Epidemiology of severe trauma in Spain. Registry of trauma in the ICU (RETRAUCI). Pilot phase

Rehabilitation after musculoskeletal injury: European perspective

Trauma is one of the main causes of death in younger people and ongoing disability worldwide. In Europe, while there is generally good organization of trauma reception and acute treatment, rehabilitation from major musculoskeletal injuries is less well defined and provided. This article documents the diverse approaches to rehabilitation after major injury in 6 European nations. The recognition of need is universal, but achieving a robust rehabilitation strategy is more elusive across the varying health care systems. Switzerland has the most robust service in the insured population. In the other countries, particularly where there is a reliance on public institutes, this provision is at best patchy. In the Netherlands, innovative patient-empowering strategies have gained traction with notable success, and in the United Kingdom, a recent randomized trial also showed this approach to be reproducible and robust. Overall, there is a clear need for learning across the national systems and implementation of a minimum set of standards.

Performance of severity indices for admission and mortality of trauma patients in the intensive care unit: a retrospective cohort study

BACKGROUND

Little is known about the performance of severity indices for indicating intensive care and predicting mortality in the Intensive Care Unit (ICU) of trauma patients. This study aimed to compare the performance of severity indices to predict trauma patients' ICU admission and mortality.

METHODS

A retrospective cohort study which analyzed the electronic medical records of trauma patients aged ≥ 18 years, treated at a hospital in Brazil, between 2014 and 2017. Physiological [Revised Trauma Score (RTS), New Trauma Score (NTS) and modified Rapid Emergency Medicine Score (mREMS)], anatomical [Injury Severity Score (ISS) and New Injury Severity Score (NISS)] and mixed indices [Trauma and Injury Severity Score (TRISS), New Trauma and Injury Severity Score (NTRISS), Base-deficit Injury Severity Score (BISS) and Base-deficit and New Injury Severity Score (BNISS)] were compared in analyzing the outcomes (ICU admission and mortality) using the Area Under the Receiver Operating Characteristics Curves (AUC-ROC).

RESULTS

From the 747 trauma patients analyzed (52.5% female; mean age 51.5 years; 36.1% falls), 106 (14.2%) were admitted to the ICU and 6 (0.8%) died in the unit. The ISS (AUC 0.919) and NISS (AUC 0.916) had better predictive capacity for ICU admission of trauma patients. The NISS (AUC 0.949), TRISS (AUC 0.909), NTRISS (AUC 0.967), BISS (AUC 0.902) and BNISS (AUC 0.976) showed excellent performance in predicting ICU mortality.

CONCLUSIONS

Anatomical indices showed excellent predictive ability for admission of trauma patients to the ICU. The NISS and the mixed indices had the best performances regarding mortality in the ICU.

Documentation of wounds in emergency departments through a forensic lens

BACKGROUND

Nurses document wounds to direct and evaluate the care. People admitted to emergency departments with wounds should be regarded as potential forensic patients, requiring meticulous documentation for evidence purposes.

AIM

To explore the documentation of wounds in emergency departments through a forensic lens and compare it between different levels of emergency departments.

METHODS

In this descriptive retrospective study, we randomly sampled 515 paper-based medical files of patients who sustained wounds admitted to three selected emergency departments. The files were analysed using a structured data collection tool the data were descriptively analysed.

RESULTS

All files included information on the type of wound (100%) and the site of the wound (100%) with most files including the mechanisms of injury (98.6%). Few files included information on blood loss (18.1%) and the size of the wound (15%). Only one file included information on the contents of the wound. No files included information on the wound's shape and the surrounding skin's condition.

CONCLUSION

Wounds were poorly documented in emergency departments, irrespective of the level of care. Nurses in emergency departments should have strict guidelines for documenting wounds since accurate documentation protects patients' human rights and protects nurses.

Results of the Spanish National Polytrauma Registry. Where are we and where are we heading?

INTRODUCTION

In 2017, the Spanish National Polytrauma Registry (SNPR) was initiated in Spain with the goal to improve the quality of severe trauma management and evaluate the use of resources and treatment strategies. The objective of this study is to present the data obtained with the SNPR since its inception.

