Practice management guidelines for geriatric trauma: the EAST Practice Management Guidelines Work Group

Geriatric Trauma Intensive Care Unit Admission Guideline is Associated With Reduction in Unplanned Intensive Care Unit Admissions

INTRODUCTION

Geriatric trauma patients experience disproportionate adverse outcomes compared to younger patients with similar injuries and represent an important target for quality improvement. Our institution created a Geriatric Trauma Intensive Care Unit (ICU) Admission Guideline to identify high-risk patients and elevate their initial level of care. The goal of implementation was reducing unplanned ICU admissions (UIAs), a recognized surrogate marker for adverse outcomes.

METHODS

The Geriatric Trauma ICU Admission Guideline was implemented on July 1, 2020, at a large academic level-1 trauma center. Using trauma registry data, we retrospectively analyzed geriatric patients who met the criteria for ICU admission 2 y preimplementation and postimplementation. The main outcome was UIAs in the target geriatric population. Secondary outcomes included hospital length of stay, ICU length of stay, ventilator days, mortality, and 30-d readmissions. Characteristics between groups were compared with t-test, Mann-Whitney U test, or chi-square test. Risk-adjusted logistic and negative binomial regressions were used for the categorical and continuous outcomes, respectively.

RESULTS

A total of 1075 patients were identified with 476 in the preimplementation and 599 in the postimplementation group. The groups were similar across most demographic and physiologic characteristics, with the exception of a higher incidence of hypertension in the preimplementation group (77.7% versus 71.6%, P = 0.02) and COVID in the postimplementation group (3.8% versus 0.4%, P < 0.001). While mechanism of injury was similar, there was a higher incidence of traumatic brain injury in the preimplementation group (35.1% versus 26.2%, P = 0.002). In the postimplementation group, there was a higher incidence ≥3 rib fractures (68% versus 61.3%, P = 0.02) and an expected increase in initial ICU level of care (69.5% versus 37.1%, P < 0.001). The odds of a UIA after guideline implementation were reduced by half (adjusted odds ratio 0.52, 95% confidence interval 0.3-0.92). There was not a significant difference in the secondary outcomes of mortality, 30-d readmission, hospital-free days, ICU-free days, or ventilator-free days.

CONCLUSIONS

Implementation of the Geriatric Trauma ICU Admission Guideline was associated with a reduction in UIAs by half in the target population. There was not a significant change in hospital-free days, ICU-free days, ventilator-free days, mortality, 30-d readmission, or venous thromboembolism. Further research is needed to better refine admission guidelines, examine the association of preventative admission on delirium, and determination of criteria that would allow safe, earlier downgrade.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Geriatric trauma triage: optimizing systems for older adults-a publication of the American Association for the Surgery of Trauma Geriatric Trauma Committee

Background

Geriatric trauma patients are an increasing population of the United States (US), sustaining a high incidence of falls, and suffer greater morbidity and mortality to their younger counterparts. Significant variation and challenges exist to optimize outcomes for this cohort, while being mindful of available resources. This manuscript provides concise summary of locoregional and national practices, including relevant updates in the triage of geriatric trauma in an effort to synthesize the results and provide guidance for further investigation.

Methods

We conducted a review of geriatric triage in the United States (US) at multiple stages in the care of the older patient, evaluating existing literature and guidelines. Opportunities for improvement or standardization were identified.

Results

Opportunities for improved geriatric trauma triage exist in the pre-hospital setting, in the trauma bay, and continue after admission. They may include physiologic criteria, biochemical markers, radiologic criteria and even age. Recent Trauma Quality Improvement Program (TQIP) Best Practices Guidelines for Geriatric Trauma Management published in 2024 support these findings.

Conclusion

Trauma systems must adjust to provide optimal care for older adults. Further investigation is required to provide pertinent guidance.

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.

