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

A narrative review: Resuscitation of older adults with hemorrhagic shock

BACKGROUND

The increasing population of older adults presents unique challenges in trauma care due to their reduced physiologic reserve compared to younger patients. Trauma-induced hemorrhage remains a leading cause of mortality, yet there is a significant gap in the optimal management of hemodynamically unstable older adults. This review aims to synthesize current literature on resuscitation strategies, coagulopathy, triage, and the impact of timely interventions in older adult trauma patients experiencing hemorrhagic shock.

STUDY DESIGN AND METHODS

A comprehensive narrative review was conducted following PRISMA-Scr guidelines. A systematic literature search was performed using PubMed, Scopus, and Web of Science databases, yielding 380 titles. After removing duplicates, 287 unique articles were screened, of which 120 full-text articles were reviewed. A total of 45 studies met the inclusion criteria and were analyzed. Studies were categorized based on resuscitation protocols (14 studies), coagulopathy management (7 studies), frailty and aging physiology (10 studies), and timing/triage in trauma care (14 studies).

RESULTS

Studies highlight the effectiveness of the shock index (SI) over traditional vital signs for identifying hemodynamic instability in older adults. Balanced transfusion ratios and whole blood resuscitation show potential benefits, though data specific to older adults remain limited. Goal-directed resuscitation protocols improve outcomes by addressing the unique physiological needs of this population. While trauma-induced coagulopathy rates are similar across age groups, older adults frequently present with pre-existing anticoagulation, complicating management. Standardized care pathways, early activation of massive transfusion protocols (MTP), and tailored resuscitation approaches are critical for optimizing care.

DISCUSSION

The growing geriatric trauma population necessitates improved resuscitation strategies tailored to their unique physiological responses. While balanced transfusions and goal-directed protocols have demonstrated efficacy, further research is required to refine these interventions specifically for older adults. Establishing standardized resuscitation guidelines and defining futility criteria will enhance decision-making and improve outcomes for this vulnerable population.

Applications of Self-Driving Vehicles in an Aging Population

Unlabelled

The proportion of older adult drivers is increasing and represents a growing population that must contemplate reducing driving and eventually stopping driving. The advent of self-driving vehicles opens vast possibilities with practical and far-reaching applications for our aging population. Advancing technologies in transportation may help to overcome transportation barriers for less mobile individuals, transcend social and geographical isolation, and improve resource and medical access. Herein, we propose various applications and benefits that self-driving vehicles have in maintaining independence and autonomy specifically for our aging population to preserve aging.

Short-term mortality prognosis in spontaneous intracranial hemorrhage: A retrospective study at 115 People's Hospital, HCMC, Vietnam

Background

Early prognosis of patients with spontaneous intracerebral hemorrhage (ICH) can help create individualized and optimized treatment plans for the patients.

Aims

This study evaluates short-term mortality and identifies risk factors in ICH patients at 115 People's Hospital within 30 days.

Design and methods

A retrospective cohort study was conducted involving 598 patients diagnosed with ICH by neurologists from December 2022 to June 2023. Diagnosis was confirmed by imaging, with symptoms appearing within 24 h of admission. Short-term mortality was defined as death within 30 days of onset.

Results

Among the 598 patients (mean age 58.4; 40% female), 110 (18.4%) died, while 488 (81.6%) survived. The ICH score (AUC = 95.75%; p < 0.001; optimal cutoff = 1.5) was more prognostic for mortality than the NIHSS score (AUC = 94.61%; optimal cutoff = 17.5; p < 0.001). Identified risk factors included age ≥ 80 (RR = 2.2, p = 0.002), ICH score ≥ 2 (RR = 38.4, p < 0.001), NIHSS score ≥ 16 (RR = 15.1, p < 0.001), hematoma volume ≥ 30 cm3 (RR = 15.1, p < 0.001), and the presence of intraventricular (RR = 7.2, p < 0.001) or subtentorial hemorrhage (RR = 2.8, p < 0.001).

Conclusions

The mortality rate for ICH was significant. The ICH score, NIHSS, and hematoma volume are effective in predicting mortality in spontaneous ICH patients.

Injury patterns and patient outcomes of abdominal trauma in the elderly population: a 5-year experience of a Major Trauma Centre

INTRODUCTION

The management of abdominal trauma in older patients is challenging due to preexisting comorbidities, impaired physiology, frailty and atypical clinical presentations. Few studies focus on the characteristics of abdominal trauma in older populations.

METHODS

A retrospective service evaluation was conducted during the period January 2017 - December 2022 at University Hospital Southampton, the designated Major Trauma Centre (MTC) of Wessex Trauma Network in the United Kingdom. Data was collected from the local Trauma Registry. Patients aged ≥ 65 years old and with Abbreviated Injury Scale (AIS) over one for the Abdomen were included. Patients aged less than 65 years old and those who died on arrival to the MTC were excluded.

RESULTS

Out of 4977 geriatric trauma patients, only 150 cases (3%) were eligible, with a mean age of 77 years and a median Injury Severity Score of 22. The trauma team activation code was triggered in just under half of all cases (49%). All-level falls were the leading mechanism (52%) and low-energy falls were significantly higher in patients aged ≥ 85 years (P <0.001). The spleen was the most frequently affected organ (27%). About 47% of abdominal injuries were severe (AIS Abdomen ≥3) and about 22% of patients required surgical or radiological intervention. Three patients sustained occult abdominal injuries and one of them had a negative CT scan initially. The overall 30-day mortality rate was 20%. Of all casualties, most were polytrauma cases (87%).

CONCLUSION

Despite the low incidence of abdominal injuries in the elderly, when these occurred, almost half were serious with AIS Abdomen ≥ 3 and almost one in four required surgical or radiological intervention. The use of single-time imaging may not be sufficient to ensure the absence of injury, as delayed manifestations of occult abdominopelvic trauma may occur. Close monitoring and regular reassessments are recommended, even with a negative CT scan on arrival. The high all-cause mortality rate may correlate with the high incidence of polytrauma in this cohort and the failure to trigger a trauma call in the Emergency Department. Future studies should focus on the development of triage tools and include the use of validated and designated frailty tools for larger population analysis.

Role of trauma center level in the outcome of severely injured geriatric patients

BACKGROUND

According to the nationally imposed standard of care in the Netherlands, severely injured patients should be brought to a Level-1 trauma center for primary treatment. If not, they are considered to be undertriaged. This study aimed to determine the incidence of undertriage among severely injured geriatric patients and to evaluate the relation between hospital-undertriage and patient outcomes in elderly.

METHODS

This retrospective cohort study used anonymized data from the regional trauma registry of 1,431 patients aged ≥70 years with an Injury Severity Score ≥16 that were admitted to hospitals within the Trauma Region West-Netherlands between 2015 and 2022. Poor patient outcome was defined as in-hospital mortality or as a Glasgow Outcome Scale (GOS) score ≤3 at hospital discharge. The association between hospital level and poor outcomes was analyzed using multivariable logistic regression analysis with adjustment for confounders after multiple imputation of missing values.

RESULTS

Seventeen percent of the severely injured geriatric patients were primarily transported to a Level-2/3 hospital. Female patients, older patients, and patients that had suffered a low-energy fall were most likely to be undertriaged. The adjusted odds ratio's for in-hospital mortality and GOS score ≤3 in Level-1 versus Level-2/3 hospitals were 1.26 (95 % confidence interval, 0.83-1.93; p = 0.28) and 0.81 (95 % confidence interval, 0.57-1.15; p = 0.24), respectively.

CONCLUSION

Undertriaged severely injured geriatric patients did not have a higher risk for poor outcomes. Level-2/3 hospitals seem to present a safe alternative for the treatment of these patients.

Predictive Limitations of the Geriatric Trauma Outcome Score: A Retrospective Analysis of Mortality in Elderly Patients with Multiple Traumas and Severe Traumatic Brain Injury

Background/Objectives: The Geriatric Trauma Outcome Score (GTOS) is used to predict in-hospital mortality in geriatric patients with trauma. However, its applicability to elderly patients with multiple traumas and severe traumatic brain injury (TBI) remains poorly understood. This study aimed to evaluate the predictive accuracy of the GTOS in elderly patients with multiple traumas and TBI and assess its performance in patients with mild and severe TBI. Methods: We retrospectively analyzed 1283 geriatric multiple trauma patients (aged ≥ 65 years) treated at a regional trauma center from 2019 to 2023. Patients were stratified into mild (head Abbreviated Injury Scale [AIS] ≤ 3) and severe (head AIS ≥ 4) TBI groups. GTOS values were calculated for each patient, and predicted mortality was compared with in-hospital mortality. GTOS predictive accuracy was assessed by analyzing the receiver operating characteristic curve. Results: Patients had a median Injury Severity Score of 18 (interquartile range: 10-25); 33.3% of patients received red blood cell transfusions within 24 h. The overall in-hospital mortality rate was 17.9%; GTOS predicted a mortality rate of 17.6% ± 0.17. The GTOS accurately predicted the in-hospital mortality in the entire cohort, achieving an Area Under the Curve (AUC) of 0.798. Predictive accuracy diminished for patients with severe TBI (AUC = 0.657), underestimating actual mortality (39.5% vs. 28.8% predicted). Conclusions: While the GTOS remains a useful tool for predicting in-hospital mortality in elderly patients with multiple traumas, it consistently underestimates mortality risk in those with severe TBI. Therefore, applying the GTOS in this patient subgroup warrants careful consideration.

Enhancing geriatric trauma mortality prediction: Modifying and assessing the Geriatric Trauma Outcome Score with net benefit and decision curve analysis

OBJECTIVE

Calibration and discrimination indicators alone are insufficient for evaluating the clinical usefulness of prediction models, as they do not account for the cost of misclassification errors. This study aimed to modify the Geriatric Trauma Outcome Score (GTOS) and assess the clinical utility of the modified model using net benefit (NB) and decision curve analysis (DCA) for predicting in-hospital mortality.