METHODS

We conducted an observational study with prospective data collection from the SNPR. The trauma patients included were over 14 years of age, with ISS ≥ 15 or penetrating mechanism of injury, from a total of 17 tertiary hospitals in Spain.

RESULTS

From 1/1/17 to 1/1/22, 2069 trauma patients were registered. The majority were men (76.4%), with a mean age of 45 years, mean ISS 22.8, and mortality 10.2%. The most common mechanism of injury was blunt trauma (80%), the most frequent being motorcycle accident (23%). Penetrating trauma was presented in 12% of patients, stab wounds being the most common (84%). On hospital arrival, 16% of patients were hemodynamically unstable. The massive transfusion protocol was activated in 14% of patients, and 53% underwent surgery. Median hospital stay was 11 days, while 73.4% of patients required intensive care unit (ICU) admission, with a median ICU stay of 5 days.

CONCLUSIONS

Trauma patients registered in the SNPR are predominantly middle-aged males who experience blunt trauma with a high incidence of thoracic injuries. Early addressed detection and treatment of these kind of injuries would probably improve the quality of trauma care in our environment.

Implementation of a major trauma team. Analysis of activation and care times in patients admitted to the ICU

OBJECTIVE

To analyze the factors associated with the activation of the severe trauma care team (STAT) in patients admitted to the ICU, to measure its impact on care times, and to analyze the groups of patients according to activation and level of anatomical involvement.

DESIGN

Prospective cohort study of severe trauma admitted to the ICU. From June 2017 to May 2019. Risk factors for the activation of the STAT analysed with logistic regression and CART type classification tree.

SETTING

Second level hospital ICU.

PATIENTS

Patients admitted consecutively.

INTERVENTIONS

No.

MAIN VARIABLES OF INTEREST

STAT activation. Demographic variables. Injury severity (ISS), intentionality, mechanism, assistance times, evolutionary complications, and mortality.

RESULTS

A total of 188 patients were admitted (46.8% of STAT activation), median age of 52 (37-64) years (activated 47 (27-62) vs not activated 55 (42-67) P = 0.023), males 84.0%. No difference in mortality according to activation. The logistic model finds as factors: care (16.6 (2.1-13.2)) and prehospital intubation (4.2 (1.8-9.8)) and severe lower extremity injury (4.4 (1.6-12.3)). Accidental fall (0.2 (0.1-0.6)) makes activation less likely. The CART model selects the type of trauma mechanism and can separate high and low energy trauma.

CONCLUSIONS

Factors associated with STAT activation were prehospital care, requiring prior intubation, high-energy mechanisms, and severe lower extremity injuries. Shorter care times if activated without influencing mortality. We must improve activation in older patients with low-energy trauma and without prehospital care.

Epidemiology of severe trauma in Navarra for 10 years: out-of-hospital/ in-hospital deaths and survivors

BACKGROUND

Major trauma is a leading cause of death. Due to the difficulties to keep a registry of these cases, few studies include all subjects, because they exclude out-of-hospital deaths. The purpose of this work was to compare the epidemiological profiles of out-of-hospital deaths, in-hospital deaths, and survivors over a 10-year period (2010-2019) of patients who had been treated by Navarre´s Health Service (Spain).

METHODS

Retrospective longitudinal cohort study using data of patients injured by an external physical force of any intentionality and with a New Injury Severity Score above 15. Hangings, drownings, burns, and chokings were excluded. Intergroup differences of demographic and clinical variables were analysed using the Kruskal Wallis test, chi-squared test, or Fisher´s exact test.

RESULTS

Data from 2,610 patients were analysed; 624 died out-of-hospital, 439 in-hospital, and 1,547 survived. Trauma incidences remained moderately stable over the 10-year period analysed, with a slight decrease in out-of-hospital deaths and a slight increase in in-hospital deaths. Patients of the out-of-hospital deaths group were younger (50.9 years) in comparison to in-hospital deaths and survivors. Death victims were predominantly male in all study groups. Intergroup differences regarding prior comorbidities and predominant type of injury were observed.