Geriatric Motorcycle-Related Outcomes: A Pennsylvania Multicenter Study

INTRODUCTION

Geriatric patients (GeP) often experience increased morbidity and mortality following traumatic insult and as a result, require more specialized care due to lower physiologic reserve and underlying medical comorbidities. Motorcycle injuries (MCCI) occur across all age groups; however, no large-scale studies evaluating outcomes of GeP exist for this particular subset of patients. Data thus far are limited to elderly participation in recreational activities such as water and alpine skiing, snowboarding, equestrian, snowmobiles, bicycles, and all-terrain vehicles. We hypothesized that GeP with MCCI will have a higher rate of mortality when compared with their younger counterparts despite increased helmet usage.

METHODS

We performed a multicenter retrospective review of MCCI patients at three Pennsylvania level I trauma centers from January 2016 to December 2020. Data were extracted from each institution's electronic medical records and trauma registry. GeP were defined as patients aged more than or equal to 65 y. The primary outcome was mortality. Secondary outcomes included ventilator days; hospital, intensive care unit, and intermediate unit length of stays; complications; and helmet use. 3:1 nongeriatric patients (NGeP) to GeP propensity score matching (PSM) was based on sex, abbreviated injury scale (AIS), and injury severity score (ISS). P ≤ 0.05 was considered significant.

RESULTS

One thousand five hundred thirty eight patients were included (GeP: 7% [n = 113]; NGP: 93% [n = 1425]). Prior to PSM, GeP had higher median Charlson Comorbidity Index (GeP: 3.0 versus NGeP: 0.0; P ≤ 0.001) and greater helmet usage (GeP: 73.5% versus NGeP: 54.6%; P = 0.001). There was a statistically significant difference between age cohorts in terms of ISS (GeP: 10.0 versus NGeP: 6.0, P = 0.43). There was no significant difference for any AIS body region. Mortality rates were similar between groups (GeP: 1.7% versus NGeP: 2.6%; P = 0.99). After PSM matching for sex, AIS, and ISS, GeP had significantly more comorbidities than NGeP (P ≤ 0.05). There was no difference in trauma bay interventions or complications between cohorts. Mortality rates were similar (GeP: 1.8% versus NGeP: 3.2%; P = 0.417). Differences in ventilator days as well as intensive care unit length of stay, intermediate unit length of stay, and hospital length of stay were negligible. Helmet usage between groups were similar (GeP: 64.5% versus NGeP: 66.8%; P = 0.649).

CONCLUSIONS

After matching for sex, ISS, and AIS, age more than 65 y was not associated with increased mortality following MCCI. There was also no significant difference in helmet use between groups. Further studies are needed to investigate the effects of other potential risk factors in the aging patient, such as frailty and anticoagulation use, before any recommendations regarding management of motorcycle-related injuries in GeP can be made.

Delta Shock Index and higher incidence of emergency surgery in older adults with blunt trauma

PURPOSE

Vital signs are important for predicting clinical outcomes in patients with trauma. However, their accuracy can be affected in older adults because hemodynamic changes are less obvious. This study aimed to examine the usefulness of changes in vital signs during transportation in predicting the need for hemostatic treatments in older patients with trauma.

METHODS

This retrospective cohort study was conducted using data from the Japan Trauma Data Bank (2004-2019). Patients aged ≥ 65 years who were hemodynamically stable at the scene were included in this study. The incidence of emergency surgery within 12 h after hospital arrival was compared between patients with delta Shock Index (dSI) > 0.1 and those with dSI ≤ 0.1. Predicting ability was examined after adjusting for patient demographics, comorbidities, vital signs at the scene and on hospital arrival, Injury Severity Score, and abbreviated injury scale in each region.

RESULTS

Among the 139,242 patients eligible for the study, 3,701 underwent urgent hemostatic surgery within 12 h. Patients with dSI > 0.1 showed a significantly higher incidence of emergency surgery than those with dSI ≤ 0.1 (871/16,549 [5.3%] vs. 2,830/84,250 [3.4%]; odds ratio (OR), 1.60 [1.48-1.73]; adjusted OR, 1.22 [1.08-1.38]; p = 0.001). The relationship between high dSI and a higher incidence of intervention was observed in patients with hypertension and those with decreased consciousness on arrival.

CONCLUSION

High dSI > 0.1 was significantly associated with a higher incidence of urgent hemostatic surgery in older patients.

