Low falls: an underappreciated mechanism of injury

Development of Imaging Criteria for Geriatric Blunt Trauma Patients

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Examining four blood biomarkers for the detection of acute intracranial abnormalities following mild traumatic brain injury in older adults

Blood-based biomarkers have been increasingly studied for diagnostic and prognostic purposes in patients with mild traumatic brain injury (MTBI). Biomarker levels in blood have been shown to vary throughout age groups. Our aim was to study four blood biomarkers, glial fibrillary acidic protein (GFAP), ubiquitin C-terminal hydrolase-L1 (UCH-L1), neurofilament light (NF-L), and total tau (t-tau), in older adult patients with MTBI. The study sample was collected in the emergency department in Tampere University Hospital, Finland, between November 2015 and November 2016. All consecutive adult patients with head injury were eligible for inclusion. Serum samples were collected from the enrolled patients, which were frozen and later sent for biomarker analyses. Patients aged 60 years or older with MTBI, head computed tomography (CT) imaging, and available biomarker levels were eligible for this study. A total of 83 patients (mean age = 79.0, SD = 9.58, range = 60-100; 41.0% men) were included in the analysis. GFAP was the only biomarker to show statistically significant differentiation between patients with and without acute head CT abnormalities [U₍₈₃₎ = 280, p < 0.001, r = 0.44; area under the curve (AUC) = 0.79, 95% CI = 0.67-0.91]. The median UCH-L1 values were modestly greater in the abnormal head CT group vs. normal head CT group [U ₍₈₃₎ = 492, p = 0.065, r = 0.20; AUC = 0.63, 95% CI = 0.49-0.77]. Older age was associated with biomarker levels in the normal head CT group, with the most prominent age associations being with NF-L (r = 0.56) and GFAP (r = 0.54). The results support the use of GFAP in detecting abnormal head CT findings in older adults with MTBIs. However, small sample sizes run the risk for producing non-replicable findings that may not generalize to the population and do not translate well to clinical use. Further studies should consider the potential effect of age on biomarker levels when establishing clinical cut-off values for detecting head CT abnormalities.

Effect of COVID 19 pandemic on time to care, use of ambulance, admission characteristics, demography, injury characteristics, management and outcome of Paediatric Orthopaedic trauma patients admitted to the trauma centre

Background: Lockdown imposed to limit the spread of COVID 19 may have had a significant effect on the time to care, demography, injury causation, injury characteristics, volume and nature of admission, management and outcome of paediatric orthopaedic trauma patients. Objective: To document the effect of lockdown on the time to care at KGMU, use of ambulance, volume and type of admissions, demography, injury causation, injury characteristics,  management and outcome of paediatric orthopaedic trauma patients. Methods:. This record review compared age, sex, type of admission, mechanism of injury, injury characteristics, type of treatment, vehicle used for transport, and outcome among patients admitted in pre-lockdown, lockdown and post lockdown.  Results: Lockdown was associated with decrease in the number of cases (p<0.01), increase in the time since injury to reception (p<0.040), a rise in the share of referred admission (p<0.040), time since reception at KGMU, time to definitive care (p<0.001), high energy falls (p<0.001), injuries at home (p<0.001), higher ISS (p<0.001), non operative treatment (p=0.038) and greater use of ambulance  (p=0.003). Conclusion: Lockdown resulted in a significant change in the causation and management of injury, significant delays in timeliness of care, reduction in the volume of admissions, an increase in injury severity and share of referral admissions.

Epidemiology of Pediatric Musculoskeletal Trauma Patients Admitted to the Trauma Center of King George’s Medical University (KGMU) During COVID-19-Induced Lockdown

Purpose: This retrospective study aims to document the epidemiology of pediatric musculoskeletal trauma patients admitted over a one and half year period to the trauma center of King George's Medical University (KGMU) and the effect of COVID-19-induced lockdown on the timeliness of care.

Methods: We analyzed data of 174 patients for demography, types of injuries, mechanism of injuries, the site where the injury was sustained, the severity of injuries, nature of the injury, and the regions involved by the injuries.

Results: Mean age was 12.44±4.4. One hundred and twelve (67.46%) were males and 62 were females (32.54%). When compared with the period prior to lockdown, significantly higher times were recorded during the lockdown for time to a reception at the trauma center (p=0.028) and the time spent in receiving area of the trauma center (p<0.001). The most common mode of injury was low energy falls (n=68; 40.96%). The most commonly involved region was the lower limb (n=156; 51.82%). The region involved by the injury and the frequency of fracture types varied with the age of the subjects. The frequency distribution of injuries in males and females was almost similar till the age of nine years. The most common injuries of the lower extremity and upper extremities were fracture shaft of the femur and supracondylar fracture of the humerus, respectively.

Conclusion: Our study presents a precise estimate of demography and injury characteristics of pediatric musculoskeletal injuries, which may be helpful in planning and policymaking. The effect of the pandemic on the timeliness of care can be used for improving the infrastructure required to handle future waves of the pandemic.

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.

Inversion Table Fall Injury, the Phantom Menace: Three Case Reports on Cervical Spinal Cord Injury

Background: An inversion device, which is used to suspend one’s body and perform traction therapy, was introduced as an inversion table under the name of “Geokkuri” in South Korea. Fall injuries while hanging on inversion tables are among the most devastating spine injuries, as the likelihood of severe neurological sequelae such as tetraplegia increases. However, its enormous danger has been overlooked and this devastating injury has become a common clinical entity over time. The limited number of studies reported imply the lack of interest of researchers in these injuries. We reviewed three cases of spinal cord injury sustained on inversion tables in different environments and report the potential danger associated with the use of inversion tables to facilitate a safer exercise environment.

Thoracolumbar spinal fractures associated with ground level falls in the elderly: An analysis of 254,486 emergency department visits

STUDY DESIGN

retrospective.

OBJECTIVES

To investigate the epidemiology of elderly (age ≥65 years) patients who presented to the emergency department (ED) in the United States with thoracolumbar (TL) fractures after ground level falls.

METHODS

Using the National Emergency Department Sample database, we queried all ED visits in the United States from 2009 through 2012 of elderly patients who presented after ground level falls. We identified patients who sustained TL fractures with and without neurological injury. Resulting data was used to analyze the fracture prevalence, ED and patient characteristics, associated injuries, treatment patterns, inpatient mortality, and hospital charges.