CONCLUSIONS

There are significant differences among the three study groups. More than half of the deaths occur out-of-hospital and the causative mechanisms differ in each of them. Thus, when designing strategies, preventive measures were considered for each group on a case-by-case basis.

Epidemiology and Associated Factors in Transfusion Management in Intensive Care Unit

Severe traumatic injury is one of the main global health issues which annually causes more than 5.8 million worldwide deaths. Uncontrolled haemorrhage is the main avoidable cause of death among severely injured individuals. Management of trauma patients is the greatest challenge in trauma emergency care, and its proper diagnosis and early management of bleeding trauma patients, including blood transfusion, are critical for patient outcomes. Aim: We aimed to describe the epidemiology of transfusion practices in severe trauma patients admitted into Spanish Intensive Care Units. Material and Methods: We performed a multicenter cross-sectional study in 111 Intensive Care Units across Spain. Adult patients with moderate or severe trauma were eligible. Distribution of frequencies was used for qualitative variables and the mean, with its 95% CI, for quantitative variables. Transfusion programmes, the number of transfusions performed, and the blood component transfused were recorded. Demographic variables, mortality rate, hospital stay, SOFA-score and haemoglobin levels were also gathered. Results: We obtained results from 109 patients. The most transfused blood component was packet red blood cells with 93.8% of total transfusions versus 43.8% of platelets and 37.5% of fresh plasma. The main criteria for transfusion were analytical criteria (43.75%), and acute anaemia with shock (18.75%) and without haemodynamic impact (18.75%). Conclusion: Clinical practice shows a ratio of red blood cells, platelets, and Fresh Frozen Plasma (FFP) of 2:1:1. It is necessary to implement Massive Transfusion Protocols as they appear to improve outcomes. Our study suggests that transfusion of RBC, platelets and FFP in a 2:1:1 ratio could be beneficial for trauma patients.

Chronic critical illness in polytrauma. Results of the Spanish trauma in ICU registry

PURPOSE

Chronic critical illness after trauma injury has not been fully evaluated, and there is little evidence in this regard. We aim to describe the prevalence and risk factors of chronic critical illness (CCI) in trauma patients admitted to the intensive care unit.

MATERIAL AND METHODS

Retrospective observational multicenter study (Spanish Registry of Trauma in ICU (RETRAUCI)). Period March 2015 to December 2019. Trauma patients admitted to the ICU, who survived the first 48 h, were included. Chronic critical illness (CCI) was considered as the need for mechanical ventilation for a period greater than 14 days and/or placement of a tracheostomy. The main outcomes measures were prevalence and risk factors of CCI after trauma.

RESULTS

1290/9213 (14%) patients developed CCI. These patients were older (51.2 ± 19.4 vs 49 ± 18.9); p < .01) and predominantly male (79.9%). They presented a higher proportion of infectious complications (81.3% vs 12.7%; p < .01) and multiple organ dysfunction syndrome (MODS) (27.02% vs 5.19%; p < .01). CCI patients required longer stays in the ICU and had higher ICU and overall in-hospital mortality. Age, injury severity score, head injury, infectious complications, and development of MODS were independent predictors of CCI.

CONCLUSION

CCI in trauma is a prevalent entity in our series. Early identification could facilitate specific interventions to change the trajectory of this process.

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.

Risk Factors Associated with Mortality in Severe Chest Trauma Patients Admitted to the ICU