Management of the Geriatric Trauma Patient

With a rapidly aging worldwide population, the care of geriatric trauma patients will be at the forefront of every career in Trauma and Acute Care Surgery. The unique intersection of advanced age, comorbidities, frailty, and physiologic changes presents a challenge in the care of elderly injured patients. It is well established that increasing age is associated with higher mortality and worse outcomes after injury, but it is also clear that there is room for improvement in the management of this special patient population.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Trauma in the Geriatric and the Super-Geriatric: Should They Be Treated the Same?

INTRODUCTION

There is paucity of studies comparing the characteristics of trauma in geriatrics and super-geriatrics. We aimed to explore the injury characteristics and outcomes of older adult trauma patients on a nationwide scale.

METHODS

This is a retrospective analysis of 2017-2019 American College of Surgeons Trauma Quality Improvement Program. We included moderate to severely injured (Injury Severity Score >8) older adult (≥65 y) trauma patients. Patients were stratified into geriatric (65 y ≤ Age <80 y) and super-geriatric (Age ≥80 y). Outcomes included interventions, complications, failure-to-rescue, withdrawal of support treatment, and mortality.

RESULTS

We identified 269,208 patients (geriatric = 57%; super-geriatric = 43%). Both groups had similar vital signs and Injury Severity Score (geriatric = 9[9-12] versus super-geriatric = 9[9-11]). The super-geriatric were more likely to have falls (71% versus 89%, P < 0.001), while the geriatric were more likely to have Motor vehicle collision (17% versus. 7%, P < 0.001). On multivariate analyses, geriatric patients were more likely to be treated at a Level I Trauma Center (adjusted Odds Ratio [aOR] = 1.1, P < 0.001), undergo hemorrhage control surgery (aOR = 1.5, P < 0.001), be admitted to the intensive care unit (aOR = 1.15, P < 0.001), or intubated (aOR = 1.4, P < 0.001). However, they were less likely to have withdrawal of support treatment (aOR = 0.37, P < 0.001) compared to the super-geriatric. Furthermore, geriatric patients were more likely to develop major complications (aOR = 1.08, P < 0.01). However, they had lower odds of failure-to-rescue (aOR = 0.69, P < 0.001) and in-hospital mortality (aOR = 0.56, P < 0.001) compared to the super-geriatric.

CONCLUSIONS

Significant differences exist in injury patterns, interventions, and outcomes between the geriatric and super-geriatric. Future studies and guidelines may need to classify older adults into geriatric and super-geriatric categories to facilitate tailored care and overall improvement of management strategies for older populations.

Design and Development of an Objective Evaluation System for a Web-Based Simulator for Trauma Management

BACKGROUND

Trauma injuries are one of the main leading causes of death in the world. Training with guidelines and protocols is adequate to provide a fast and efficient treatment to patients that suffer a trauma injury.

OBJECTIVES

This study aimed to evaluate deviations from a set protocol, a new set of metrics has been proposed and tested in a pilot study.

METHODS

The participants were final-year students from the Universidad Autónoma de Madrid and first-year medical residents from the Hospital Universitario La Paz. They were asked to train four trauma scenarios with a web-based simulator for 2 weeks. A test was performed pre-training and another one post-training to evaluate the evolution of the treatment to those four trauma scenarios considering a predefined trauma protocol and based on the new set of metrics. The scenarios were pelvic and lower limb traumas in a hospital and in a prehospital setting, which allow them to learn and assess different trauma protocols.

RESULTS

The results show that, in general, there is an improvement of the new metrics after training with the simulator.

CONCLUSION

These new metrics provide comprehensive information for both trainers and trainees. For trainers, the evaluation of the simulation is automated and contains all relevant information to assess the performance of the trainee. And for trainees, it provides valuable real-time information that could support the trauma management learning process.

Age and sex differences in blood product transfusions and mortality in trauma patients at a level I trauma center

Objectives

Hemorrhage is a common complication of trauma. We evaluated age and sex differences in treatment with blood product transfusions and massive transfusions as well as in-hospital mortality following trauma at a Level 1 Trauma Center.