RESULTS

Of the 6,654,526 ED visits in the elderly for ground level falls, 254,486 (3.8%) were associated with a diagnosis of TL fracture. 39% patients had multiple injuries, and upper extremity fractures were the most common associated injuries. Overall, 55.6% were admitted to the hospital. Of those, 77.7% were treated non-operatively, 20.4% were treated with cement augmentation alone, 1.5% were treated with spinal fusion surgery, and 0.4% were treated with spinal decompression alone. The overall rate of inpatient mortality was 2.14%.

CONCLUSIONS

This investigation evaluated the epidemiology of elderly patients who presented to the ED in the United States with TL fractures after ground level falls. The study demonstrated a rather high incidence of TL fractures in this patient cohort. As a result, it is important for ED physicians and orthopaedic surgeons to be highly suspicious of TL fractures in elderly patients who sustain low energy trauma. With the continued aging of the population and rising health care costs, future effort ought to focus on fall prevention and increased surveillance for TL injuries in the elderly.

Effect of Height of Fall on Mortality in Patients with Fall Accidents: A Retrospective Cross-Sectional Study

Background: Accidental falls are a common cause of injury and deaths. Both ground-level falls (GLF) and non-GLF may lead to significant morbidity or mortality. This study aimed to explore the relationship between height of falls and mortality. Method: This is a retrospective study based on the data from a registered trauma database and included 8699 adult patients who were hospitalized between 1 January 2009 and 31 December 2017 for the treatment of fall-related injuries. Study subjects were divided into three groups of two categories based on the height of fall: GLF (group I: < 1 m) and non-GLF (group II: 1–6 m and group III: > 6 m). The primary outcome was in-hospital mortality. The adjusted odds ratio (AOR) of mortality adjusted for age, sex, and comorbidities with or without an injury severity score (ISS) was calculated using multiple logistic regression. Results: Among the 7001 patients in group I, 1588 in group II, and 110 in group III, patients in the GLF group were older, predominantly female, had less intentional injuries, and had more pre-existing comorbidities than those in the non-GLF group. The patients in the non-GLF group had a significantly lower Glasgow Coma Scale (GCS), a higher injury severity score (ISS), worse physiological responses, and required more procedures performed in the emergency department. The mortality rate for the patients in group I, II, and III were 2.5%, 3.5%, and 5.5%, respectively. After adjustment by age, sex, and comorbidities, group II and group III patients had significantly higher adjusted odds of mortality than group I patients (AOR 2.2, 95% CI 1.64–2.89, p < 0.001 and AOR 2.5, 95% CI 1.84–3.38, p < 0.001, respectively). With additional adjustment by ISS, group II did not have significantly higher adjusted odds of mortality than group I patients (AOR 1.4, 95% CI 0.95–2.22, p = 0.082), but group III patients still had significantly higher adjusted odds of mortality than group I patients (AOR 10.0, 95% CI 2.22–33.33, p = 0.002). Conclusion: This study suggested that patients who sustained GLF and non-GLF were distinct groups of patients, and the height of fall did have an impact on mortality in patients of fall accidents. A significantly higher adjusted odds of mortality was found in the GLF group than in the non-GLF group after adjusting for age, sex, and comorbidities.

Profile and outcome of patients with ground-level falls

BACKGROUND

A ground-level fall is one of the most common modes of injury sustained across all age groups. For older adults, ground level falls can result in multiple injuries and are associated with significant morbidity and mortality.

METHODOLOGY

This retrospective observational study included all patients presenting with fall from a ground level to our emergency department (ED) from January 2018 to December 2018. Demographics, details of incident, severity of injury, and outcome were analyzed.

RESULTS

During the study period, 596 patients with a mean age of 40.9 (standard deviation [SD]: 25.9) years were included in the analysis. A quarter (23%) were aged less than 15 years, while the elderly (>60 years) comprised of 29.5%. Half the patients were triaged as priority 2 (53.8%). The lower limbs (36.6%), upper limbs (23.9%), and face (15.3%) were the body areas that were most commonly injured. The new injury severity score (NISS) was more than 8 in 28% of patients. Multivariate logistic regression analysis showed the elderly (>60 years) to have a higher odds (2.51 95% confidence interval [CI]: 1.57-4.02) of sustaining a fracture of a dislocation. One fifth of the patients (120/596; 20.1%) required hospital admission with only one fatality. Fifteen patients (2.5%) left the hospital against medical advice. Two-thirds (66.3%) required only conservative management, while 19.9% required major surgical intervention.

CONCLUSION

A ground-level fall is a common mode of injury in children (<15 years) and the elderly (>60 years). The extremities and face are the most common areas of the body that are prone to injuries. Age-friendly infrastructure modifications at home, work places, and in public areas for elders and ensuring playground safety for children are the needs of the hour to decrease falls on level ground.

Implementation of new standard operating procedures for geriatric trauma patients with multiple injuries: a single level I trauma centre study

BACKGROUND

The demographic changes towards ageing of the populations in developed countries impose a challenge to trauma centres, as geriatric trauma patients require specific diagnostic and therapeutic procedures. This study investigated whether the integration of new standard operating procedures (SOPs) for the resuscitation room (ER) has an impact on the clinical course in geriatric patients. The new SOPs were designed for severely injured adult trauma patients, based on the Advanced Trauma Life Support (ATLS) and imply early whole-body computed tomography (CT), damage control surgery, and the use of goal-directed coagulation management.

METHODS

Single-centre cohort study. We included all patients ≥65 years of age with an Injury Severity Score (ISS) ≥ 9 who were admitted to our hospital primarily via ER. A historic cohort was compared to a cohort after the implementation of the new SOPs.

RESULTS

We enrolled 311 patients who met the inclusion criteria between 2000 and 2006 (group PreSOP) and 2010-2012 (group SOP). There was a significant reduction in the mortality rate after the implementation of the new SOPs (P = .001). This benefit was seen only for severely injured patients (ISS ≥ 16), but not for moderately injured patients (ISS 9-15). There were no differences with regard to infection rates or rate of palliative care.

CONCLUSIONS

We found an association between implementation of new ER SOPs, and a lower mortality rate in severely injured geriatric trauma patients, whereas moderately injured patients did not obtain the same benefit.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03319381, retrospectively registered 24 October 2017.