Our objective was to determine outcomes of severe chest trauma admitted to the ICU and the risk factors associated with mortality. An observational, prospective, and multicenter registry of trauma patients admitted to the participating ICUs (March 2015-December 2019) was utilized to collect the patient data that were analyzed. Severe chest trauma was defined as an Abbreviated Injury Scale (AIS) value of ≥3 in the thoracic area. Logistic regression analysis was used to evaluate the contribution of severe chest trauma to crude and adjusted ORs for mortality and to analyze the risk factors associated with mortality. Overall, 3821 patients (39%) presented severe chest trauma. The sample's characteristics were as follows: a mean age of 49.88 (19.21) years, male (77.6%), blunt trauma (93.9%), a mean ISS of 19.9 (11.6). Crude and adjusted (for age and ISS) ORs for mortality in severe chest trauma were 0.78 (0.68-0.89) and 0.43 (0.37-0.50) (p < 0.001), respectively. In-hospital mortality in the severe chest trauma patients without significant traumatic brain injury (TBI) was 5.63% and was 25.71% with associated significant TBI (p < 0.001). Age, the severity of injury (NISS and AIS-head), hemodynamic instability, prehospital intubation, acute kidney injury, and multiorgan failure were risk factors associated with mortality. The contribution of severe chest injury to the mortality of trauma patients admitted to the ICU was very low. Risk factors associated with mortality were identified.

Characteristics and Outcomes of Critically Ill Trauma Patients in Australia and New Zealand (2005-2017)

OBJECTIVES

To compare the characteristics of adults admitted to the ICU in Australia and New Zealand after trauma with nonelective, nontrauma admissions. To describe trends in hospital mortality and rates of discharge home among these two groups.

DESIGN

Retrospective review (2005-2017) of the Australia and New Zealand Intensive Care Society's Center for Outcome and Resource Evaluation Adult Patient Database.

SETTING

Adult ICUs in Australia and New Zealand.

PATIENTS

Adult (≥17 yr), nonelective, ICU admissions.

INTERVENTION

Observational study.

MEASUREMENTS AND MAIN RESULTS

We compared 77,002 trauma with 741,829 nonelective, nontrauma patients. Trauma patients were younger (49.0 ± 21.6 vs 60.6 ± 18.7 yr; p < 0.0001), predominantly male (73.1% vs 53.9%; p < 0.0001), and more frequently treated in tertiary hospitals (74.7% vs 45.8%; p < 0.0001). The mean age of trauma patients increased over time but was virtually static for nonelective, nontrauma patients (0.72 ± 0.02 yr/yr vs 0.03 ± 0.01 yr/yr; p < 0.0001). Illness severity increased for trauma but fell for nonelective, nontrauma patients (mean Australia and New Zealand risk of death: 0.10% ± 0.02%/yr vs -0.21% ± 0.01%/yr; p < 0.0001). Trauma patients had a lower hospital mortality than nonelective, nontrauma patients (10.0% vs 15.8%; p < 0.0001). Both groups showed an annual decline in the illness severity adjusted odds ratio (odds ratio) of hospital mortality, but this was slower among trauma patients (trauma: odds ratio 0.976/yr [0.968-0.984/yr; p < 0.0001]; nonelective, nontrauma: odds ratio 0.957/yr [0.955-0.959/yr; p < 0.0001]; interaction p < 0.0001). Trauma patients had lower rates of discharge home than nonelective, nontrauma patients (56.7% vs 64.6%; p < 0.0001). There was an annual decline in illness severity adjusted odds ratio of discharge home among trauma patients, whereas nonelective, nontrauma patients displayed an annual increase (trauma: odds ratio 0.986/yr [0.981-0.990/yr; p < 0.0001]; nonelective, nontrauma: odds ratio 1.014/yr [1.012-1.016/yr; p < 0.0001]; interaction: p < 0.0001).

CONCLUSIONS

The age and illness severity of adult ICU trauma patients in Australia and New Zealand has increased over time. Hospital mortality is lower for trauma than other nonelective ICU patients but has fallen more slowly. Trauma patients have become less likely to be discharged home than other nonelective ICU patients.

Machine learning techniques for mortality prediction in critical traumatic patients: anatomic and physiologic variables from the RETRAUCI study

Background

Interest in models for calculating the risk of death in traumatic patients admitted to ICUs remains high. These models use variables derived from the deviation of physiological parameters and/or the severity of anatomical lesions with respect to the affected body areas. Our objective is to create different predictive models of the mortality of critically traumatic patients using machine learning techniques.