Methods

This cross-sectional study evaluated trauma data from a Level 1 trauma center registry from January 2013 to December 2017. The primary outcome was amount of blood products (packed red blood cells (PRBCs), plasma, platelets), and massive transfusion (MT) by biological sex and by age group: 16-24 (youth), 25-59 (middle age), and >=60 (older age) The secondary outcome was in-hospital mortality to hospital discharge.

Results

There were 13596 trauma patients in the registry, mean age was 48 years, 4589 (34%) female and 9007 (66%) male, and median ISS of 9. Male patients received significantly more PRBC transfusions than female patients within 4-hours 6.6% vs 4.4%, and 24-hours 6.7% vs 4.5% respectively. Older patients received significantly fewer PRBC transfusions within 4-hours and 24-hours than their younger counterparts, with 6.9% in the youth group, 6.8% in the middle age group, and 3.9% in the older group (p<0.001). When adjusted for injury severity, the odds of receiving a blood transfusion within 4 hours of injury was significantly lower in older females. Using multivariate analysis, predictors of mortality included (in order of significance) injury severity, older age, transfusion within 4 hours of injury, penetrating trauma, and male sex.

Conclusion

In this large trauma cohort, older female trauma patients were less likely to receive blood products compared to younger females and to their older male counterparts, even after adjusting for injury severity. Predictors of mortality included injury severity, older age, early transfusion, penetrating trauma, and male sex. Following trauma, older women appear vulnerable to undertreatment. Further study is needed to determine the reasons for these differences and their impact on patient outcomes.

The process of identifying major trauma in the older person in a single major trauma centre: A service evaluation

BACKGROUND

Diagnosis of major trauma in the older person is increasingly recognised as clinically challenging with recent reports finding that older patients sustaining major trauma are commonly under-recognised and subsequently are not receiving gold standard major trauma care. This paper is a service evaluation of the processes of major trauma (ISS > 15) care for patients > 65 years presenting to a UK major trauma centre.

AIM

To identify modifiable factors within the patient journey that might inform future service improvement initiatives.

METHODS

TARN audit data and retrospective notes review of 190 patients > 65 presenting to UHS ED from 1st January 2018 - 31st December 2018 who did not receive a level 1 trauma call on arrival were used to achieve the dataset. Descriptive statistics were combined with multiple logistic regression to look for associations between specific process factors and a missed or delayed diagnosis.

RESULTS

The evaluation found that, of the cohort not receiving a level 1 trauma call, 42 (22.1%) patients received a level 2 trauma call; 87 (45.7%) patients were seen initially by a senior clinician, with only 31 (16.3%) patients meeting best practice tariff for consultant within 5 min; 60 (31.5%) patients were seen directly in the resuscitation room; 48 (25.2%) patients received a trauma CT scan with only 27 (14.2%) meeting BPT for CT head within 1 h; 142 (74.7%) patients were admitted to a trauma specialty after discharge from ED. A total of 76 (40%) patients had a missed diagnosis of major trauma with 80 (42%) having a delayed diagnosis. Logistic regression showed a significant association between being seen in a standard initial assessment area (referred to as pitstop in this article) vs the resuscitation room as a first location (p = 0.007) with a delayed diagnosis; and a significant association between plain film imaging vs CT imaging (p = 0.000) and no trauma call vs trauma call (p = 0.009) with a missed diagnosis of major trauma.

CONCLUSION

The findings of this service evaluation suggest that service improvement initiatives should be aimed at the early stages of the patient journey to improve missed or delayed diagnoses of major trauma in this patient group.

Traumatic hemorrhage and chain of survival

Trauma is the number one cause of death among Americans between the ages of 1 and 46 years, costing more than $670 billion a year. Following death related to central nervous system injury, hemorrhage accounts for the majority of remaining traumatic fatalities. Among those with severe trauma that reach the hospital alive, many may survive if the hemorrhage and traumatic injuries are diagnosed and adequately treated in a timely fashion. This article aims to review the recent advances in pathophysiology management following a traumatic hemorrhage as well as the role of diagnostic imaging in identifying the source of hemorrhage. The principles of damage control resuscitation and damage control surgery are also discussed. The chain of survival for severe hemorrhage begins with primary prevention; however, once trauma has occurred, prehospital interventions and hospital care with early injury recognition, resuscitation, definitive hemostasis, and achieving endpoints of resuscitation become paramount. An algorithm is proposed for achieving these goals in a timely fashion as the median time from onset of hemorrhagic shock and death is 2 h.