METHODS

The Trauma Quality Improvement Program (TQIP) 2017 was used to identify geriatric trauma patients (≥ 65 years) treated at Level I trauma centers. The outcome of interest was in-hospital mortality. The GTOS was modified to include additional patient, injury, and treatment characteristics identified through machine learning methods, focusing on early risk stratification. Calibration and discrimination indicators, along with NB and DCA, were utilized for evaluation.

RESULTS

Of the 67,222 admitted geriatric trauma patients, 5.6% died in the hospital. The modified GTOS score included the following variables with associated weights: initial airway intervention (5), Glasgow Coma Scale ≤13 (5), packed red blood cell transfusion within 24 h (3), penetrating injury (2), age ≥ 75 years (2), preexisting comorbidity (1), and torso injury (1), with a total range from 0 to 19. The modified GTOS demonstrated a significantly higher area under the curve (0.92 vs. 0.84, p < 0.0001), lower misclassification error (4.9% vs. 5.2%), and lower Brier score (0.036 vs. 0.042) compared to the original GTOS. DCA showed that using the modified GTOS for predicting in-hospital mortality resulted in higher NB than treating all, treating none, and treating based on the original GTOS across a wide range of clinician preferences.

CONCLUSIONS

The modified GTOS model exhibited superior predictive ability and clinical utility compared to the original GTOS. NB and DCA offer valuable complementary methods to calibration and discrimination indicators, comprehensively evaluating the clinical usefulness of prediction models and decision strategies.

Age-related mortality risk in cycling trauma: analysis of the National Trauma Databank 2017-2023

BACKGROUND

Cycling promotes health but carries significant injury risks, especially for older adults. In the U.S., cycling fatalities have increased since 1990, with adults over 50 now at the highest risk. As the population ages, the burden of cycling-related trauma is expected to grow, yet age-specific factors associated with mortality risk remain unclear. This study identifies age-specific mortality risk thresholds to inform targeted public health strategies.

METHODS

We conducted a cross-sectional analysis of the National Trauma Data Bank (NTDB) data (2017-2023) on non-motorized cycling injuries. A total of 185,960 records were analyzed using logistic regression with splines to evaluate the relationship between age and mortality risk. The dataset was split into training (80%) and testing (20%) sets. Age thresholds where mortality risk changed were identified, and models were adjusted for injury severity, comorbidities, and helmet use.

RESULTS

The median patient age was 43 years (IQR 20-58). Four key age thresholds (12, 17, 31, and 69) were identified, with the largest mortality increase after age 69. Our model achieved an AUC of 0.93, surpassing traditional age cutoff models, with 84.6% sensitivity and 88.0% specificity.

CONCLUSIONS

Age is a significant predictor of mortality in cycling trauma, with marked increases in risk during adolescence and for adults over 69. These findings underscore the need for age-targeted interventions, such as improved cycling infrastructure for teens and enhanced safety measures for older adults. Public health initiatives should prioritize these vulnerable age groups to reduce cycling-related mortality.

Whole blood for old blood: Use of whole blood for resuscitation in older trauma patients

INTRODUCTION

Older patients are expected to comprise 40 % of trauma admissions in the next 30 years. The use of whole blood (WB) has shown promise in improving mortality while lowering the utilization of blood products. However, the use of WB in older trauma patients has not been examined. The objective of our study is to determine the safety and efficacy of a WB first transfusion strategy in injured older patients.

METHODS

Older trauma patients, defined as age ≥55 years old, were reviewed from March 2016-November 2021. Patients that received a WB first resuscitation strategy were compared to those that received a ratio based component strategy. Demographics as well as complications rates, blood product transfusion volumes, and mortality were evaluated. Univariate and multivariable analysis was used to determine independent predictors of mortality.

RESULTS

There were 388 older trauma patients that received any blood products during the study period. A majority of patients received a WB first resuscitation strategy (83 %). Compared to patients that received component therapy, patients that received WB first were more likely female, less likely to have a penetrating mechanism, and had a slightly lower injury severity score. The-30 day mortality rate was comparable (WB 36% vs component 37 %, p = 0.914). While rates of AKI were slightly higher in those that received WB, this did not result in increased rates of renal replacement therapy (3 % vs 2 %, p = 1). Further, compared to patients that received components, patients that were resuscitated with a WB first strategy significantly utilized lower median volumes of platelets (0 mL vs 197 mL, p < 0.001), median volumes of plasma (0 mL vs 1253 mL, p < 0.001, and median total volume of blood products (1000 mL vs 2859 mL, p < 0.001).

CONCLUSION

The use of WB in the older trauma patient appears safe, with mortality and complication rates comparable to component therapy. Blood product utilization is significantly less in those that are resuscitated with WB first.

Negative effects of lifespan extending intervention on resilience in mice

One key goal of basic aging research is the development of reliable assays of both current and future health. These assays could dramatically accelerate progress toward developing health-extending interventions by obviating the need for full lifespan studies, especially if they were informative relatively early in life. One potential approach is the assessment of physiological resilience, defined as the ability to recover from an adverse event. Here, using CB6F1 mice, we evaluated four potential resilience assays, each quantifying recovery from a physiological challenge with clear relevance to humans. The challenges were: (1) anesthesia recovery, (2) restoration of hemoglobin levels after a blood draw, (3) speed of wound healing, and (4) survival after pathogen exposure. We evaluated how each changed with age and with interventions known to extend health in males only (17α-estradiol) or both sexes (calorie restriction). We found that three of the four (recovery from anesthesia, blood draw, and pathogen exposure) showed significant and expected age effects, but wound healing did not. None of the three age-sensitive assays responded to the health-extending interventions in the way we expected, and for some assays, including anesthesia response, interventions actually worsened outcomes. Possible explanations are: (1) our interventions were too brief, (2) the ages we evaluated were too young, (3) our assays did not capture important features of organismal resilience, or (4) organismal resilience is not as clearly related to current or future health as hypothesized. Future studies are needed to determine which of these interpretations is valid and to determine whether other resilience metrics may be more informative about current and future health.

An Abdominal Seat Belt Sign is Associated With Similar Incidence of Hollow Viscus Injury but Increased In-Hospital Mortality in Older Adult Trauma Patients: A PCSA Multicenter Study

BACKGROUND

The abdominal seat belt sign (SBS) is associated with an increased risk of hollow viscus injury (HVI). Older age is associated with worse outcomes in trauma patients. Thus, older trauma patients ≥65 years of age (OTPs) may be at an increased risk of HVI with abdominal SBS. Therefore, we hypothesized an increased incidence of HVI and mortality for OTPs vs younger trauma patients (YTPs) with abdominal SBS.

STUDY DESIGN

This post hoc analysis of a multi-institutional, prospective, observational study (8/2020-10/2021) included patients >18 years old with an abdominal SBS who underwent abdominal computed tomography (CT) imaging. Older trauma patients were compared to YTPs (18-64 years old) with bivariate analyses.

RESULTS

Of the 754 patients included in this study from nine level-1 trauma centers, there were 110 (14.6%) OTPs and 644 (85.4%) YTPs. Older trauma patients were older (mean 75.3 vs 35.8 years old, P < .01) and had a higher mean Injury Severity Score (10.8 vs 9.0, P = .02). However, YTPs had an increased abdominal abbreviated-injury scale score (2.01 vs 1.63, P = .02). On CT imaging, OTPs less commonly had intraabdominal free fluid (21.7% vs 11.9%, P = .02) despite a similar rate of abdominal soft tissue contusion (P > .05). Older trauma patients also had a statistically similar rate of HVI vs YTPs (5.5% vs 9.8%, P = .15). Despite this, OTPs had increased mortality (5.5% vs 1.1%, P < .01) and length of stay (LOS) (5.9 vs 4.9 days P < .01).

CONCLUSION

Despite a similar rate of HVI, OTPs with an abdominal SBS had an increased rate of mortality and LOS. This suggests the need for heightened vigilance when caring for OTPs with abdominal SBS.

Failure to Rescue in Geriatric Ground-Level Falls: The Role of Frailty on Not-So-Minor Injuries

INTRODUCTION

The measure of mortality following a major complication (failure to rescue [FTR]) provides a quantifiable assessment of the level of care provided by trauma centers. However, there is a lack of data on the effects of patient-related factors on FTR incidence. The aim of this study was to identify the role of frailty on FTR incidence among geriatric trauma patients with ground-level falls (GLFs).

METHODS

This is a retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program database (2017-2020). All geriatric (aged ≥ 65 ys) trauma patients with GLFs admitted to a level I trauma center were included. Transferred patients, those with severe head injuries (head abbreviated injury scale ≥ 3), and those who died within 24 h of admission or whose length of stay was ≤1 d were excluded. FTR was defined as death following a major complication (cardiac arrest, myocardial infarction, sepsis, acute respiratory distress syndrome, unplanned intubation, acute renal failure, cerebrovascular accident, ventilator-associated pneumonia, or pulmonary embolism). Patients were stratified into frail (F) and nonfrail (NF) based on the 11-Factor Modified Frailty Index. Multivariable regression analyses were performed to identify the independent effect of frailty on the incidence of FTR.

RESULTS

Over 4 ys, 34,100 geriatric patients with GLFs were identified, of whom 9140 (26.8%) were F. The mean (standard deviation) age was 78 (7) years and 65% were female. The median injury severity score was 9 (5-10) with no difference among F and NF groups (P = 0.266). Overall, F patients were more likely to develop major complications (F: 3.6% versus NF: 2%, P < 0.001) and experience FTR (F: 1.8%% versus NF: 0.6%, P < 0.001). Moreover, among patients with major complications, F patients were more likely to die (F: 47% versus NF: 27%, P < 0.001). On multivariable regression analysis, frailty was identified as an independent predictor of major complications (adjusted odds ratio: 1.98, 95% confidence interval [1.70-2.29], P < 0.001) and FTR (adjusted odds ratio: 2.26, 95% confidence interval [1.68-3.05], P < 0.001).