Methods

We used 9625 records from the RETRAUCI database (National Trauma Registry of 52 Spanish ICUs in the period of 2015–2019). Hospital mortality was 12.6%. Data on demographic variables, affected anatomical areas and physiological repercussions were used. The Weka Platform was used, along with a ten-fold cross-validation for the construction of nine supervised algorithms: logistic regression binary (LR), neural network (NN), sequential minimal optimization (SMO), classification rules (JRip), classification trees (CT), Bayesian networks (BN), adaptive boosting (ADABOOST), bootstrap aggregating (BAGGING) and random forest (RFOREST). The performance of the models was evaluated by accuracy, specificity, precision, recall, F-measure, and AUC.

Results

In all algorithms, the most important factors are those associated with traumatic brain injury (TBI) and organic failures. The LR finds thorax and limb injuries as independent protective factors of mortality. The CT generates 24 decision rules and uses those related to TBI as the first variables (range 2.0–81.6%). The JRip detects the eight rules with the highest risk of mortality (65.0–94.1%). The NN model uses a hidden layer of ten nodes, which requires 200 weights for its interpretation. The BN find the relationships between the different factors that identify different patient profiles. Models with the ensemble methodology (ADABOOST, BAGGING and RandomForest) do not have greater performance. All models obtain high values ​​in accuracy, specificity, and AUC, but obtain lower values ​​in recall. The greatest precision is achieved by the SMO model, and the BN obtains the best recall, F-measure, and AUC.

Conclusion

Machine learning techniques are useful for creating mortality classification models in critically traumatic patients. With clinical interpretation, the algorithms establish different patient profiles according to the relationship between the variables used, determine groups of patients with different evolutions, and alert clinicians to the presence of rules that indicate the greatest severity.

Concomitant Traumatic Brain Injury and Hemorrhagic Shock: Outcomes Using the Spanish Trauma ICU Registry (RETRAUCI)

BACKGROUND

To compare the main outcomes of trauma patients with and without traumatic brain injury (TBI), hemorrhagic shock, and the combination of both using data from the Spanish trauma intensive care unit (ICU) registry (RETRAUCI).

METHODS

Patients admitted to the participating ICUs from March 2015 to May 2019 were included in the study. The main outcomes were analyzed according to the presence of TBI, hemorrhagic shock, and/or both. Comparison of groups with quantitative variables was performed using the Kruskal-Wallis test, and differences between groups with categorical variables were compared using the Chi-square test or Fisher's exact test as appropriate. A P value <.05 was considered significant.

RESULTS

Overall, 310 patients (3.98%) were presented with TBI and hemorrhagic shock. Patients with TBI and hemorrhagic shock received more red blood cell (RBC) concentrates, fresh frozen plasma (FFP), a higher ratio FFP/RBC, and had a higher incidence of trauma-induced coagulopathy (60%) (P < .001). These patients had higher mortality (P < .001). Intracranial hypertension was the leading cause of death (50.4%).

CONCLUSIONS

Concomitant TBI and hemorrhagic shock occur in nearly 4% of trauma ICU patients. These patients required a higher amount of RBC concentrates and FFP and had an increased mortality.

Risk Factors Associated With Early and Late Posttraumatic Multiorgan Failure: An Analysis From RETRAUCI

OBJECTIVE

To analyze factors associated with the development of early and late multiorgan failure (MOF) in trauma patients admitted to the intensive care unit (ICU).

METHODS

Spanish Trauma ICU Registry (RETRAUCI). Data collected from 52 trauma ICU between March 2015 and December 2019. We analyzed the incidence, outcomes, and the risk factors associated with early (< 72 h) or late (beyond 72 h) MOF in trauma ICU patients. Multiple logistic regression analysis was performed to analyze associated factors.

RESULTS

After excluding patients with incomplete data, 9,598 trauma ICU patients constituted the study population. Up to 965 patients (10.1%) presented with MOF, distributed by early MOF in 780 patients (8.1%) and late MOF in 185 patients (1.9%). The multivariate analysis showed that early MOF was associated with: ISS ≥ 16 (OR 2.80), hemodynamic instability (OR from 2.03 to 43.05), trauma-associated coagulopathy (OR 2.32), and acute kidney injury (OR 4.10). Late MOF was associated with: age > 65 years (OR 1.52), hemodynamic instability (OR from 1.92 to 9.94), acute kidney injury (OR 4.22), and nosocomial infection (OR 17.23). MOF was closely related to mortality (crude OR (95% CI) 4.77 (4.22-5.40)).