Serum Neurofilament Light Is Elevated Differentially in Older Adults with Uncomplicated Mild Traumatic Brain Injuries

Neurofilament light (NF-L) might have diagnostic and prognostic potential as a blood biomarker for mild traumatic brain injury (mTBI). However, elevated NF-L is associated with several neurological disorders associated with older age, which could confound its usefulness as a traumatic brain injury biomarker. We examined whether NF-L is elevated differentially following uncomplicated mTBI in older adults with pre-injury neurological disorders. In a case-control study, a sample of 118 adults (mean age = 62.3 years, standard deviation [SD] = 22.5, range = 18-100; 52.5% women) presenting to the emergency department (ED) with an uncomplicated mTBI were enrolled. All participants underwent head computed tomography in the ED and showed no macroscopic evidence of injury. The mean time between injury and blood sampling was 8.3 h (median [Md] = 3.5; SD = 13.5; interquartile range [IQR] = 1.9-6.0, range = 0.8-67.4, and 90% collected within 19 h). A sample of 40 orthopedically-injured trauma control subjects recruited from a second ED also were examined. Serum NF-L levels were measured and analyzed using Human Neurology 4-Plex A assay on a HD-1 Single Molecule Array (Simoa) instrument. A high correlation was found between age and NF-L levels in the total mTBI sample (r = 0.80), within the subgroups without pre-injury neurological diseases (r = 0.76) and with pre-injury neurological diseases (r = 0.68), and in the trauma control subjects (r = 0.76). Those with mTBIs and pre-injury neurological conditions had higher NF-L levels than those with no pre-injury neurological conditions (p < 0.001, Cohen's d = 1.01). Older age and pre-injury neurological diseases are associated with elevated serum NF-L levels in patients with head trauma and in orthopedically-injured control subjects.

Severe blunt trauma in Finland and Estonia: comparison of two regional trauma repositories

Purpose

Evolving trauma system of Estonia has undergone several reforms; however, performance and outcome indicators have not been benchmarked previously. Thus, we initiated a baseline study to compare demographics, management and outcomes of severely injured patients between Southern Finland and Northern Estonia utilizing regional trauma repositories.

Methods

A comparison of data fields of the Helsinki University Hospital trauma registry (HTR) and trauma registry at the North Estonia Medical Centre in Tallinn (TTR) between 1/1/2015 and 31/12/2016 was performed. The inclusion criterion was Injury Severity Score > 15. Transferred patients, patients with penetrating injuries, and pediatric patients were excluded. The data for comparison included demographics, Trauma Score-Injury Severity Score (TRISS), mortality, and standardized mortality ratio (SMR). Primary outcome was mortality and SMR per TRISS methodology.

Results

During the 2-year study period, 324 patients from the HTR and 152 from the TTR were included. Demographic profile was similar between the repositories with the exception of severe abdominal injuries being more prevalent at the TTR (25.0% vs. 13.3%, p = 0.002). Predominant injury mechanism was non-ground level fall in both repositories. Mortality was similar at 14.5% and 13.6% at the TTR and HTR, respectively (adj. p = 0.762; OR 1.13, 95% CI 0.64–1.99). SMR was lower at the HTR compared to the TTR (0.65 vs. 0.77, p > 0.05), however, the difference did not reach statistical significance.

Conclusion

Benchmarking trauma repositories at a national level provides opportunities for quality and performance improvements. We observed comparable demographic profile and outcome indicators in the compared regional trauma systems.

Severe Injuries from Low-height Falls in the Elderly Population

BACKGROUND

Falls from low-height can cause severe injuries in the elderly population. This study was conducted to determine characteristics of injuries from low-height falls.

METHODS

We retrospectively review surveillance data on injured patients who presented to six emergency departments from January 2011 to December 2015. Study subjects were divided into severe group and non-severe group based on severity of injury. The general and clinical characteristics were compared between the two groups and analyzed factors related with severe injuries.

RESULTS

Of 1,190 elderly patients, severe group comprised 82 patients (7%). The severe group was 2 years younger than the non-severe group. In the severe group, 61% was men and 34% in the non-severe group. In the non-severe, the injuries more commonly occurred at residential facilities and indoors than those in the severe group. Paid work during injury occurrence was 15%, and the more patients presented with non-alert consciousness in the severe group. The most common regions of major injury were head and neck in the severe group.

CONCLUSION

Paid work, non-alert consciousness, and major injury to head and neck are relating factors to severe injuries in the elderly population.

Traumatic brain injury in high versus low falls in young children and adolescents: a retrospective analysis

OBJECTIVE So-called low falls are gaining interest in traumatology. To date, there are no studies on low versus high falls in the pediatric population. The aim of the current analysis was to characterize the symptoms, diagnostics, and injuries associated with high versus low falls and to examine the effect of fall height on injuries and outcome in the context of current guideline-based recommendations. METHODS After obtaining study approval from the local ethics committee, the authors reviewed the data for patients ages 5-17 years who had been consecutively treated at either hospital associated with the University Medical Center Hamburg in the period from January 2009 to August 2014 for diagnoses including traumatic brain injury (TBI). Retrospective analysis of the electronic patient charts was performed to obtain data on demographics; accident mechanism; initial neurological status with respect to consciousness, symptoms, and Glasgow Coma Scale score; radiological studies; diagnoses; length of stay; all intracranial procedures; and Glasgow Outcome Scale (GOS) score. RESULTS Sixty-five fall-related TBIs among 380 patients were identified; 26 patients fell from a height of 3 m or more and 28 fell from a height under 3 m (height undocumented in 11 cases). Patients who fell from ≥ 3 m were 22 times more likely than those who fell from < 3 m to undergo spiral CT studies in the emergency room (p = 0.05). In addition, there was a 7.4 times greater chance of undergoing cranial CT (p = 0.02). There were significantly more noncerebral injuries requiring surgery in patients who fell from ≥ 3 m versus those who fell from < 3 m (p = 0.007). There was no difference in the frequency of neurosurgical procedures performed between low and high groups. Follow-up ranged from 0 to 92 months (mean 12.5 months, median 0 months). There was no significant difference in good (GOS score 4-5) and poor (GOS score 1-3) outcomes between high and low falls (p = 0.208). CONCLUSIONS Low falls can be associated with intracranial hemorrhages requiring ICU monitoring and/or surgery. The authors encourage intensive monitoring and CT scans based on clinical presentation, not on fall height.