CONCLUSIONS

Among geriatric trauma patients with GLFs, frailty increases the risk-adjusted odds of FTR by more than two times. One in every two F patients with a major complication does not survive to discharge. Future efforts should concentrate on improving patient-related and hospital-related factors to decrease the risk of FTR among these vulnerable populations.

The geriatric trauma hospitalist service: An analysis of a management strategy for injured older adults

BACKGROUND

Management of geriatric trauma patients requires balancing chronic comorbidities with acute injuries. We developed a care model in which patients are managed by hospitalists with trauma-centered education and hypothesized that clinical outcomes would be similar to outcomes in patients primarily managed by trauma surgeons.

METHODS

This was a retrospective study of trauma patients aged ≥65 from January 2020 to December 2021. Groups were defined by admitting service: trauma surgery service (TSS) or geriatric trauma hospitalist service (GTHS). The primary outcome was in-hospital mortality. Regression analyses and inverse probability treatment weighted (IPTW) propensity score (PS) analyses were performed to determine the association between admitting service and outcomes.

RESULTS

A total of 1004 patients were eligible for inclusion-580 GTHS and 424 TSS admissions. GTHS patients were older (82 vs. 74, p < 0.001), more likely to have suffered blunt trauma (99.5% vs. 95%, p < 0.001), more likely to have comorbidities (91.2% vs. 87%, p < 0.001), had higher Charlson Comorbidity Indexes (CCIs), and had lower median injury severity scores (9 vs. 13, p < 0.001). Rates of mortality, delirium, 30-day readmission, and overall complications were low and similar between groups. While TSS patients were likely to be discharged home, GTHS had more discharges to skilled nursing facilities and longer length of stay (LOS). On multivariable analysis adjusted for age, ISS, CCI, and sex, patients admitted to GTHS had lower odds of death with an odds ratio of 0.15 (95% confidence interval [CI] 0.02-0.75, p = 0.03) when compared to TSS. On IPTW PS analysis, patients admitted to GTHS had similar odds of death with an odds ratio of 0.3 (95% CI 0.06-1.6, p = 0.16).

CONCLUSIONS

Protocolized admission criteria to a GTHS resulted in similar low mortality rates but longer LOS when compared to patients admitted to a TSS. This care model may inform other trauma centers in developing their strategies for managing the increasing volume of vulnerable injured older adults.

Association between SARC-F scores and risk of adverse outcomes in older patients with cardiovascular disease: a prospective study at a tertiary hospital in the south of Vietnam

Introduction

Older patients typically face elevated mortality rates and greater medical resource utilization during hospitalizations compared to their younger counterparts. Sarcopenia, serving as a prognostic indicator, is related to disability, diminished quality of life, and increased mortality. The SARC-F questionnaire, known for its cost-effectiveness, offers a valuable means of assessing sarcopenia. This study aims to explore the association between SARC-F scores and risk of adverse outcomes in elderly patients with cardiovascular disease at a Ho Chi Minh City hospital.

Method

Participants aged 60 and above, admitted to the Department of Cardiology - Interventional and Cardiovascular Emergency of Thong Nhat Hospital in Ho Chi Minh City from November 2021 to June 2022, were recruited for the prospective, single-center study. The prognostic outcomes included all-cause death and the initial occurrence of emergency re-hospitalization within 6 months' post-discharge. The Kaplan-Meier analysis compared the overall survival rates between different SARC-F score groups.

Results

The study enrolled 285 patients with a median age of 74 (67, 81). During a 6-month follow-up period, there were 14 cases of mortality. A SARC-F score of 4 or higher was significantly associated with an increased risk of all-cause mortality, with HR of 2.02 (95% CI: 1.39-2.92, p < 0.001), and higher incidence of re-hospitalization events with RR of 1.66 (95% CI: 1.06 to 2.59, p = 0.026). Kaplan-Meier survival analysis indicated a notably higher mortality rate in the patients with high SARC-F scores (p < 0.001).

Conclusion

In elderly patients with cardiovascular disease, the SARC-F questionnaire could serve as a simple and cost-effective method for detecting mortality and the risk of re-hospitalization.

Clinical Audit to Assess Orthogeriatrician Input to the Management of Elderly Trauma Patients

OBJECTIVE

The primary objective of this study is to assess the adherence of our department to the British Orthopaedic Association's Standards for Trauma and Orthopaedics (BOAST) guidelines for "the care of the older or frail orthopaedic trauma patient" and the results of this adherence on clinical patient outcome measures.

METHODS

This was a clinical audit. All ≥65-year-olds admitted to the orthopaedic department with a fragility fracture between 8 September 2022 and 8 March 2023 with a length of stay (LOS) of >72 hours were included. Patients were stratified into hip fracture (HF) and non-hip fracture (NHF) patients. A further similar cohort of NHF admissions between 8 March and 8 May 2023 was added to the data. The adherence of both cohorts to the national guidelines was recorded. Primary outcome measures of each cohort were recorded such as LOS and patient mortality.

RESULTS

Data from 70 patients was collected. HF patients adhered to the guideline 79.4% of the time (31/39 patients) compared to NHF patients at only 19.3% of the time (6/31 patients) (p<0.001). Further, on average, HF patients were seen by an orthogeriatrician 15 times compared to just five times for NHF patients during their hospital stay (p<0.001). No significant difference in LOS or in mortality at 30 days post-admission was observed.

CONCLUSION

Medical orthogeriatric care is unequal despite similar LOS and mortality between both cohorts; thus, increasing orthogeriatrician input in NHF patients may lead to better patient outcomes for these patients.

Demographic shifts reshaping the landscape of hand trauma: a comprehensive single-center analysis of changing trends in hand injuries from 2007 to 2022

INTRODUCTION

Hand injuries constitute up to 30% of the total cases treated in emergency departments. Over time, demographic changes, especially an aging population, and shifts in workplace safety regulations and healthcare policies have significantly impacted the landscape of hand trauma. This study aims to identify and analyze these evolving trends over nearly two decades.

METHODS

In this retrospective, cross-sectional study, we investigated patients who were admitted to the high-volume regional hand trauma center of a university hospital between January 2007 and December 2022. We analyzed trends in patients' demographics and annual alterations of injuries. For the comparative analysis, patients were divided into two groups based on the time of presentation: the early cohort (2007-2014) and the current cohort (2015-2022).

RESULTS

A total of 14,414 patients were admitted to our emergency department within the study period. A significant annual increase in patient age was identified (R2 = 0.254, p = 0.047). The number of presentations increased annually by an average of 2% (p < 0.001). The incidence of the following hand injuries significantly increased: sprains/strains (+ 70.51%, p = 0.004), superficial lacerations (+ 53.99%, p < 0.001), joint dislocations (+ 51.28%, p < 0.001), fractures (carpal: + 49.25%, p = 0.003; noncarpal: + 39.18%, p < 0.001), deep lacerations (+ 37.16%, p < 0.001) and burns and corrosions (+ 29.45%, p < 0.001). However, rates of amputations decreased significantly (- 22.09%, p = 0.04).

CONCLUSIONS

A consistent and significant annual increase in both the total number of injuries and the average age of patients was identified. An aging population may increase injury rates and comorbidities, stressing healthcare resources. Our study underscores the need to adapt healthcare structures and reimbursement policies, especially for outpatient hand injury care.

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.

Incidence and predictors of mortality among road traffic accident victims admitted to hospitals at Hawassa city, Ethiopia

BACKGROUND

Globally, road traffic accidents are the eighth-leading cause of death for all age groups. The estimated number of road traffic deaths in low income countries was more than three times as high as in high-income countries. Africa had the highest rate of fatalities attributed to road traffic accidents. Ethiopia has the highest number of road traffic fatalities among Sub-Saharan African countries. The main objective of this study was to determine the incidence and predictors of mortality among road traffic victims admitted to hospitals in Hawassa City.

METHODS

A facility-based retrospective cohort study was conducted using secondary data from hospital records. A total of 398 road traffic accident victims admitted to selected hospitals in Hawassa city from January 2019 to December 2021 participated in the study. Data were analyzed using STATA version 14.1. The Cox regression model was used to determine the predictors of mortality. A hazard ratio with a 95% confidence interval and a cut-off value of P<0.05 was used to declare the risk and statistical significance, respectively.

RESULT

The incidence rate of mortality for road traffic accident victims was 7.34 per 10,000 person-hours. The predictors of mortality were the value of GCS at admission <8 (aHR = 5.86; 95% CI: 2.00-17.19), GCS at admission 9-12 (aHR = 3.27; 95% CI: 1.28-8.40), the value of SBP at admission ≤89mmHg (aHR = 4.41; 95% CI: 2.22-8.77), admission to the ICU (aHR = 3.89; 95% CI: 1.83-8.28) and complications (aHR = 5.48; 95% CI: 2.74-10.01).

CONCLUSION

The incidence of mortality among road traffic victims admitted to hospitals in Hawassa city was high. Thus, thorough follow-up and intensive management should be given to victims with critical health conditions.