Quantifying the Impact of Comorbidities on Length of Stay in Geriatric Fall-Related Injuries

Geriatric patients who fall are among the most common mechanisms of injury presenting to trauma centers. We sought to quantify the impact of various comorbidities on length of stay (LOS) in these patients to identify areas for intervention. A level 1 trauma center's registry was queried for patients ≥65 years old with fall related injuries admitted with LOS greater than 2 days. Over 7 years, 3714 patients were included. Mean age was 80.9 ± 8.7 years. All patients fell from heights of 6 feet or less. Median total LOS was 5 days, interquartile range [3,8]. Overall mortality rate was 3.3%. The most common comorbidities were cardiovascular (57.1%), musculoskeletal (31.4%), and diabetes (20.8%). Multivariate linear regression modeling LOS identified diabetes, pulmonary, and psychiatric diseases associated with longer lengths of stay (P < .05). As trauma centers refine care for geriatric trauma patients, comorbidity management represents an opportunity for proactive intervention.

Models of acute care for injured older patients-Australia and New Zealand practice

INTRODUCTION

The epidemiology of injured patients has changed, with an increasing predominance of severe injury and deaths in older (65 years and above) patients after low falls. There is little evidence of the models of care that optimise outcomes for injured older patients. This study aims to describe clinician perspectives of existing models of acute care for injured older patients in Australia and New Zealand.

METHODS

This cross-sectional online survey of healthcare professionals (HCP) managing injured older patients in Australia or New Zealand hospitals was conducted between November 2nd and December 12th, 2020. Recruitment was via survey link and snowball sampling to professional organisations and special interest groups via email and social media. HCP were asked, using a Likert scale, how likely four typical case vignettes were to be admitted to one of twelve options for ongoing care. Additional questions explored usual care components.

RESULTS

Participants (n=157) were predominantly Australian medical professionals in a major trauma service (MTS) or metropolitan hospital. The most common age defining "geriatric" was aged 65 years and older (43%). HCP described variability in the models and components of acute care for older injured patients in Australia and New Zealand. As a component of care, cognitive, delirium and frailty screening are occurring (60%, 61%, 46%) with HCP from non-major trauma services (non-MTS) reporting frailty and cognitive impairment screening more likely to occur in the emergency department (ED). Access to an acute pain service was more likely in a MTS. Participants described poor likelihood of a geriatrician (highest 16%) or physician (highest 12%) review in ED CONCLUSION: Despite a low response rate, HCP in Australia and New Zealand describe variability in acute care pathways for injured older patients. Given the change in epidemiology of injury towards older patients with low force mechanisms, models of acute injury care should be evaluated to define a cost-effective model and components of care that optimise patient-centred outcomes relevant to injured older patients. HCP described some factors they perceive to determine care, and outcomes of variability, offering guidance for future research and resource allocation in the Australia and New Zealand trauma system.

Age as the Impact on Mortality Rate in Trauma Patients

Background

Globally, the fastest-growing population is that of older adults. Geriatric trauma patients pose a unique challenge to trauma teams because the aging process reduces their physiologic reserve. To date, no agreed-upon definition exists for the geriatric trauma patients, and the appropriate age cut point to consider patients at increased risk of mortality is unclear.

Objectives

To determine the age cut point at which age impacts the mortality rate in trauma patients in Thailand.

Materials and Methods

This was a retrospective cohort and prognostic analysis study conducted in trauma patients ≥40 years. Patient data were retrieved from the trauma registry database and hospital information system in Songklanagarind Hospital. The estimated sample size of 1,509 patients was calculated based on the trauma registry data. The age with the maximum mortality rate was used as the cut point to define the elderly population. Hospital cost, intensive care unit (ICU) length of stay, gender, precomorbidity, mechanism of injury, injury severity score (ISS), and trauma and injury severity score were analyzed for any correlation with mortality, and whether or not they were associated with elderly trauma patients.

