physiological reserve.

Mechanisms of injury and resulting injury patterns are markedly changed in the elderly population and new management strategies are needed. From initial triage to long-term rehabilitation, these patients require care that differs from the everyday standard.

In the current review, the special requirements of this increasing patient population are reviewed and management options discussed. With the increase in orthogeriatrics as a speciality, the current status quo will almost certainly shift towards a more tailored treatment approach for the elderly patient. Further research expanding our current knowledge is needed to reduce the high morbidity and mortality rate.

Cite this article: Braun BJ, Holstein J, Fritz T, Veith NT, Herath S, Mörsdorf P, Pohlemann T. Polytrauma in the elderly: a review. EFORT Open Rev 2016;1:146-151. DOI: 10.1302/2058-5241.1.160002.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Preinjury statin use is associated with a higher risk of multiple organ failure after injury: a propensity score adjusted analysis

BACKGROUND

Recent studies suggest that statin use may improve outcome in critically ill patients. This has been attributed to the pleiomorphic effect and modulation of inflammatory mediators that occurs with statin use. We sought to determine whether preinjury statin (PIS) use was associated with improved outcome in severely injured blunt trauma patients.

METHODS

Data were obtained from a multicenter prospective cohort study evaluating outcomes in blunt injured adults with hemorrhagic shock. Patients aged 55 years and older were analyzed. Those with isolated traumatic brain injury, cervical cord injury, and those who survived <24 hours were excluded. A propensity score predicting statin use was created using logistic regression. Cox proportional hazard regression was then used to evaluate the effects of PIS use on mortality and the development of multiple organ failure (MOF, multiple organ dysfunction syndrome >5) and nosocomial infection (NI) after adjusting for important injury characteristics and the propensity of taking PISs.

RESULTS

Overall mortality and MOF rates for the study cohort (n = 295) were 21% and 50%, respectively. Over 24% of patients (n = 71) reported PIS use. Kaplan-Meier analysis revealed no difference in NI or mortality over time but did show a significant higher incidence of MOF in those with PIS use (p = 0.04). Regression analysis verified PIS was independently associated with an 80% higher risk of MOF (hazard ratio: 1.8; 95% confidence interval, 1.1-2.9) and was found to be one of the strongest independent risk factors for the development of MOF.

CONCLUSION

PIS use was independently associated with a higher risk of MOF postinjury. These results are contrary to previous analyses. The protective effect of statins may be lost in the severely injured, and modulation of the inflammatory response may result in higher morbidity. Further studies are required to better understand the impact and potential therapeutic utility of this commonly prescribed medication both before and after injury.