Correction of In-Patient Severe Hypernatremia in an 81-Year-Old Female With Hypopituitarism

Hypernatremia has been significantly associated with in-hospital mortality and discharge to long-term care facilities. The appropriate correction of electrolyte disturbances, especially sodium, is important to consider to prevent the addition of central nervous system disturbances, such as cerebral edema and eventual brain injury. The importance of maintaining a proper correction of hypernatremia has been well studied and used in clinical practice. Choosing to use a hypotonic solution is a key principle. It is of utmost importance to adjust the rate of correction based on the patient's symptoms, underlying etiology, and associated comorbidities. This case demonstrates how a correction formula was used and adjusted accordingly in an 81-year-old female with severe hypernatremia and metabolic encephalopathy with multiple comorbidities, including hypopituitarism. It is noteworthy to examine the correction rate, how it was calculated and delivered, and how the main cause of the hypernatremia was determined. Considering all these factors can help to properly administer any additional corrective medications, such as desmopressin (DDAVP) in a patient with diabetes insipidus (DI) secondary to hypopituitarism, or adjust the correcting rate based on signs, symptoms, and laboratory findings.

Diagnostic Peritoneal Aspiration or Lavage in Stratified Groups of Hypotensive Blunt Trauma Patients

BACKGROUND

Some reports suggest Diagnostic peritoneal aspiration (DPA) or lavage (DPL) may better select which hypotensive blunt trauma patients (BTPs) require operation, compared to ultrasonography. However, whether both moderately hypotensive (systolic blood pressure [SBP] < 90 mmHg) and severely hypotensive (SBP < 70 mmHg) patients benefit from DPA/DPL is unclear. We hypothesized DPA/DPL used within the first hour increases risk of death for severely vs moderately hypotensive BTPs.

METHODS

The 2017-2019 Trauma Quality Improvement Program database was queried for BTPs ≥ 18 years old with hypotension upon arrival. We compared moderately and severely hypotensive groups. A multivariable logistic regression analysis was performed controlling for age, comorbidities, emergent operation, blood transfusions, and injury profile.

RESULTS

From 134 hypotensive patients undergoing DPA/DPL, 66 (49.3%) had severe hypotension. Patients in both groups underwent an emergent operation (43.9% vs 58.8%, P = .09) in a similar amount of time (median, 42-min vs 54-min, P = .11). Compared to the moderately hypotensive group, severely hypotensive patients had a higher rate and associated risk of death (84.8% vs 50.0%, P < .001) (OR 5.40, CI 2.07-14.11, P < .001). The strongest independent risk factor for death was age ≥ 65 (OR 24.81, CI 4.06-151.62, P < .001).

DISCUSSION

Among all BTPs undergoing DPA/DPL within the first hour of arrival, an over 5-fold increased risk of death for patients with severe hypotension was demonstrated. As such, DPA/DPL within this group should be used with caution, particularly for older patients, as they may be better served by immediate surgeries. Future prospective research is needed to confirm these findings and elucidate the ideal DPA/DPL population in the modern era of ultrasonography.

Defining Characteristics of Middle-Aged and Geriatric Orthopedic Trauma in New York City over a 7-Year Period

OBJECTIVES

Examine the patterns and defining characteristics of middle-aged and geriatric patients who sustain orthopedic trauma in New York City.

STUDY DESIGN

Retrospective cohort study.

METHODS

11,677 patients >55 years old treated for traumatic orthopedic injuries were grouped into cohorts based on their age group (cohorts of 55-64, 65-74, 75-84, 85-94, ≥95 years) and year of presentation (2014-2021). Each patient was reviewed for demographics/comorbidities, injury mechanism/type, mortality data. Comparative analyses were conducted.

RESULTS

The average age of our cohort was 74 years old. The majority of patients were female (69%) and sustained their injuries via a ground level fall. The most common injuries sustained by patients occurred at the upper extremity (40%), hip (26%), and lower extremity (25%) with 820 (7%) patients sustaining polytrauma. The incidence of hip fractures and pelvic injuries increased with older age. Older patients had a higher rate of mortality through 1-year in addition to a longer length of stay. In contrast, the incidence of injury to the upper and lower extremity decreased with older age.

CONCLUSIONS

The rate of mortality out through 1-year following orthopedic trauma increased as patients got older. Significantly more women experienced a traumatic injury during 2014-2021. As age increased, ground level falls were the most common mechanism of injury with injuries more likely to occur in the axial skeleton, notably the hip and pelvis. Younger patients experienced higher rates of upper and lower extremity trauma. Providers should keep these patterns in mind to optimize care for middle-aged and geriatric trauma patients.

Analysis of Trauma Characteristics Between the Older and Younger Adult Patient from the Pan Asian Trauma Outcome Study Registry (PATOS)

OBJECTIVE

Asia is experiencing a demographic shift toward an aging population at an unrivaled rate. This can influence the characteristics and outcomes of trauma. We aim to examine different characteristics of older adult trauma patients compared to younger adult trauma patients and describe factors that affect the outcomes in Asian countries.

METHODS

This is a retrospective, international, multicenter study of trauma across participating centers in the Pan Asian Trauma Outcome Study (PATOS) registry, which included trauma cases aged ≥18 years, brought to the emergency department (ED) by emergency medical services (EMS) from October 2015 to November 2018. Data of older adults (≥65 years) and younger adults (<65 years) were analyzed and compared. The primary outcome measure was in-hospital mortality, and secondary outcomes were disability at discharge and hospital and intensive care unit (ICU) length of stays.

RESULTS

Of 39,804 trauma patients, 10,770 (27.1%) were older adults. Trauma occurred more among older adult women (54.7% vs 33.2%, p < 0.001). Falls were more frequent in older adults (66.3% vs 24.9%, p < 0.001) who also had higher mean Injury Severity Score (ISS) compared to the younger adult trauma patient (5.4 ± 6.78 vs 4.76 ± 8.60, p < 0.001). Older adult trauma patients had a greater incidence of poor Glasgow Outcome Scale (GOS) (13.4% vs 4.1%, p < 0.001), higher hospital mortality (1.5% vs 0.9%, p < 0.001) and longer median hospital length of stay (12.8 vs 9.8, p < 0.001). Multiple logistic regression revealed age (adjusted odds ratio [AOR] 1.06, 95%CI 1.02-1.04, p < 0.001), male sex (AOR 1.60, 95%CI 1.04-2.46, p = 0.032), head and face injuries (AOR 3.25, 95%CI 2.06-5.11, p < 0.001), abdominal and pelvic injuries (AOR 2.78, 95%CI 1.48-5.23, p = 0.002), cardiovascular (AOR 2.71, 95%CI 1.40-5.22, p = 0.003), pulmonary (AOR 3.13, 95%CI 1.30-7.53, p = 0.011) and cancer (AOR 2.03, 95%CI 1.02-4.06, p = 0.045) comorbidities, severe ISS (AOR 2.06, 95%CI 1.23-3.45, p = 0.006), and Glasgow Coma Scale (GCS) ≤8 (AOR 12.50, 95%CI 6.95-22.48, p < 0.001) were significant predictors of hospital mortality.

CONCLUSIONS

Older trauma patients in the Asian region have a higher mortality rate than their younger counterparts, with many significant predictors. These findings illustrate the different characteristics of older trauma patients and their potential to influence the outcome. Preventive measures for elderly trauma should be targeted based on these factors.

Factors Associated With Triage Decisions in Older Adult Trauma Patients: Impact on Mortality and Morbidity

INTRODUCTION

As medical advances have significantly increased the life expectancy among older adults, the number of older patients requiring trauma care has risen proportionately. Nevertheless, it is unclear among this growing population which sociodemographic and economic factors are associated with decisions to triage and transfer to level I/II centers. This study aims to assess for any association between patient sociodemographic characteristics, triage decisions, and outcomes during acute trauma care presentations.

METHODS

The National Trauma Data Bank was queried for patients aged 65 and older with an injury severity score > 15 between the years 2007 to 2017. Factors associated with subsequent levels of triage on presentation were assessed using multivariate logistic regression, and associations of levels of triage with outcomes of mortality, morbidity, and hospital length of stay are examined using logistic and linear regression models.

RESULTS

Triage of 210,310 older adult trauma patients showed significant findings. American Indian patients had higher odds of being transferred to level I/II centers, while Asian, Black, and Native Hawaiian patients had lower odds of being transferred to level I/II centers when compared to Caucasian patients (P < 0.001). Regarding insurance, self-pay (uninsured) patients were less likely to be transferred to a higher level of care; however, this was also demonstrated in private insurance holders (P < 0.001). Caucasian patients had significantly higher odds of mortality, with Black patients (odds ratio [OR] 0.80 [0.75, 0.85]) and American Indian patients (OR 0.87 [0.72, 1.04]) having significantly lower odds (P < 0.001). Compared to government insurance, private insurance holders (OR 0.82 [0.80, 0.85]) also had significantly lower odds of mortality, while higher odds among self-pay were observed (OR 1.75 [1.62, 1.90]), (P < 0.001).

CONCLUSIONS

Access to insurance is associated with triage decisions involving older adults sustaining trauma, with lower access increasing mortality risk. Factors such as race and gender were less likely to be associated with triage decisions. However, due to this study's retrospective design, further prospective analysis is necessary to fully assess the decisions that influence trauma triage decisions in this patient population.

In-hospital, 30- and 90-day mortality in elderly trauma patients with operative feeding tubes

BACKGROUND

Nutrition is essential in the treatment of elderly trauma patients (ETP). ETP experience dysphagia at rates six times higher than the non-trauma elderly population (NTEP) and are at increased risk for malnutrition. Operative feeding tube (OFT) placement is often used to aid with the nutritional management of ETP. Elderly patients experience higher rates of morbidity and mortality when compared to the general population, especially in the traumatic setting, with some data suggesting in-hospital mortality as high as 10%. However, the mortality rates and associated comorbidities associated with OFT in ETP are unknown. The purposes of this study were to establish the mortality rate in hospital as well as 30- and 90-days following discharge among elderly trauma patients (ETP) receiving OFT, and to assess factors associated with mortality within this population.