CONCLUSIONS

Multiorgan failure was recorded in 10% of trauma ICU patients, with early MOF being the predominant form. Early and late MOF forms were associated with different risk factors, suggesting different pathophysiological pathways. Early MOF was associated with higher severity of injury and severe bleeding-related complications and late MOF with advanced age and nosocomial infection.

Extra corporeal membrane oxygenation in the critical trauma patient

PURPOSE OF REVIEW

The purpose of this review is to describe recent evidence regarding the use of extracorporeal membrane oxygenation (ECMO) as salvage therapy for severe cardiac or respiratory failure in patients with trauma. The characteristics of this cohort of patients, including the risk of bleeding and the need for systemic anticoagulation, are generally considered as relative contraindications to ECMO treatment. However, recent evidence suggests that the use of ECMO should be taken in consideration even in this group of patients.

RECENT FINDINGS

The recent findings suggest that venous-venous ECMO can be feasible in the treatment of refractory respiratory failure and severe acute respiratory distress syndrome trauma-related. The improvement of ECMO techniques including the introduction of centrifugal pumps and heparin-coated circuits are progressively reducing the amount of heparin required; moreover, the application of heparin-free ECMO showed good outcomes and minimal complications. Venous-arterial ECMO has emerged as a salvage intervention in patients with cardiogenic shock and after cardiac arrest. Venous-arterial ECMO provides circulatory support allowing time for other treatments to promote recovery in presence of acute cardiopulmonary failure. Only poor-quality evidence is available, for venous-arterial ECMO in trauma patients.

SUMMARY

ECMO can be considered as a safe rescue therapy even in trauma patients, including neurological injury, chest trauma as well as burns. However, evidence is still poor; further studies are warranted focusing on trauma patients undergoing ECMO, to better clarify the effect on survival, the type and dose of anticoagulation to use, as well as the utility of dedicated multidisciplinary trauma-ECMO units.

Development of trauma systems in Europe-reports from England, Germany, the Netherlands, and Spain

Major trauma systems have evolved in many European countries and have resulted in improved care in terms of mortality and morbidity. Many of the systems have similar history, with reports of either poor services, or a single disaster, driving change of policy and set up. We report on 4 European systems, looking at the background, set up and some of the results. Similar issues are identified including the importance of triage, the concentration of specialist skills which require patients to bypass hospitals, and the standardization of treatment protocols. The issues of rehabilitation and the increasing importance of measuring outcome with patient reported metrics are discussed.

A new global health outcome score after trauma (GHOST) for disability, cognitive impairment, and health-related quality of life: data from a prospective cross-sectional observational study

Background:Trauma patients experience morbidity related to disability and cognitive impairment that negatively impact their health-related quality of life (HRQoL). We assessed the impact of trauma on disability, cognitive impairment and HRQoL after intensive care in patients with and without traumatic brain injury (TBI) and created a predictive score to identify patients with worse outcome. Methods:We identified 262 patients with severe trauma (ISS>15) admitted to the emergency room of a level 1 trauma center. Patients above 13 years were included. After 6 months, patients were assessed for disability, cognitive impairment, and HRQoL. A global health outcome score after trauma (GHOST) was obtained through the combination of these domains. Logistic regression analysis was considered for the effect of demographic, trauma and hospital factors on global outcome. p > 0.05. Statistics performed with SPSS 23.0. Results:Patients with the worst outcomes were older and had a longer length of Intensive Care Unit (ICU) stay. The effect of gender was found in all "GHOST dimensions". TBI was not significantly associated with worse outcome. Conclusions:No significant differences were seen on disability, cognitive impairment and decreased HRQoL in patients with or without TBI. Our GHOST score showed that female gender, older age, and longer ICU stay were significantly associated with the worst outcome. Abbreviations: AIS: Abbreviated Injury Scale; EQ-5D: EuroQol 5-dimensions; EQ-5D-3L: EuroQol 5-dimensions 3-levels; GCS: Glasgow Coma Scale; GOSE: Glasgow Outcome Scale Extended; HRQoL: Health-Related Quality of Life; ICU: Intensive Care Unit; ISS: Injury Severity Score; MMS: Mini Mental State; NICE: National Institute for Health and Care Excellence; RTS: Revised Trauma Score; TBI: Traumatic brain injury; TRISS: Trauma Injury Severity Score; VAS: Visual Analogue Scale.