Epidemiology of Severely and Fatally Injured Patients in Western Part of Norway

Background and Aims:

Analysis of the injury mechanism and characteristics of severely and fatally injured patients in the western part of Norway.

Material and Methods:

We did a prospective registration of all severely injured patients hospitalized during a three-year period. The files of severely injured patients that died at scene or during transport were retrospectively retrieved from the Forensic Department. A total of 558 patients with an Injury Severity Score > 15 were included.

Results:

Four-hundred-forty-four men (79.6 %) and 114 women (20.4 %) with a median age of 36 and 51.5 years respectively were included. The proportion of female patients older than 80 years were 19.3 % compared to 5.6 % for men. A total of 215 (38.5 %) patients died and 149 (69.3 %) of these patients died on scene or during transport. The incidence of severely injured patients in Hordaland County was 30 per 100 000 inhabitants per year. The incidence was lowest among children below 5 years (7/100 000/year) and highest among persons older than 80 years (95/100 000/year). Men had a 3.8 times greater risk of getting seriously injured compared to women. Road traffic accidents were the cause of the injuries in 235 (42.1%) patients and 35.8% of these patients died. A total of 215 (38.5 %) patients were injured due to falls and 30.2 % of these patients died. Patients who had sustained falls were significantly older than patents with other injury mechanisms (p < 0.001, CI = 13.0–20.2). The proportion of patients with penetrating injuries was 7.3 %.

Conclusion:

The incidence of severely injured patients was 30/100000/year. Men and elderly people had a higher risk of getting severely injured. Falls were the dominating injury mechanism among elderly.

Utility of computed tomographic imaging of the cervical spine in trauma evaluation of ground-level fall

BACKGROUND

Computed tomography (CT) of the cervical spine (C-spine) is routinely ordered for low-risk mechanisms of injury, including ground-level fall. Two commonly used clinical decision rules (CDRs) to guide C-spine imaging in trauma are the National Emergency X-Radiography Utilization Study (NEXUS) and the Canadian Cervical Spine Rule for Radiography (CCR).

METHODS

Retrospective cross-sectional study of 3,753 consecutive adult patients presenting to an urban Level I emergency department who received C-spine CT scans were obtained over a 6-month period. The primary outcome of interest was prevalence of C-spine fracture. Secondary outcomes included fracture stability, appropriateness of imaging by NEXUS and CCR criteria, and estimated radiation dose exposure and costs associated with C-spine imaging studies.

RESULTS

Of the 760 patients meeting inclusion criteria, 7 C-spine fractures were identified (0.92% ± 0.68%). All fractures were identified by NEXUS and CCR criteria with 100% sensitivity. Of all these imaging studies performed, only 69% met NEXUS indications for imaging (50% met CCR indications). C-spine CT scans in patients not meeting CDR indications were associated with costs of $15,500 to $22,000 by NEXUS ($14,600-$25,600 by CCR) in this single center during the 6-month study period.

CONCLUSION

For ground-level fall, C-spine CT is overused. The consistent application of CDR criteria would reduce annual nationwide imaging costs in the United States by $6.8 to $9.6 million based on NEXUS ($6.4-$15.6 million based on CCR) and would reduce population radiation dose exposure by 0.8 to 1.1 million mGy based on NEXUS (0.7-1.9 million mGy based on CCR) if applied across all Level I trauma centers. Greater use of evidence-based CDRs plays an important role in facilitating emergency department patient management and reducing systemwide radiation dose exposure and imaging expenditures.

LEVEL OF EVIDENCE

Diagnostic study, level III.

Impact of age on the clinical outcomes of major trauma

PURPOSE

In view of demographic changes over the past few decades, the average age of trauma patients is progressively increasing. We therefore aimed to summarize the specific characteristics of geriatric trauma and to identify potential fields for further research to improve the care of elderly trauma patients.

METHODS

Review of the literature.

RESULTS

Due to the diverse risk factors (e.g., pre-existing conditions, limited physiological reserve), geriatric patients are prone to developing severe complications, even after less severe trauma. Yet, age is not considered as the only predictor of worse outcomes, and it should not be considered the only criterion for limiting care in those patients. It is crucial that age-specific treatment guidelines are developed to optimize the outcomes for senior trauma patients. Based on the current literature, these guidelines should emphasize the importance of field triage directly to a trauma center, along with the activation of the trauma team. Furthermore, early intensive monitoring, aggressive resuscitation, and time of surgical intervention are of upmost importance to reduce mortality.

CONCLUSION

The impact of several factors [age, premedical conditions (PMC), decreased physiological reserves, and impaired immune function] on the post-traumatic course of elderly trauma patients needs to be clarified in future experimental and clinical studies for the early identification of geriatric high-risk patients and for the development of age-adapted therapeutic strategies.

Managing older adults with ground-level falls admitted to a trauma service: the effect of frailty

OBJECTIVES

To determine whether frail elderly adults are at greater risk of fracture after a ground-level fall (GLF) than those who are not frail.

DESIGN

Prospective observational study.

SETTING

Level 1 trauma center.

PARTICIPANTS

All elderly (≥65) adults presenting after a GLF over 1 year (N = 110; mean age ± SD 79.5 ± 8.3, 54% male).

MEASUREMENT

A Frailty Index (FI) was calculated using 50 preadmission frailty variables. Participants with a FI of 0.25 or greater were considered to be frail. The primary outcome measure was a new fracture; 40.1% (n = 45) of participants presented with a new fracture. The secondary outcome was discharge to an institutional facility (rehabilitation center or skilled nursing facility). Multivariate logistic regression was performed.

RESULTS

Forty-three (38.2%) participants were frail. The median Injury Severity Score was 14 (range 9-17), and the mean FI was 0.20 ± 0.12. Frail participants were more likely than those who were not frail to have fractures (odds ratio (OR) = 1.8, 95% confidence interval (CI) = 1.2-2.3, P = .01). Thirty-six (32.7%) participants were discharged to an institutional facility. Frail participants were more likely to be discharged to an institutional facility (OR = 1.42, 95% CI = 1.08-3.09, P = .03) after a GLF.