METHODS

A retrospective review of all trauma patients from a single Level I Trauma Center from 01/2010-09/2020 was conducted. Exclusion criteria were patients under 65 years of age or those with previously placed OFT. Demographics, comorbidities, injury mechanisms, injury severity scores (ISS), and OFT data were collected from the institutional trauma registry. Mortality data were obtained using the Social Security Death Index. Mortality at discharge, 30 days, and 90 days following discharge were the primary outcomes. Bivariate analysis was conducted to compare characteristics and comorbidities of patients alive and dead at the time points of interest.

RESULTS

There were 151 ETP who received OFT. Patients were largely male (67.5%), severely injured via a blunt mechanism (95%), and had a median age of 76 years. 11 (7.3%) experienced in-hospital mortality following feeding tube placement, 21 (13.9%) died within 30 days, and 31 (20.5%) within 90 days. Bivariate analysis demonstrated that ETP who died were more likely to have a history of dementia (p = 0.004), congestive heart failure (p = 0.014), and end-stage liver disease (p = 0.034). No other patient or injury factors were associated with mortality after OFT placement.

CONCLUSION

Mortality rates for ETP with OFT were higher than anticipated, yet favorable compared to recently reported data. Patients who died were more likely to have dementia, CHF, or ESLD than those who survived. The few comorbidities associated with mortality suggest that nearly all ETP who undergo OFT placement are at risk for mortality. Additionally, the data highlights the importance of early goals of care discussions for ETP and their loved ones when operative feeding tubes are being considered.

LEVEL OF EVIDENCE

Level III.

STUDY TYPE

Prognostic/Therapeutic/Diagnostic Test/Economic/Decision.

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.

A qualitative study of older adult trauma survivors' experiences in acute care and early recovery

BACKGROUND

Older adults (aged ≥ 65 yr) account for a substantial proportion of hospital admissions for severe injury, yet little is known about their care experiences and views regarding outcomes. We sought to characterize the acute care and early recovery experiences of older adults who had been discharged after traumatic injury, with a long-term goal to inform the selection of patient-centred process and outcome measures in geriatric trauma.

METHODS

From June 2018 to September 2019, we conducted telephone interviews with adults aged 65 years or older who had been discharged after traumatic injury within 6 months from Sunnybrook or London Health Sciences Centres in Ontario, Canada. Using interpretive description and thematic analysis, we drew on social science theories of illness and aging for data interpretation. We analyzed data to the point of theoretical saturation.

RESULTS

We interviewed 25 trauma survivors aged 65-88 years. Most were injured in a fall. Four themes characterized participants' experiences, as follows: "I don't feel like a senior" (i.e., participants disliked being viewed as a senior or as needing senior-specific care); "don't bother telling him anything" (i.e., participants perceived ageist assumptions and treatment in acute care processes); getting back to normal (i.e., participants emphasized their active lifestyles and functional recovery as goals of care); "I have lost control of my life" (i.e., substantial social and personal losses linked to participants' experiences and adaptations to aging generally).

INTERPRETATION

Findings suggest that older adults experience social and personal loss after injury, and underscore how implicit age bias may influence care experiences and outcomes. This can inform improvements in injury care and guide providers in the selection of patient-centred outcome measures.

Blunt traumatic aortic injury in the elderly population

OBJECTIVE

Blunt thoracic aortic injury (BTAI) is a major cause of morbidity and mortality in trauma patients. Although outcomes for BTAI have been described in younger patient populations, elderly patients may present with different patterns of injury and have unique factors contributing to morbidity and mortality. This study aims to describe patterns of presentation and management in elderly patients presenting with BTAI using a nationwide database.

METHODS

Patients aged 65 years and older with BTAI from 2007 through 2016 were identified from the American College of Surgeons Trauma Quality Improvement Program database. Baseline demographics, initial physiologic variables, and clinical outcomes were extracted from the database. Our primary outcome was in-hospital mortality. An adjusted Poisson generalized regression model was used to compare rates of mortality for thoracic endovascular aortic repair (TEVAR), open repair, and nonoperative management.

RESULTS

During the study period, 1322 patients aged 65 years and over sustained BTAI and survived past triage. Mean age was 74.7 years, and 60% were male. There were low incidence rates of concomitant major head (9.4%), spine (3.1%), and abdominal (5.7%) injuries. Three hundred fifty (26.5%) underwent TEVAR, 58 (4.4%) open repair, and 914 (69.1%) were managed nonoperatively. Utilization of TEVAR increased from 13.1% to 32.7% from 2007 to 2015, with subsequent decline to 19.9% in 2016 in favor of nonoperative management. Age, gender, and mean Injury Severity Scores (ISS) did not significantly differ by management. In-hospital mortality for the entire cohort was 37.9%. In an adjusted Poisson generalized regression model using inverse probability of treatment weighting controlling for age, race, gender, ISS, and hypotension, TEVAR was associated with the lowest mortality rate (1.31 deaths/100 person-years; 95% confidence interval [CI], 1.17-1.46) compared with open repair (2.53; 95% CI, 2.32-2.75; P < .001) and nonoperative management (3.91; 95% CI, 3.60-4.25; P < .001). There was a higher incidence of acute kidney injury, acute respiratory distress syndrome, and surgical site infection in the TEVAR group.

CONCLUSIONS

This study describes the management of and outcomes for BTAI in the elderly population. The majority of patients did not undergo operative repair, which was associated with a higher risk of in-hospital mortality. In an adjusted analysis, TEVAR was associated with the lowest mortality rate, compared with open repair and nonoperative management.

Chronic Disease Comorbidities Among Injured Patients in Cameroon: A Retrospective Cohort Study

INTRODUCTION

Chronic diseases are increasing but underdiagnosed in low-income and middle-income countries (LMICs), where injury mortality is already disproportionately high. We estimated prevalence of known chronic disease comorbidities and their association with outcomes among injured patients in Cameroon.

MATERIALS AND METHODS

Injured patients aged ≥15 y presenting to four Cameroonian hospitals between October 2017 and January 2020 were included. Our explanatory variable was known chronic disease; prevalence was age-standardized. Outcomes were overall in-hospital mortality and admission or transfer from the emergency department (ED). Associations between known chronic disease and outcomes were evaluated using logistic regression adjusted for age, gender, estimated injury severity score (eISS), hospital, and household socioeconomic status. Unadjusted eISS-stratified and age-stratified outcomes were also compared via chi-squared tests.

RESULTS

Of 7509 injured patients, 370 (4.9%) reported at least one known chronic disease; age-standardized prevalence was 8.4% (95% confidence interval [CI] 7.5%-9.2%). Patients with known chronic disease had higher mortality (4.6% versus 1.5%, adjusted odds ratio [aOR]: 2.61 [95% CI: 1.25-5.47], P = 0.011) and were more likely to be admitted or transferred from the ED (38.7% versus 19.8%, aOR: 1.40 [95% CI: 1.02-1.92], P = 0.038) compared to those without known comorbidities. Crude differences in mortality (11.3% versus 3.3%, P = 0.002) and hospital admission or transfer (63.8% versus 46.6%, P = 0.011) were most notable for patients with eISS 16-24.

CONCLUSIONS

Despite underdiagnosis among Cameroonians, we demonstrated worse injury outcomes among those with known chronic diseases. Integrating chronic disease screening with injury care may help address underdiagnosis in Cameroon. Future work should assess whether chronic disease prevention in LMICs could improve injury outcomes.

Differences in time-critical interventions and radiological examinations between adult and older trauma patients: A national register-based study

BACKGROUND

Older trauma patients are reported to receive lower levels of care than younger adults. Differences in clinical management between adult and older trauma patients hold important information about potential trauma system improvement targets. The aim of this study was to compare prehospital and early in-hospital management of adult and older trauma patients, focusing on time-critical interventions and radiological examinations.

METHODS

Retrospective analysis of the Norwegian Trauma Registry for 2015 through 2018. Trauma patients 16 years or older met by a trauma team and with New Injury Severity Score of 9 or greater were included, dichotomized into age groups 16 years to 64 years and 65 years or older. Prehospital and emergency department clinical management, advanced airway management, chest decompression, and admission radiological examinations was compared between groups applying descriptive statistics and appropriate statistical tests.

RESULTS

There were 9543 patients included, of which 28% (n = 2711) were 65 years or older. Older patients, irrespective of injury severity, were less likely attended by a prehospital doctor/paramedic team (odds ratio [OR], 0.64; 95% confidence interval [CI], 0.57-0.71), conveyed by air ambulance (OR, 0.65; 95% CI, 0.58-0.73), and transported directly to a trauma center (OR, 0.86; 95% CI, 0.79-0.94). Time-critical intervention and primary survey radiological examination rates only differed between age groups among patients with New Injury Severity Score of 25 or greater, showing lower rates for older adults (advanced airway management: OR, 0.60; 95% CI, 0.47-0.76; chest decompression: OR, 0.46; 95% CI, 0.25-0.85; x-ray chest: OR, 0.54; 95% CI, 0.39-0.75; x-ray pelvis: OR, 0.69; 95% CI, 0.57-0.84). However, for the patients attended by a doctor/paramedic team, there were no management differences between age groups.

CONCLUSION

Older trauma patients were less likely to receive advanced prehospital care compared with younger adults. Older patients with very severe injuries received fewer time-critical interventions and radiological examinations. Improved dispatch of doctor/paramedic teams to older adults and assessment of the impact the observed differences have on outcome are future research priorities.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Differences in characteristics between patients ≥ 65 and < 65 years of age with orthopaedic injuries after severe trauma

Aim

Many trauma patients have associated orthopaedic injuries at admission. The existing literature regarding orthopaedic trauma often focuses on single injuries, but there is a paucity of information that gives an overview of this group of patients. Our aim was to describe the differences in characteristics between polytrauma patients ≥ 65 and < 65 years of age suffering orthopaedic injuries.

Methods

Patients registered in the Norwegian Trauma Registry (NTR) with an injury severity score (ISS) > 15 and orthopaedic injuries, who were admitted to Haukeland University Hospital in 2016–2018, were included. Data retrieved from the patients’ hospital records and NTR were analysed. The patients were divided into two groups based on age.