Results

A total of 1,523 trauma patients ≥40 years were included in the study. The median age in both the survival and death groups was 61 years, with gender in both groups being similar (p value = 0.259). In the multivariate logistic regression analyses, the adjusted odds ratio (OR) showed that increasing age was significantly associated with mortality (OR = 1.05; 95% CI, 1.02–1.07; p value <0.001). In the age group of 70 to 79 years and >80 years, the odds of mortality were significantly increased (OR 3.29, 95% CI, 1.24–8.68; p value = 0.016 and OR 3.29, 95% CI, 1.27–12.24; p value = 0.018, respectively).

Conclusion

Age is a significant risk factor for mortality in trauma patients. The mortality significantly increased at the age of 70 and higher.

The Need for Trauma Management Training and Evaluation on a Prehospital Setting

Trauma is one of the leading causes of death in the world, being the main cause of death in people under 45 years old. The epidemiology of these deaths shows an important peak during the first hour after a traumatic event. Therefore, learning how to manage traumatic injuries in a prehospital setting is of great importance. Medical students from Universidad Autónoma performed 66 different simulations to stabilize a trauma patient on a prehospital scene by using a web-based trauma simulator. Then, a panel of trauma experts evaluated the simulations performed, observing that, on average, an important number of simulations were scored below 5, being the score values provided from 0, minimum, to 10, maximum. Therefore, the first need detected is the need to further train prehospital trauma management in undergraduate education. Additionally, a deeper analysis of the scores provided by the experts was performed. It showed a great dispersion in the scores provided by the different trauma experts per simulation. Therefore, a second need is identified, the need to develop a system to objectively evaluate trauma management.

Page phenomenon in a transplanted kidney: is it salvageable?

A male in his late 70s with a history of an uncomplicated kidney transplantation 20 years prior was brought to the Emergency Department after experiencing blunt abdominal trauma following a motor vehicle collision. Imaging revealed a large perinephric haematoma, a retroperitoneal haematoma and multiple fractures. He was admitted to the intensive care unit where a renal haematoma was found to be expanding with ultrasonography (US) and developed renal dysfunction including anuria and hyperkalemia. His creatinine rose to twice his baseline and Doppler US showed elevated resistive indices, confirming extrinsic compression and causing a Page phenomenon. An open surgical exploration through the upper aspect of his Gibson incisional scar was performed followed by evacuation of the haematoma. An intraoperative US was done demonstrating good flow in the renal vessels. His postoperative course was uncomplicated and was discharged home with renal function back to baseline. On follow-up, he continued to have a good renal function.

Nine year in-hospital mortality trends in a high-flow level one trauma center in Italy

Trauma is the leading cause of death in young people with a considerable socio-economic impact worldwide. A trimodal distribution of trauma mortality was described in the past, but recently different studies underlined a progressive change in trauma mortality distribution linked to improvement in trauma care. This study aimed to analyze the mortality trends in a Level-One Trauma Center in Italy. Data on 6065 patients consecutively admitted to the Trauma Center between 2011 and 2020 were selected and retrospectively analyzed. Causes of Death (CODs) and time of death were stratified in four main groups and the patient sample was further divided into five age groups. Multivariate regression models were then performed to identify independent predictors of mortality. The most common COD in all age groups was Central Nervous System injuries. Immediate deaths (in ED) affected mostly patients over 75 years of age (34.3%). Deaths caused by massive hemorrhage occurred soon upon arrival in the ED, whereas deaths due to other causes (e.g. sepsis, MOF) after the first week. Patients' characteristics, the need for emergency procedures and high trauma severity scores were independent predictors of deaths. This study represented the first analysis on trauma mortality distribution in Italy over a nine-year period. The trimodal distribution described in the past seems to be no longer present in Italy, due to improvements in trauma systems and critical care. However, the high number of immediate and acute deaths underlies a persisting need for efforts in injury prevention and control .