CONCLUSION

Frail individuals have a higher likelihood of fractures and discharge to an institutional facility after a GLF than those who are not frail. The FI may be used as an adjunct for decision-making when developing a discharge plan for an elderly adult after a GLF.

Ground-level geriatric falls: a not-so-minor mechanism of injury

Introduction. Ground-level falls are typically regarded as a minor mechanism of injury that do not necessitate trauma team activation; however, they represent a significant proportion of hospitalised trauma and can result in multisystem injury. Case Presentation. A 79-year-old nursing home resident was brought to the emergency department following an unwitnessed fall. She suffered dementia and had a seizure in the department resulting in a reduced GCS, making history and examination difficult. She was diagnosed with a right proximal humerus fracture and admitted under joint orthopedic and medical care. Following orthopedic review, further X-rays were requested which showed bilateral neck of femur fractures. The following day she had bilateral hip hemiarthroplasties and K-wire stabilisation of the right shoulder. Several days later, when cognition had improved, she was noted to be avoiding use of the left arm and was found to also have a left proximal humerus fracture which was managed conservatively. Conclusion. Trauma patients with reduced cognitive function should undergo full ATLS assessment, and a prospective trial is required to see if age should be incorporated as a criteria for trauma team activation. More liberal use of advanced imaging such as a full body CT-scan may be beneficial.

Advancing age and trauma: triage destination compliance and mortality in Victoria, Australia

OBJECTIVE

To describe the association between increasing age, pre-hospital triage destination compliance, and patient outcomes for adult trauma patients.

METHODS

A retrospective data review was conducted of adult trauma patients attended by Ambulance Victoria (AV) between 2007 and 2011. AV pre-hospital data was matched to Victorian State Trauma Registry (VSTR) hospital data. Inclusion criteria were adult patients sustaining a traumatic mechanism of injury. Patients sustaining secondary traumatic injuries from non-traumatic causes were excluded. The primary outcomes were destination compliance and in-hospital mortality. These outcomes were evaluated using multivariable logistic regression.

RESULTS

There were 326,035 adult trauma patients from 2007 to 2011, and 18.7% met the AV pre-hospital trauma triage criteria. The VSTR classified 7461 patients as confirmed major trauma (40.9%>55 years). Whilst the trauma triage criteria have high sensitivity (95.8%) and a low under-triage rate (4.2%), the adjusted odds of destination compliance for older trauma patients were between 23.7% and 41.4% lower compared to younger patients. The odds of death increased 8% for each year above age 55 years (OR: 1.08; 95% CI: 1.07, 1.09).

CONCLUSIONS

Despite effective pre-hospital trauma triage criteria, older trauma patients are less likely to be transported to a major trauma service and have poorer outcomes than younger adult trauma patients. It is likely that the benefit of access to definitive trauma care may vary across age groups according to trauma cause, patient history, comorbidities and expected patient outcome. Further research is required to explore how the Victorian trauma system can be optimised to meet the needs of a rapidly ageing population.

Characteristics and costs of ditch-related injuries: a report from a single emergency center in Okayama

Aim

This study was designed to identify the incidence, injury patterns, and financial burden of ditch-related injuries to provide a reference for establishing guidelines on the prevention of such injuries.

Methods

A retrospective chart review in a tertiary care hospital in Okayama city, Japan, focused on patients injured following a ditch-related fall and requiring intensive care between April 2012 and August 2013. Analysis was carried out to describe the epidemiology of ditch-related injuries.

Results

Thirteen patients (median age, 60 years) met the inclusion criteria. The median time lag between the fall and rescue was approximately 1.5 h. Ten patients were injured in residential areas, and three were injured in rural areas. Eight patients were riding a bicycle at the time of the accident. Head and spine injuries predominated, although there were two cases of drowning, of which one died. The injury severity score ranged from 1 to 50 (mean, 17.8 ± 13). At the time of discharge from the intensive care unit, 6, 4, and 1 patients were classified into cerebral performance categories 1, 3, and 4, respectively. There were two in-hospital deaths, resulting in a case fatality rate of 15.3%. The total cost during the review period was ¥27,572,630, with a mean cost of ¥2,120,971 per patient.

Conclusion

Ditch-related injuries are associated with a high rate of poor neurological outcome and pose a financial burden on the health insurance system. Injury prevention efforts directed at decreasing the risk of ditch-related falls are required to minimize these outcomes.

Characteristics of intentional fall injuries in the ED

INTRODUCTION

This study was conducted to examine the characteristics of intentional fall injuries and the factors associated with their prognosis.

METHODS

The study included 8992 patients with unintentional falls from a height (nonintentional group) and 144 patients with intentional falls from a height (intentional group). General and clinical characteristics were compared between the 2 groups. Intentional fall cases were divided into severe and nonsevere groups, and the factors associated with severe injury were evaluated by comparing these groups.

RESULTS

The most common age group was younger than 14 years in the nonintentional group and between 30 and 44 years old in the intentional group. For the nonintentional group, 65% of the patients were male, and 48% were male in the intentional group. Fall heights of more than 4 m were most common in the intentional group. Discharge was the most common result in the nonintentional group; however, death before arrival at the emergency department (ED) or during ED treatment occurred in 54.9% of patients in the intentional group. In the severe injury group within the intentional group, patients were older, and the height of the fall was higher. Factors associated with severe injury in the intentional group included being a high school graduate rather than a college graduate and greater fall height.

CONCLUSION

The risk of severe injury increased with fall height in the intentional group, and a high school level of education rather than a college level of education was associated with more severe injury.

Lower extremity fractures in falls

INTRODUCTION

Lower extremity fractures are very common in victims of falls. These fractures are usually associated with other bodily injuries and can lead to permanent disability if appropriate management is not provided. The aim of this study was to evaluate the incidence and outcomes of associated injuries in victims of falls with lower extremity fractures.

METHODS

This is a retrospective review (1995-2006) of all fall-related trauma patients evaluated at our Level I trauma center. Injuries were categorized as: isolated femur fractures (FF), isolated tibia fractures (TF), and both femur and tibia fractures (FTF). Data were analyzed for differences in patterns of injury, associated fractures and injuries, and mortality and morbidity according to age groups within patients with minor body injuries expressed by Abbreviated Injury Score (AIS) < 3.