Outcomes of very elderly trauma ICU patients. Results from the Spanish trauma ICU registry

OBJECTIVE

To analyze outcomes and factors related to mortality among very elderly trauma patients admitted to intensive care units (ICUs) participating in the Spanish trauma ICU registry.

DESIGN

A multicenter nationwide registry. Retrospective analysis. November 2012-May 2017.

SETTING

Participating ICUs.

PATIENTS

Trauma patients aged ≥80 years.

INTERVENTIONS

None.

MAIN VARIABLES OF INTEREST

The outcomes and influence of limitation of life sustaining therapy (LLST) were analyzed. Comparisons were established using the Wilcoxon test, Chi-squared test or Fisher's exact test as appropriate. Multiple logistic regression analysis was performed to analyze variables related to mortality. A p-value <0.05 was considered statistically significant.

RESULTS

The mean patient age was 83.4±3.3 years; 281 males (60.4%). Low-energy falls were the mechanisms of injury in 256 patients (55.1%). The mean ISS was 20.5±11.1, with a mean ICU stay of 7.45±9.9 days. The probability of survival based on the TRISS methodology was 69.8±29.7%. The ICU mortality rate was 15.5%, with an in-hospital mortality rate of 19.2%. The main cause of mortality was intracranial hypertension (42.7%). The ISS, the need for first- and second-tier measures to control intracranial pressure, and being admitted to the ICU for organ donation were independent mortality predictors. LLST was applied in 128 patients (27.9%). Patients who received LLST were older, with more severe trauma, and with more severe brain injury.

CONCLUSIONS

Very elderly trauma ICU patients presented mortality rates lower than predicted on the basis of the severity of injury.

Severe trauma in the geriatric population

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

Scoring severity in trauma: comparison of prehospital scoring systems in trauma ICU patients

PURPOSE

We evaluated the predictive ability of mechanism, Glasgow coma scale, age and arterial pressure (MGAP), Glasgow coma scale, age and systolic blood pressure (GAP), and triage-revised trauma Score (T-RTS) scores in patients from the Spanish trauma ICU registry using the trauma and injury severity score (TRISS) as a reference standard.

METHODS

Patients admitted for traumatic disease in the participating ICU were included. Quantitative data were reported as median [interquartile range (IQR), categorical data as number (percentage)]. Comparisons between groups with quantitative variables and categorical variables were performed using Student's T Test and Chi Square Test, respectively. We performed receiving operating curves (ROC) and evaluated the area under the curve (AUC) with its 95 % confidence interval (CI). Sensitivity, specificity, positive predictive and negative predictive values and accuracy were evaluated in all the scores. A value of p < 0.05 was considered significant.

RESULTS

The final sample included 1361 trauma ICU patients. Median age was 45 (30-61) years. 1092 patients (80.3 %) were male. Median ISS was 18 (13-26) and median T-RTS was 11 (10-12). Median GAP was 20 (15-22) and median MGAP 24 (20-27). Observed mortality was 17.7 % whilst predicted mortality using TRISS was 16.9 %. The AUC in the scores evaluated was: TRISS 0.897 (95 % CI 0.876-0.918), MGAP 0.860 (95 % CI 0.835-0.886), GAP 0.849 (95 % CI 0.823-0.876) and T-RTS 0.796 (95 % CI 0.762-0.830).

CONCLUSIONS

Both MGAP and GAP scores performed better than the T-RTS in the prediction of hospital mortality in Spanish trauma ICU patients. Since these are easy-to-perform scores, they should be incorporated in clinical practice as a triaging tool.