Results

The study comprised 175 patients, of which 128 (73%) and 47 (27%) were aged < 65 (Group 1) and ≥ 65 years (Group 2), respectively. The ISS and the new injury severity score (NISS) were similar in both groups. The dominating injury mechanism was traffic-related and thoracic injury was the most common location of main injury in both groups. The groups suffered a similar number of orthopaedic injuries. A significantly higher proportion of Group 1 underwent operative treatment for their orthopaedic injuries than in Group 2 (74% vs. 53%). The mortality in Group 2 was significantly higher than that in Group 1 (15% vs. 3%). In Group 2 most deaths were related to traffic injuries (71%). High energy falls and traffic-related incidents caused the same number of deaths in Group 1. In Group 1 abdominal injuries resulted in most deaths, while head injuries was the primary reason for deaths in Group 2.

Conclusions

Although the ISS and NISS were similar, mortality was significantly higher among patients aged ≥ 65 years compared to patients < 65 years of age. The younger age group underwent more frequently surgery for orthopaedic injuries than the elderly. There may be multiple reasons for this difference, but our study does not have sufficient data to draw any conclusions. Future studies may provide a deeper understanding of what causes treatment variation between age groups, which would hopefully help to further develop strategies to improve outcome for the elderly polytrauma patient.

Elderly trauma patients and the effect of trauma scores on hospitalization decision

Objectives

Hospitalization, mortality and trauma scores are important in trauma patients aged ≥65 years. The present study aimed to investigate the use of trauma scores in the prediction of hospitalisation and mortality in trauma patients aged ≥65 years.

Material and Methods

Patients aged ≥65 years who presented to the emergency department with trauma over a one-year period were included in the study. Baseline data of the patients together with their Glasgow Coma Scale (GCS), Revised Trauma Score (RTS), Injury Severity Score (ISS), hospitalisation and mortality were analysed.

Results

A total of 2264 patients were included in the study, of whom 1434 (63.3%) were women. The most common mechanism of trauma was simple falls. Mean GCS scores, RTSs and ISSs of the inpatients were 14.87 ± 0.99, 6.97 ± 0.343 and 7.22 ± 5.826, respectively. Furthermore, a significant negative correlation was found between the duration of hospitalisation and GCS scores (r= -0.158, p <0.001) and RTSs (r= -0.133, p <0.001), whereas a positive significant correlation with ISSs (r= 0.306, p <0.001) was observed. The ISSs (p <0.001) of the deceased individuals were significantly elevated, whereas their GCS scores (p <0.001) and RTSs (p <0.001) were significantly decreased.

Conclusion

All trauma scoring systems can be used to predict hospitalisation, but the results of the present study suggest that the use of ISS and GCS in making the decision regarding mortality is more appropriate.

A Model of Care to Improve Survival of Older Trauma Patients: Geriatrics Co-Management

BACKGROUND

Trauma patients older than 80 years of age have higher mortality rates compared to younger peers. No studies have investigated the effectiveness of geriatrics co-management on mortality in general trauma.

METHODS

Retrospective cohort study from 2015-2016 comparing overall and inpatient mortality in a geriatrics trauma co-management (GTC) program versus usual care (UC). Demographic and outcome measures were obtained from the trauma registry at an 11-bed trauma critical care unit within a 719-bed Level 1 Trauma Center. 1,572 patients, 80 years and older, with an admitting trauma diagnosis were evaluated. Primary outcome was in-hospital mortality and overall mortality (defined as inpatient death or discharge to hospice). Secondary outcomes included hospital length of stay (LOS), Intensive Care Unit (ICU) LOS, discharge location, and medical complications.

RESULTS

346 patients (22%) were placed in the GTC program. Overall mortality was lower in the GTC (4.9%) when compared with UC (11.9%), representing a 57% reduction (95% OR CI 0.24-0.75, p-value = 0.0028). There was a 7.42% hospital mortality rate in the UC group compared to 2.6% in the GTC group (95% CI 0.21-0.92, p-value = 0.0285) representing a 56% decrease in in-hospital mortality. GTC patients had a longer mean LOS (6.4 days versus 5.3 days, p-value <0.0001). More GTC patients were sent to inpatient rehabilitation facilities or skilled nursing facilities (80% versus 60%, p-value <0.0001).

CONCLUSIONS

Geriatrics trauma co-management of trauma patients above the age of 80 may reduce mortality and deserves formal study.

Predictors of mortality in trauma patients with acute respiratory distress syndrome receiving extracorporeal membrane oxygenation

Objective

Trauma-related Acute Respiratory Distress Syndrome (TR-ARDS) mortality ranges from 30 to 80%. Extracorporeal membrane oxygenation (ECMO) has demonstrated a survival benefit in select cases of TR-ARDS. In order to provide improved patient selection, we evaluated predictors of mortality in TR-ARDS patients receiving ECMO, hypothesizing age and severe thoracic trauma as risk factors for mortality.

Methods

The Trauma Quality Improvement Program (2010-2016) was queried for patients ≥ 18-years-old with TR-ARDS receiving ECMO. Survivors were compared to those who died. A multivariable logistic regression model was used for analysis and included covariates known to increase risk of mortality in trauma patients.

Results

From 362 TR-ARDS patients on ECMO, 226 (62.4%) survived and 136 (37.6%) died. Those who died were older (median, 28 vs. 24-years-old, p = 0.036) and had a higher injury severity score (29 vs. 26, p = 0.040) than survivors. After adjusting for covariates, independent predictors of mortality included a severe head (OR=2.66, CI=1.29-5.49, p = 0.008) and thorax (OR =3.52, CI=1.96-6.33, p < 0.001) injury. Age ≥ 65-years-old was not a predictor of mortality (p = 0.432).

Discussion

Age ≥ 65 years did not appear to increase the risk of mortality in patients with TR-ARDS receiving ECMO. However, those with severe head or thorax injury had more than a two-fold and three-fold increased risk of death, respectively. TR-ARDS patients differ from medical ARDS patients in terms of etiology, age and injuries. Thus, prior pre-ECMO mortality prediction models may lack predictive capability for trauma patients. Future prospective studies are needed to confirm our findings and develop guidelines for utilization of ECMO for trauma patients.

Development and Validation of a Nomogram for Adverse Outcomes of Geriatric Trauma Patients Based on Frailty Syndrome

Purpose

Currently, assessing trauma severity alone in geriatric trauma patients (GTPs) cannot accurately predict the risk of serious adverse outcomes during hospitalization. As an emerging concept in recent years, frailty syndrome is closely related to the poor prognosis of many diseases in elderly patients, including trauma. A logistic model for predicting adverse outcomes in elderly trauma patients during hospitalization was constructed in elderly patients, and the predictive efficacy of the model was verified.

Patients and Methods

Trauma patients aged ≥65 years between June 2020 and September 2021 were selected and randomly divided into a training set and validation set at a ratio of 3:1. Mid arm muscle circumference (MAMC) was measured to determine the degree of frailty. LASSO regression was used to screen appropriate variables for the construction of a prognostic model. The logistic regression model was established and presented in the form of a nomogram. Calibration curves and ROC curves were used to verify the performance of the model.

Results

A total of 209 patients were enrolled, including 143 (68.4%) males and 66 (31.6%) females, with an average age of 70.8 ± 4.8 years. Ageless Charlson comorbidity index, BT unit, ISS, GCS, MAMC, prealbumin and lactic acid levels were screened by LASSO regression to construct a prognostic model. The AUC of the ROC analysis prediction model was 0.89 (95% CI 0.80–0.97) in the validation set. The results of the Hosmer–Lemeshow test for the validation set were χ2 = 11.23, P = 0.189.

Conclusion

The prognostic model of adverse outcomes in GTPs has good accuracy and differentiation, which can improve the prediction results of risk stratification of GTPs during hospitalization by medical staff and provide a new idea for prognostic prediction.

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.

Predicting mortality in elderly trauma patients: a review of the current literature

PURPOSE OF REVIEW

Advances in medical care allow patients to live longer, translating into a larger geriatric patient population. Adverse outcomes increase with older age, regardless of injury severity. Age, comorbidities, and physiologic deterioration have been associated with the increased mortality seen in geriatric trauma patients. As such, outcome prediction models are critical to guide clinical decision making and goals of care discussions for this population. The purpose of this review was to evaluate the various outcome prediction models for geriatric trauma patients.

RECENT FINDINGS

There are several prediction models used for predicting mortality in elderly trauma patients. The Geriatric Trauma Outcome Score (GTOS) is a validated and accurate predictor of mortality in geriatric trauma patients and performs equally if not better to traditional scores such as the Trauma and Injury Severity Score. However, studies recommend medical comorbidities be included in outcome prediction models for geriatric patients to further improve performance.

SUMMARY

The ideal outcome prediction model for geriatric trauma patients has not been identified. The GTOS demonstrates accurate predictive ability in elderly trauma patients. The addition of medical comorbidities as a variable in outcome prediction tools may result in superior performance; however, additional research is warranted.

The Impact of Delays in Interfaculty Transfer on Outcomes in Elderly Trauma Patients

BACKGROUND

Delay to definitive treatment is a significant and persistent challenge to trauma systems across the United States, especially in rural communities with limited resources. We hypothesized that elderly trauma patients with delay in transfer would have increased morbidity and mortality. This study evaluates the relationship between inter-facility transfer time and outcomes in elderly trauma patients, and the validity of the 4-hour dwell time as a performance improvement benchmark.

METHODS

The National Trauma Registry and Emergency Medical Services Database were queried from January 2010 to January 2018. Inclusion criteria included age ≥65, blunt mechanism, and transfer from another facility. Correlation analysis was used to evaluate the association between clinical and demographic variables and transfer time. Multicollinearity was evaluated using the variance inflation factor.