RESULTS

Three hundred and thirty-two patients (64.8 %) had FF, 164 patients (32 %) had TF, and 16 patients (3.2 %) presented with FTF. The incidence of severe trauma was 9.4 % (Injury Severity Score, ISS > 25). A higher incidence of ISS > 25 was observed in patients with FF. Increased mortality was observed in the elderly group, especially in patients with an isolated femur fracture.

CONCLUSION

Patients with a combination of femur and tibia fractures have a significantly higher risk of associated injuries compared to patients with either a femur or a tibia fracture. Elderly patients (≥65 years of age) have higher morbidity and mortality compared to younger patients after falls. Clinicians evaluating these patients should be aware of these injury patterns. Further studies assessing the impact of age and pattern of injury in patients following falls are warranted.

Acute assessment of brain injuries in ground-level falls

OBJECTIVE

The purpose of this study was to characterize traumatic brain injuries (TBI) sustained in ground-level falls (GLFs). The focus was on factors associated with acute computed tomographic (CT) findings.

METHODS

The sample included 575 subjects examined and treated at the Tampere University Hospital emergency department (ED). Retrospective data collection consisted of subject- and injury-related data and clinical information from the emergency department. All CT scans were analyzed and systematically coded.

RESULTS

Ground-level falls were the mechanism of injury in 48.3% (n = 278) of the subjects. In the GLF group, independent risk factors for acute traumatic CT findings were long-term alcohol abuse, older age, being found on the ground, and left temporoparietal and occipital location of direct head impact. There were no significant differences in the incidence of any intracranial traumatic lesion type between those with GLFs and other causes of TBI. None of the classic clinical TBI severity markers studied were associated with acute traumatic CT findings in patients with GLFs.

CONCLUSIONS

Older age and long-term alcohol abuse increase the likelihood of acute intracranial CT abnormalities. The pattern of intracranial traumatic CT findings does not differ from other causes of TBI. Clinical signs and indices of TBI severity did not predict traumatic CT findings.

Correlation between pattern and mechanism of injury of free fall

To define the pattern of injury and aetiology of death of patients who have sustained major trauma due to high fall and its relationship with the mechanism of free fall. A total of 188 consecutive patients who sustained a high fall were included after the TRAUMASUR database was retrospectively reviewed. Demographic characteristics, severity scores, injury type, aetiology of high fall, mortality rate and aetiology of death were analysed. The mean age was 39.7 years (SD 15.5). The main aetiologies were work related (40.4 %) and suicide attempt (22.3 %). The mean injury severity score (ISS) and New Injury Severity Score (NISS) were 27.3 and 34.1, respectively. The most common cause of mortality within the intentional group was exsanguination (66 %), and the most frequent aetiology of death within the non-intentional group was endocranial hypertension (69 %). Differences were found with regard to the pattern of injuries and the aetiology of death according to the mechanism of free fall.

Development of statewide geriatric patients trauma triage criteria

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Ground level falls are associated with significant mortality in elderly patients

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

[Injury severity and pattern at the scene. What is the influence of the mechanism of injury?]

BACKGROUND

The mechanism of injury is the major cause for trauma team activation and emergency room resuscitation of trauma victims. To date, it remains unclear to what extent the injury mechanism influences injury pattern and severity.

METHODS

A comprehensive systematic literature search based on Medline was carried out.

RESULTS

Only a limited number of studies are available which investigated the influence of injury mechanisms on injury patterns and severity. There are no specific mechanisms for traumatic brain and spine injuries. Injuries to the chest and abdomen most frequently resulted from motor vehicle accidents involving passengers sitting on the side of the impact. Steering wheel deformity correlated with the injury severity. Pelvic fractures occurred most frequently due to motor vehicle accidents. The highest mortality resulted from pedestrians being struck by a vehicle and additional loss of life in the same vehicle compartment.

CONCLUSIONS

The systematic literature research showed inconsistent results regarding the influence of trauma mechanisms on the resulting injury. Therefore, a treatment algorithm for trauma patients should be independent of the mechanism which is represented in several training programs (e.g. ATLS and PHTLS). However, the mechanism of injury may increase the alertness of the trauma team with respect to injury distribution and severity.

Impact of falls on early mortality from severe traumatic brain injury

BACKGROUND

The causes of severe traumatic brain injury (TBI) vary by age and other demographic characteristics. Mortality after trauma is higher for elderly than younger patients. This study is based on 2779 patients with severe TBI treated at 24 trauma centers enrolled in a New York State quality improvement program. The prospectively collected database includes information on age, sex, mechanism of injury, initial Glasgow Coma Scale score, blood pressure, pupillary assessment, and CT scan findings. This multi-center study was conducted to explore the impact of falls on early mortality from severe TBI among the elderly.

RESULTS

After exclusion criteria were applied, a total of 2162 patients were eligible for analysis. Falls contributed to 21% of all severe TBI, 12% occurring from > 3 meters and 9% from < 3 meters. Two-week mortality ranged from 18% due to injuries other than falls to 31% due to falls from < 3 meters (p =< 0.0001). Mortality after a severe TBI is much greater among older people, reaching 58% for people 65 years and older sustaining a fall from < 3 meters.

CONCLUSION

Among those 65 and older, falls contributed to 61% of all injuries and resulted in especially high mortality among individuals experiencing low falls. Preventive efforts directed toward older people to avoid falls from < 3 meters could have a significant impact on mortality.

The effects of trauma center care, admission volume, and surgical volume on paralysis after traumatic spinal cord injury

OBJECTIVE

To evaluate compliance with American College of Surgeons (ACS) guidelines and whether trauma center designation, hospital traumatic spinal cord injury (TSCI) case volume or spinal surgery volume is associated with paralysis. We hypothesized a priori that trauma center care, by contrast to nontrauma center care, is associated with reduced paralysis at discharge.

SUMMARY BACKGROUND DATA

Approximately 11,000 persons incur a TSCI in the United States annually. The ACS recommends all TSCI patients be taken to a level I or II trauma center.