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.

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

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

Improving mortality in older adult trauma patients: Are we doing better?

BACKGROUND

Older adult trauma is associated with high morbidity and mortality. Individuals older than 65 years are expected to make up more than 21% of the total population and almost 39% of trauma admissions by 2050. Our objective was to perform a national review of older adult trauma mortality and identify associated risk factors to highlight potential areas for improvement in quality of care.

MATERIALS AND METHODS

This is a retrospective cohort study of the National Trauma Data Bank including all patients age ≥65 years with at least one International Classification of Diseases, Ninth Revision, Clinical Modification trauma code admitted to a Level I or II US trauma center between 2007 and 2015. Variables examined included demographics, comorbidities, emergency department vitals, injury characteristics, and trauma center characteristics. Multilevel mixed-effect logistic regression was performed to identify independent risk factors of in-hospital mortality.

RESULTS

There were 1,492,759 patients included in this study. The number of older adult trauma patients increased from 88,056 in 2007 to 158,929 in 2015 (p > 0.001). Adjusted in-hospital mortality decreased in 2014 to 2015 (odds ratio [OR], 0.88; 95% confidence interval [CI], 0.86-0.91) when compared with 2007 to 2009. Admission to a university hospital was protective (OR, 0.83; 95% CI, 0.74-0.93) as compared with a community hospital admission. There was no difference in mortality risk between Level II and Level I admission (OR, 1.00; 95% CI, 0.92-1.08). The strongest trauma-related risk factor for in-patient mortality was pancreas/bowel injury (OR, 2.25; 95% CI, 2.04-2.49).

CONCLUSION

Mortality in older trauma patients is decreasing over time, indicating an improvement in the quality of trauma care. The outcomes of university based hospitals can be used as national benchmarks to guide quality metrics.

LEVEL OF EVIDENCE

Therapeutic/Care Management, Level IV.

Effect of age on the efficacy of tranexamic acid: An analysis of heterogeneity of treatment effect within the CRASH-2 dataset

BACKGROUND

Trauma is a major cause of morbidity and mortality in older adults and will become more common as the population ages. Tranexamic acid (TXA) is a lysine analogue frequently used in the setting of significant trauma with hemorrhage. The aim of this study is to investigate the heterogeneity of treatment effect of TXA as it relates to patient age during trauma care.

METHODS

We included patients from the CRASH-2 trial who were randomized within 3 h of injury. Patients were stratified into age groups <26 years, 26 to 35 years, 36 to 45 years, 46 to 55 years, and >55 years. Multiple logistic regression models were utilized to evaluate adjusted odds ratios (OR) with 95% confidence intervals (CI) for mortality. Heterogeneity of treatment effect was evaluated using Akaike and Bayesian information criteria to determine the optimum logistic regression model after which a Wald Chi-square test was utilized to evaluate statistical significance.

RESULTS

On univariate analysis, TXA administration decreased mortality within the <26 years cohort (decrease of 2.1%, 95% CI 0.2 to 4.0), 46 to 55 years cohort (decrease 6.7%, 95% CI 2.7 to 10.7), and >55 years cohort (decrease of 5.3%, 95% CI 0.4 to 10.3). On adjusted analysis, when compared to the 36 to 45 years cohort, the <26 year cohort experienced a decreased mortality (OR 0.72, 95% CI 0.62 to 0.85) whereas the >55 year cohort experienced increased mortality (OR 1.8, 95% CI 1.5 to 2.2). Assessment for heterogeneity of treatment effect of TXA administration between groups approached but did not reach statistical significance (p = 0.11).

CONCLUSIONS

Mortality related to trauma increases with age, however, there does not appear to be heterogeneity of treatment effect for TXA administration among different age groups.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Traumatic brain injury in patients aged ≥65 years versus patients aged ≥80 years: a multicenter prospective study of mortality and medical resource utilization

Objective

This study aimed to determine whether there is a difference in mortality and medical resource utilization between geriatric (aged ≥65 years) and super-geriatric patients (aged ≥80 years) with traumatic brain injury (TBI).