RESULTS

1535 patients were identified. This cohort was further subdivided into 4 cohorts based on dwell time: 0-1.5 hours (n = 384), ≥1.5-1.9 hours (n = 379), 1.9-<2.5 hours (n = 383), and ≥2.5 hours (n = 388). Analysis revealed that shorter dwell time was associated with male gender (P = .0039), higher ISS (injury severity score) (P < .0001), lower RTS (revised trauma score) (P < .0001), higher pre-hospital arrest (P = .0066), lower initial GCS (Glasgow Coma Scale) (P = .0012), higher mortality, longer ICU, and ventilator length of stay (P < .0001). Longer dwell times were associated with discharge from the hospital to home or skilled nursing facility as well as lower mortality (P < .0001).

DISCUSSION

Longer dwell time was inversely related to outcome. More severely injured patients were rapidly transferred. This represents a mature rural trauma system. In addition, dwell time should be scrutinized as a meaningful indicator within a performance improvement program.

Comparison of National Surgical Quality Improvement Program Surgical Risk Calculator, Trauma and Injury Severity Score, and American Society of Anesthesiologists Physical Status to predict operative trauma mortality in elderly patients

BACKGROUND

The Trauma and Injury Severity Score (TRISS) uses anatomical and physiologic variables to predict mortality. Elderly (65 years or older) trauma patients have increased mortality and morbidity for a given TRISS, in part because of functional status and comorbidities. These factors are incorporated into the American Society of Anesthesiologists Physical Status (ASA-PS) and National Surgical Quality Improvement Program Surgical Risk Calculator (NSQIP-SRC). We hypothesized scoring tools using comorbidities and functional status to be superior at predicting mortality, hospital length of stay (LOS), and complications in elderly trauma patients undergoing operation.

METHODS

Four level I trauma centers prospectively collected data on elderly trauma patients undergoing surgery within 24 hours of admission. Using logistic regression, five scoring models were compared: ASA-PS, NSQIP-SRC, TRISS, TRISS-ASA-PS, and TRISS-NSQIP-SRC.Brier scores and area under the receiver operator characteristics curve were calculated to compare mortality prediction. Adjusted R2 and root mean squared error were used to compare LOS and predictive ability for number of complications.

RESULTS

From 122 subjects, 9 (7.4%) died, and the average LOS was 12.9 days (range, 1-110 days). National Surgical Quality Improvement Program Surgical Risk Calculator was superior to ASA-PS and TRISS at predicting mortality (area under the receiver operator characteristics curve, 0.978 vs. 0.768 vs. 0.903; p = 0.007). Furthermore, NSQIP-SRC was more accurate predicting LOS (R2, 25.9% vs. 13.3% vs. 20.5%) and complications (R2, 34.0% vs. 22.6% vs. 29.4%) compared with TRISS and ASA-PS. Adding TRISS to NSQIP-SRC improved predictive ability compared with NSQIP-SRC alone for complications (R2, 35.5% vs. 34.0%; p = 0.046). However, adding ASA-PS or TRISS to NSQIP-SRC did not improve the predictive ability for mortality or LOS.

CONCLUSION

The NSQIP-SRC, which includes comorbidities and functional status, had superior ability to predict mortality, LOS, and complications compared with TRISS alone in elderly trauma patients undergoing surgery.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic; Level III.

Upper Extremity Deep Venous Thrombosis Risk Factors, Associated Morbidity and Mortality in Trauma Patients

BACKGROUND

The literature on upper extremity deep venous thrombosis (UEDVT) is not as abundant as that on lower extremities. This study aimed to identify the risk factors for UEDVT, associated mortality and morbidity in trauma patients and the impact of pharmacological prophylaxis therein.

METHODS

A 3-year retrospective review of patients admitted to a Level 1 trauma center was conducted. Patients aged 18 years or older who had experienced a traumatic event and had undergone an upper extremity ultrasound (UEUS) were included in the study. Multiple logistic regression was used to identify independent risk factors that contributed to UEDVT.

RESULTS

A total of 6,607 patients were admitted due to traumatic injuries during the study period, of whom 5.6% (373) had at least one UEUS during their hospitalization. Fifty-six (15%) were diagnosed with an UEDVT, as well as three non-fatal pulmonary emboli (PE) and four (7.1%) deaths, p = 0.03. Pharmacological prophylaxis with low-molecular-weight heparin (LMWH) or unfractionated heparin showed a protective effect against UEDVT; among the patients positive for UEDVT, 14 of 186 patients (7.5%) received LMWH, while 42 of 195 (21.5%) did not receive LMWH (p < 0.001). Multiple logistic regression revealed that the presence of upper extremity fractures, peripherally inserted central catheter (PICC) lines, and traumatic brain injury (TBI) were independent risk factors for UEDVT.

CONCLUSIONS

UEDVT are associated with a higher mortality. The presence of upper extremity fractures, PICC lines, and TBI were independent risk factors for UEDVTs. Further, pharmacological prophylaxis reduces the risk of UEDVT.

Disparity in prehospital scene time for geriatric trauma patients

BACKGROUND

Geriatric patients face disparities in prehospital trauma care. We hypothesized that geriatric trauma patients are more likely to experience prolonged prehospital scene time than younger adults.

METHODS

Retrospective analysis of the 2017 National Emergency Medical Services Information System. Patients who met anatomic or physiologic trauma criteria based on national triage guidelines were included (n = 16,356). Geriatric patients (age≥65, n = 3594) were compared to younger adults (age 18-64). The primary outcome was prolonged scene time (>10 min). Multivariable logistic regression was performed, controlling for patient demographics, on-scene treatments, and injury severity.

RESULTS

Geriatric patients were more likely to experience prolonged scene time than younger adults after controlling for other factors (OR 1.78, 95% CI 1.57-2.04, p < 0.001). The likelihood of prolonged scene time reached OR 2.29 (95% CI 1.85-2.84) for patients age 70-79 and OR 2.66 (95% CI 2.07-3.42) for patients age 80-89, relative to age 18-29.

CONCLUSIONS

Geriatric trauma patients are more likely than younger adults to have prolonged prehospital scene time. This disparity may be caused by delayed recognition of injury severity or age-related cognitive biases.

CHA2DS2-VASc and has-BLED scores do not accurately stratify risk for stroke or bleed in fall victims with atrial fibrillation

BACKGROUND

Falls are the leading cause of morbidity and mortality in the elderly. Non-valvular Atrial fibrillation (AF) is present in up to 9% of this group and often requires oral anticoagulation (OAC). The CHA₂DS₂-VASc and HAS-BLED scores are validated tools assessing risk of ischemic stroke from AF and major bleeding (MB) from OAC. It is unclear if these predictions remain accurate in post-fall patients. This study seeks to determine the stroke and major bleeding rate in atrial fibrillation patients after a ground level fall and identify if validated risk scoring systems accurately stratify risk in this cohort.

METHODS

Retrospective review of patients with AF presented to the emergency department after a fall. CHA₂DS₂-VASc and HAS-BLED scores were calculated. Follow up information was reviewed to 1 year. Patients were grouped according to discharge thromboprophylaxis plan (DTP): no treatment, Anti-platelet (AP), OAC, and AP + OAC. Outcomes were ischemic stroke, MB, or death at 1 year. Ischemic stroke and MB rates were calculated. Kruskal-Wallis, Χ², Fisher's exact, and multivariable logistic regression were used to evaluate for clinical associations.

RESULTS

192 patients were included. MB rate was 14.5 bleeds/100 person-years, and ischemic stroke rate was 10.9/100 person-years. There were no observed differences between DTPs. Overall, one-year mortality was 22.1%. On unadjusted analysis, CHA₂DS₂-VASc did associate with ischemic stroke (p = 0.03); HAS-BLED did not associate with MB (p = 0.17). After logistic regression accounting for known risk factors, neither system associated with ischemic stroke or MB.

CONCLUSIONS

Fall patients are at higher risk for both ischemic stroke and MB compared to previously published reports. Current risk assessment tools should be used with caution. Further study of risk factors is warranted to guide medication decisions in these patients.

Critical care ultrasound in geriatric trauma resuscitation leads to decreased fluid administration and ventilator days

BACKGROUND

Geriatric trauma populations respond differently than younger trauma populations. Critical care ultrasound (CCUS) can guide resuscitation, and it has been shown to decrease intravenous fluid (IVF), lower time until operation, and lower mortality in trauma. Critical care ultrasound-guided resuscitation has not yet been studied in geriatric trauma. We hypothesized that incorporation of CCUS would decrease amount of IVF administered, decrease time to initiation of vasopressors, and decrease end organ dysfunction.

METHODS

A PRE-CCUS geriatric trauma group between January 2015 and October 2016 was resuscitated per standard practice. A POST-CCUS group between January 2017 and December 2018 was resuscitated based on CCUS performed by trained intensivist upon admission to the intensive care unit and 6 hours after initial ultrasound. The PRE-CCUS and POST-CCUS groups underwent propensity score matching, yielding 60 enrollees in each arm. Retrospective review was conducted for demographics, clinical outcomes, and primary endpoints, including amount of IVF in the first 48 hours, duration to initiation of vasopressor use, and end organ dysfunction. Wilcoxon two-sample, χ2 tests, and κ statistics were performed to check associations between groups.

RESULTS

There was no statistical difference between PRE-CCUS and POST-CCUS demographics and Injury Severity Scores. Intravenous fluid within 48 hours decreased from median [interquartile range] of 4941 mL [4019 mL] in the PRE-CCUS to 2633 mL [3671 mL] in the POST-CCUS (p = 0.0003). There was no significant difference between the two groups in time to initiation of vasopressors, vasopressor duration, lactate clearance, intensive care unit length of stay, or hospital length of stay. There was a significant decrease in ventilator days, with 26.7% PRE-CCUS with ventilation longer than 2 days, and only 6.7% POST-CCUS requiring ventilation longer than 2 days (p = 0.0033).