METHODS

We studied 4121 patients diagnosed with TSCI by ICD-9-CM criteria in the 2001 hospital discharge files of 7 states (Florida, Massachusetts, New Jersey, New York, Texas, Virginia, Washington), who were treated in 100 trauma centers and 601 nontrauma centers. We performed multivariate analyses, including a propensity score quintile approach, adjusting for differences in case mix and clustering by hospital and by state. We also studied 3125 patients using the expanded modified Medicare Provider Analysis and Review records for the years 1996, 2001, and 2006 to assess temporal trends in paralysis by trauma center designation.

RESULTS

Mortality was 7.5%, and 16.3% were discharged with paralysis. Only 57.9% (n = 2378) received care at a designated trauma center. Trauma centers had a 16-fold higher admission caseload (20.7 vs. 1.3; P < 0.001) and 30-fold higher surgical volume (9.6 vs. 0.3; P < 0.001). In the multivariate propensity analysis, paralysis was significantly lower at trauma centers (adjusted odds ratio 0.67; 95% confidence interval, 0.53-0.85; P = 0.001). Higher surgical volume, not higher admission volume, was associated with lower risk of paralysis. Indeed, at nontrauma centers, higher admission caseload was associated with worse outcome. There was no significant difference in mortality.

CONCLUSIONS

Trauma center care is associated with reduced paralysis after TSCI, possibly because of greater use of spinal surgery. National guidelines to triage all such patients to trauma centers are followed little more than half the time.

The Value of the Trauma Mechanism in the Triage of Severely Injured Elderly

BACKGROUND

The triage of trauma patients is currently based on the trauma mechanism. However, it is known that elderly patients can sustain severe injuries due to insignificant trauma mechanisms. As such, triage methods might be questionable.

OBJECTIVE

To evaluate whether current trauma triage criteria are appropriate in severely injured elderly patients.

METHODS

To analyze the effect of the trauma mechanism on triage and treatment, consecutive patients ≥ 55 years of age, with an injury severity score > 15, treated from 2002 to 2005 were divided into those who sustained a high-energy trauma (HET) versus a low energy trauma (LET). Pre-hospital and in-hospital data, injury characteristics, and data on mortality and disablement one year postinjury (sickness impact profile) were analyzed for HET and LET groups.

RESULTS

Age, sex and co-morbidity rate were similar in 84 HET patients and 107 LET patients. HET patients (mean ISS 28) received more sophisticated trauma care than LET patients (mean ISS 22), although mortality was similar (38 vs. 34%). Long-term disablement was also similar (median SIP scores 4 vs. 6). Severe head injuries and the Revised Trauma Score were related to mortality. Physical disablement was related to preexisting co-morbidities. No variables were related to psychosocial disablement.

CONCLUSIONS

In elderly people a low energy trauma may lead to severe consequences. Not only the trauma mechanism, but also age, co-morbidity, and the likelihood of a brain injury should be leading in the triage and subsequent management of severely injured elderly.

Head injury mortality in a geriatric population: differentiating an "edge" age group with better potential for benefit than older poor-prognosis patients

A comparison of outcomes between different modes of head-injury treatment in the elderly has important bearing on questions of cost-effectiveness and medical ethics. Here, we have examined rates of mortality in elderly head-trauma victims to determine whether it is valid to differentiate an "edge" age group of younger elderly patients, 65-74 years of age, from older elderly patients, considering possible benefit from intensive treatment and surgical intervention. We collected data from 1926 cases of head trauma and separated them into three age groups: 14-64 years, 65-74 years, and 75 years or older. We then compared these groups with respect to cause of injury, severity of injury, and whether or not treatment included either admission to an Intensive Care Unit (ICU) or surgical intervention. We found that road traffic accidents were the major cause of head injury in the younger age group, whereas in the elderly falls predominated. Mortality was higher in the elderly in all the head injury severity subgroups. Young subjects with a Glasgow Coma Scale (GCS) score of less than or equal to 8 tended to benefit from ICU treatment whereas patients 75 and over did not, regardless of their severity of injury. For these patients who were in the 65-74 age group, the data suggested that some benefit was likely. Patients 75 and older were significantly less likely to survive surgical intervention than younger patients. We conclude that it is valid to treat patients in the age group 65-74 years as a separate group from those patients 75 and older. Patients in this younger subset of the elderly may benefit from ICU treatment or surgical intervention. However, the patients in our older subset of elderly patients clearly did not, and they had a significantly higher risk of surgical mortality.

Epidemiology of geriatric trauma in United Arab Emirates

The mechanisms and outcome of trauma in hospitalized elderly patients were studied. The data of Al-Ain Hospital Trauma Registry were prospectively collected over a period of 3 years (2003-2006). All elderly trauma-patients above 60 years who were admitted to surgical ward or who died on arrival were studied. Demography of patients, mechanism of injury, Injury Severity Score (ISS), hospital stay and mortality were analyzed. There were 121 patients (70 males and 51 females). Mean (range) age was 69 years (60-100), 42% were United Arab Emirates (UAE) nationals. The two most common mechanisms of injury were falls (55%) followed by road traffic collisions (RTC) (32%). The median (range) ISS of the group was 5 (1-34). The ISS median (interquartile range) of falling down, RTC, and fall from height were 4 (4-9), 6 (4-10), and 8 (5-9), respectively (p=0.31). Forty-one percentage of injuries occurred at home. The mean (range) hospital stay was 12.4 (1-150) days. Six patients (5%) were admitted to the intensive care unit. Overall mortality was 6% (7 patients), of whom 5 were pedestrians hit by cars. We concluded that low-energy trauma from falls was the most common cause of injury in the elderly. Mortality was high mainly from pedestrian injuries.

Geriatric neurologic emergencies

Geriatrics is an important subspecialty within the field of emergency medicine and represents a burgeoning area of practice. The special vulnerability of elderly patients to neurologic disease and injury and the comparative subtlety of clinical presentation mean that physicians should have a lower threshold for laboratory studies, radiologic imaging, consultation, and admission. Transferring appropriate patients to tertiary centers that offer specialized trauma and neurologic and neurosurgical care greatly enhances survival and functional outcomes.

Epidemiology of blunt head injury victims undergoing ED cranial computed tomographic scanning

STUDY OBJECTIVE

We sought to describe the epidemiology of emergency department (ED) patients with blunt head injury undergoing cranial computed tomography (CT) scanning for the evaluation of possible traumatic brain injury (TBI).

METHODS

Prospective, multicenter, observational study of ED patients undergoing cranial CT after blunt head injury. Patient's date of birth, sex, and race/ethnicity were documented before CT scanning. Individual patients were considered to have "significant" TBI if the official radiographic interpretation at the end of all imaging studies associated with the trauma was consistent with any of a set of predefined diagnoses. The relative prevalence of TBI among various prespecified groups from those undergoing cranial CT scanning was also calculated.

RESULTS

Of 13728 patients who were enrolled, 8988 (65%) were men and 1193 (8.7%) had a significant acute TBI. Demographic findings associated with increased risk of TBI, among patients selected for scanning, included the following: age below 10 years (relative risk [RR] = 1.44, 95% confidence interval [CI], 1.19-1.77); age above 65 years (RR = 1.59; 95% CI, 1.40-1.80), and male sex (RR = 1.27; 95% CI, 1.30-1.43).

CONCLUSION

Among patients selected for cranial CT scanning after blunt head injury, men, patients younger than 10 years, and those older than 65 years have an increased likelihood of significant TBI.

A Simple Fall in the Elderly: Not So Simple

BACKGROUND

The goal of this study was to evaluate the burden of falls in the elderly in a Canadian tertiary trauma center.

METHODS

Patients admitted to Charles-LeMoyne Hospital with a low velocity fall (LVF) from April 1, 1993 to March 31, 2000 were individually reviewed. Elderly was defined as age 65 years and older. A region was considered to be injured if Abbreviated Injury Scale was greater than or equal to 2.

RESULTS

There were 2,333 patients with LVF, 41.4% of all blunt trauma admissions. Median Injury Severity Score was 9 for elderly compared with 5 for young (p < 0.001). Injuries were significantly more frequent to head, face, thorax, and lower limbs in the elderly. Mortality (13.4% versus 0.9%; p < 0.001), length of stay (median = 15 versus 3 days; p < 0.001) and long-term care facility reference (19.3% versus 1.1%, p < 0.001) were significantly higher in the elderly.

CONCLUSIONS

LVF is a frequent cause of admission for trauma in the elderly. Despite the apparent benign nature of the mechanism, LVF is associated with more severe injuries and worse outcome.

Is trauma centre care helpful for less severely injured patients?

BACKGROUND

Trauma centres have been shown to reduce the number of preventable deaths from serious injuries. This is due largely to the rapid response of surgeons and health care teams to resuscitate, evaluate, and operate if necessary. Less is known about the effectiveness of trauma centre care on those patients who have not incurred immediate life-threatening problems and may not be as critically injured. The purpose of this study was to review the use of physician and hospital resources for this patient population to determine whether trauma team and trauma centre care is helpful or even needed.

METHODS

This was a retrospective study of consecutive trauma patients (n=1592) admitted from 1998 to 2002 to the trauma service of an urban level I trauma centre and recorded in the hospital trauma registry. Patients were triaged in a tiered response to more or less severely injured. All patients' care was directed by trauma surgeons.

RESULTS

Of the 1592 patients, 398 (25%) received a full trauma team response (Class I), 1194 were less seriously injured (Class II). The ISS for the Class I patients was 19+/-18 and for Class II patients 10+/-10. Nineteen percent of Class II patients had an ISS>15. Overall mortality in Class II patients was 2% including 20 unexpected deaths. Four hundred and three Class II patients (34%) had multisystem injuries. Of the Class II patients 423 (35%) were sent to the ICU or OR from the ED, 106 of whom required an immediate operation and 345 required an operation prior to discharge. Complications developed in 129 patients (11%), the majority of which were pulmonary.

CONCLUSIONS

A large proportion of those patients thought initially to be less severely injured required resources available in a trauma centre, including specialty care, intensive care, and operating room accessibility. Over one-third of these patients had multisystem injuries and almost 20% were considered major trauma, needing prioritisation of care and expertise ideally found in a trauma centre environment. Complications developed in a sizable number of patients. This patient population, because of its heterogeneity and propensity for critical illness, deserves the resources of a trauma centre.

Should Patients with Isolated Hip Fractures Be Included in Trauma Registries?

BACKGROUND

Patients with isolated hip fractures are frequently excluded from trauma registries. The goal of this study was to show that patients with these injuries have higher resource use and poorer outcomes than the rest of the trauma population.

METHODS

The Quebec Trauma Registry was used to identify all trauma patients from April 1, 1998, to March 31, 2003. Patients who were dead on arrival at the emergency room were excluded. Isolated hip fracture (HIP) was defined as a diagnosis of a single fracture to the neck of the femur (Abbreviated Injury Scale 1990 codes 851808.3, 851810.3, 851812.3, and 851818.3) secondary to a fall and for which the Injury Severity Score was 9 or 10 (no other Abbreviated Injury Scale code higher than 1). Patients with all other trauma diagnosis (OT) were used for comparison. Outcome variables were length of hospital stay, length of intensive care unit (ICU) stay, in-hospital complications, and status and orientation at discharge. Chi-square and Wilcoxon rank-sum tests were used.

RESULTS

There were 68,422 patients: 14,426 (21.1%) HIP patients and 53,996 (78.9%) OT patients. The median Injury Severity Score was 9 for HIP (range, 9-10) and 9 for OT (range, 1-75). Mean length of hospital stay was 18.4 days for HIP compared with 11.7 days for OT (p < 0.0001). HIP patients represented 29.5% of the total hospital stay. ICU stay was required for 1,353 HIP patients (9.4%) and for 12,395 (23.0%) OT patients (p < 0.0001). Mean ICU stay was 3.9 days for HIP compared with 5.5 days for OT (p = 0.0006). In-hospital mortality was 8.5% in HIP compared with 3.7% in OT (p < 0.0001). HIP represented 62.7% of patients referred for long-term care and 39.3% of patients referred to a rehabilitation center.

CONCLUSION

Patients with HIP represented 21.1% of admissions while accounting for 42% of total days of hospitalization and 38% of deaths. Patients with hip fractures have a significantly higher risk of death, prolonged hospital stay, and complication rate, and are more often transferred to a rehabilitation center or to a long-term nursing home than the rest of the trauma population despite lower severity. They require multidisciplinary care typical of the rest of the trauma population and should be included in the trauma registry if the registry is to document the full outcome and resource use of the trauma population.