CONCLUSION

Critical care ultrasound can be a useful addition to geriatric resuscitation. The POST-CCUS received less IV fluid and had decreased ventilator days. While mortality, lactate clearance, complications, and hospital stay were not statistically different, there was a perception that CCUS was a useful adjunct for assessing volume status and cardiac function.

LEVEL OF EVIDENCE

Therapeutic, level II.

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.

Major Trauma in Elderly Patients: Worse Mortality and Outcomes in an Italian Trauma Center

Introduction:

Major trauma is the leading cause of mortality in the world in patients younger than 40 years. However, the proportion of elderly people who suffer trauma has increased significantly. The purpose of this study is to assess the correlation of old age with mortality and other unfavorable outcomes.

Methods:

We assessed on one hand, anatomical criteria such as ISS values and the number of body regions affected, on the other hand, hemodynamic instability criteria, various shock indices, and Glasgow Coma Scale. Finally, we also evaluated biochemical parameters, such as lactate, BE, and pH values. We conducted a prospective and monocentric observational study of all the patients referred to the Emergency Department of the IRCCS Fondazione Policlinico S. Matteo in Pavia for major trauma in 13 consecutive months: January 1, 2018–January 30, 2019. We compared the elderly population (>75 years) and the younger population (≤75).

Results:

We included 501 patients, among which 10% were over the age of 75 years. The mortality rate was higher among the older patients than among the younger (4% vs. 1.33%; P = 0.050). Hemodynamic instability was more common in the older patients than in the younger (26% vs. 9%; P < 0.001). More older patients (44%) had an ISS >16, in comparison with 32% of younger patients (P = 0.01).

Conclusions:

The elderly showed worse outcomes in terms of mortality, hospitalization rate, hemodynamic instability criteria, and anatomical and biochemical parameters.

Trends in Geriatric Ground-Level Falls: Report from the National Trauma Data Bank

INTRODUCTION

Ground-level falls (GLF) are typically reported as a minor mechanism of injury; however, they represent a significant portion of hospitalized geriatric trauma patients as they can result in multisystem injury in this subset of the population. Our study aimed to analyze trends in geriatric trauma falls on the national level.

METHODS

We performed a 5-y (2011-2015) analysis of the American College of Surgeons National Trauma Data Bank (ACS-NTDB) and included all geriatric trauma patients (age ≥ 65 y) who presented with GLF. GLF was identified using ICD-9 E CODES. Our outcome measures were national incidence of GLF, and overall discharge disposition and trauma center level discharge disposition following GLF. We used Cochran Armitage test and multivariate regression analysis.

RESULTS

We analyzed a total of 1,017,326 geriatric trauma patients, of which 39% had had a fall as a mechanism of injury. Among those who fell, mean age was 78 ± 7, 63% were females, and 85% were whites. The incidence of falls significantly increased over the study period, and was noted to be proportional to age, with a plateau beyond age 85 y old. The rate of discharge to SNF and/or Rehab significantly increased over the study period; however, discharge to home and mortality rates trended downwards over the study period. Discharge to SNF and/or Rehab was significantly lower among level I trauma centers compared to other level trauma centers. Conversely, discharge to home was higher in level I trauma centers compared to other level trauma centers.

CONCLUSION

Around one in three elderly trauma patients were admitted following a GLF with an overall increased incidence of falls over time. Although overall mortality rates decreased, there was an increase in adverse discharge disposition and loss of functional independence over the study period, mostly among those admitted to non-level I trauma centers.

Epidemiology of trauma admissions in a level 1 trauma center in Northern Italy: a nine-year study

The aim of this study was to analyze the results of 9 years of trauma care and data collection in a level 1 urban trauma center in Northern Italy. Overall, 6065 patients have been included in the study; the number of patients managed yearly has doubled between 2011 and 2019. This rise mostly involved patients with injury severity score (ISS) < 16. Most injuries (94%) were blunt. Road traffic accidents, especially involving motorcycles, were the most common cause of injury. Self-inflicted injuries were responsible for less than 5% of trauma but they were severe in 56% of cases. The median age was 38 and it remained constant over the years; 43% of patients had 14-39 years of age. Different characteristics and patterns of injury were observed for each age group and gender. Males were more likely to be injured in the central years of life while females presented a trimodal pattern in the age distribution. Young adults (14-39 years old) were overall at higher risk of self-harm. Overall mortality was equal to 5.2%. Most deceased were male and ≥ 65 years of age.

Redefining geriatric trauma: 55 is the new 65

INTRODUCTION

As the prevalence of geriatric trauma patients has increased, protocols are being developed to address the unique requirements of this demographic. However, categorical definitions for geriatric patients vary, potentially creating confusion concerning which patients should be cared for according to geriatric-specific standards. The aim of this study was to identify data-driven cut points for mortality based on age to support implementation of age-driven guidelines.

METHODS

Adults aged 18 to 100 years with blunt or penetrating injury were selected from 95 hospitals' trauma registries. Change point analysis techniques were used to detect inflection points in the proportion of deaths at each age. Based on these calculated points, patients were allocated into age groups, and their characteristics and outcomes were compared. Logistic regression was used to estimate risk-adjusted in-hospital mortality controlling for sex, race, Injury Severity Score, Glasgow Coma Scale, and number of comorbidities.

RESULTS

A total of 255,099 patients were identified (female, 45.7%; mean age, 59.3 years; mean Injury Severity Score, 8.69; blunt injury, 92.6%). Statistically significant increases in mortality rate were noted at ages 55, 77, and 82 years. Compared with the referent group (age, <55 years), adjusted odds ratios (AORs) showed increases in mortality if age 55 to 76 years (AOR, 2.42), age 77 to 81 years (AOR, 4.70), or age 82 years or older (AOR, 6.43). National Trauma Data Standard-defined comorbidities significantly increased once age surpassed 55 years, as the rate more than doubled for each of the older age categories (p < 0.001). As age increased, each group was more likely to be female, have dementia, sustain a ground level fall, and be discharged to a skilled nursing facility (p < 0.001).

CONCLUSION

This large multicenter analysis established a clinically and statistically significant increase in mortality at ages 55, 77, and 82 years. This research strongly suggests that trauma patients older than 55 years be considered for inclusion in geriatric trauma protocols. The other age inflection points identified (77 and 82 years) may also warrant additional specialized care considerations.

LEVEL OF EVIDENCE

Epidemiological study, level III; Care management, level IV.

Late Mortality Prediction of Neutrophil-to-lymphocyte and Platelet Ratio in Patients With Trauma Who Underwent Emergency Surgery: A Retrospective Study

BACKGROUND

We aimed to evaluate the usefulness of neutrophil-to-lymphocyte (N/L) and neutrophil-to-lymphocyte platelet (N/LP) ratios in predicting late mortality of patients with trauma who underwent emergency surgery.

MATERIALS AND METHODS

We retrospectively evaluated patients with trauma older than 19 y who underwent emergency surgery at our level I trauma center. Blood count-based ratios (N/L and N/LP at days 1, 3, and 7 of hospitalization) and trauma scores were analyzed. Statistical analysis was performed using univariable logistic regression and receiver operating curves.

RESULTS

A total of 209 patients were evaluated. N/LP at day 7, N/L at day 7, Trauma Injury Severity Score, Revised Trauma Score, and Injury Severity Score were significantly associated with late mortality. Area under the receiver operating characteristic curves for predicting mortality was highest for N/LP at day 7 (0.867 [95% confidence interval 0.798-0.936], P < 0.001). The group with N/LP greater than the cutoff value (9.3, sensitivity 77.3%, specificity 83.1%) at day 7 showed higher mortality than the group with N/LP less than the cutoff value (35.4% versus 3.2%, P < 0.001, respectively) at day 7.

CONCLUSIONS

N/LP at day 7 may be a superior predictor of late mortality compared with preexisting trauma scores in patients with major trauma undergoing emergency surgery, by better reflecting the systemic inflammation status.

The Impact of Under-triage on Trauma Outcomes in Older Populations ≥65 Years

BACKGROUND

Undertriage of older trauma patients is implicated as a cause for outcome disparities. Undertriage is defined by an Injury Severity Score (ISS) ≥16 without full trauma activation. We hypothesized that in patients ≥65 years, undertriage is associated with unfavorable discharge.

METHODS

This is a retrospective study of patients ≥65 years admitted at a Level 1 Trauma Center between July 2016 and June 2018 with blunt trauma. The Matrix method was used to determine the undertriage rate, and outcomes were compared between undertriaged and fully activated patients with ISS ≥16. Favorable outcomes in undertriaged patients instigated further analyses to determine factors that predicted unfavorable discharge condition, defined by discharge from the hospital with severe disability, persistent vegetative state, and in-hospital death.

RESULTS

The undertriage rate was 7.9%. When compared to fully activated patients with ISS ≥16, a lower percentage of undertriaged patients were discharged in an unfavorable condition (16.6% vs 64.7%, P < .001). On the multivariate analysis, male sex (OR = 1.52), preexisting coronary artery disease (OR = 1.86), age >90 years (OR = 2.31), ISS 16-25 (OR = 3.50), Glasgow Coma Score (GCS) ≤14 (OR = 6.34), and ISS >25 (OR = 9.64) were significant independent risk factors for unfavorable discharge.

DISCUSSION

The undertriage rate in patients ≥65 years was higher than the accepted standard (5%). However, undertriaged patients had better outcomes than those fully activated with ISS ≥16. Factors more predictive of unfavorable discharge condition were GCS ≤14 and ISS >25. These data suggest that ISS alone is a poor marker for assessing undertriage in older patients. Additional parameters established in this study should be considered as potential markers for better predicting outcomes in older trauma patients.