Methods

We obtained comprehensive data (demographics, injury characteristics, injury severities, and outcomes) of geriatric and super-geriatric TBI patients from an emergency department-based injury surveillance system database from 2011 to 2016. Multivariate logistic regression analysis was performed to compare the mortality and nonroutine discharge (NRDC) status between both groups.

Results

Among 442,533 TBI patients, 48,624 were older than 65 years. A total of 48,446 patients (37,140 geriatric and 11,306 super-geriatric) without exclusion criteria were included in the final analysis. Both overall in-hospital mortality (adjusted odds ratio, 1.88; 95% confidence interval [CI], 1.28 to 2.74; P=0.001) and NRDC (adjusted odds ratio, 1.35; 95% CI, 1.07 to 1.71; P=0.011) were significantly higher in the super-geriatric group. In the stratified analysis, there were no significant differences in NRDC rate for all stratifications of treatment timing (emergency department vs. ward admission), but mortality remained to be significant for all stratifications.

Conclusion

Super-geriatric TBI patients showed a significantly higher risk-adjusted overall mortality and more inadequate medical resource utilization than did geriatric TBI patients. However, super-geriatric patients were more likely to undergo NRDC after admission; thus, further research about age-related health inequalities is needed in the treatment of super-geriatric patients.

The impact of frailty on trauma outcomes using the Clinical Frailty Scale

Background

Population ageing is a worldwide phenomenon; thanks to improvements in medical care and living standards. The Office of National Statistics in the UK predicts that the fastest growing age group in coming decades will be those over 85 years. This is reflected in Trauma Audit and Research Network data, which has highlighted a shift in caseload from a majority of young males to elderly patients at UK Major Trauma Centres (MTC). This study of elderly trauma patients admitted to a UK MTC reviews the links between frailty, using the Canadian Study of Health and Aging Clinical Frailty Scale (CFS), and outcomes from trauma.

Methods

A retrospective database review of patients > 65 years old admitted to our MTC was performed. We identified 1125 eligible patients of which 729 had a recorded CFS. Those without a CFS were omitted. The primary outcome measured was in-hospital mortality. Secondary measures were Injury Severity Score, length of stay, trauma team activation on arrival and discharge destination. Multivariate regression analyses were performed using STATA v 15.

Results

Those of CFS 5–9 (frail) were 2.6 times more likely to die than the CFS 1–4 (pre-frail) (OR 2.65, 95% CI 1.47–4.78). The frail group was also 56% less likely to have a trauma call on admission (OR 0.44, 95% CI 0.30–0.65) and 61% less likely to be discharged to their usual place of residence (OR 0.39, 95% CI 0.28–0.55).

Conclusion

We advocate the use of the Clinical Frailty Scale as a screening tool for frailty in trauma patients, highlighting those at risk of increased length of stay and mortality, subsequently assisting healthcare providers with setting realistic expectations with family members.

Level of evidence

Level III, prognostic and epidemiological

Incorporating age improves the Glasgow Coma Scale score for predicting mortality from traumatic brain injury

Background

The Glasgow Coma Scale (GCS) score has been adapted into categories of severity (mild, moderate, and severe) and are ubiquitous in the trauma setting. This study sought to revise the GCS categories to account for an interaction by age and to determine the discrimination of the revised categories compared with the standard GCS categories.

Methods

The American College of Surgeons National Trauma Data Bank registry was used to identify patients with traumatic brain injury (TBI; ICD-9 codes 850-854.19) who were admitted to participating trauma centers from 2010 to 2015. The primary exposure variables were GCS score and age, categorized by decade (teens, 20s, 30s…, 80s). In-hospital mortality was the primary outcome for examining TBI severity/prognostication. Logistic regression was used to calculate the conditional probability of death by age decade and GCS in a development dataset (75% of patients). These probabilities were used to create a points-based revision of the GCS, categorized as low (mild), moderate, and high (severe). Performance of the revised versus standard GCS categories was compared in the validation dataset using area under the receiver operating characteristic (AUC) curves.

Results

The final population included 539,032 patients with TBI. Age modified the performance of the GCS, resulting in a novel categorization schema for each age decile. For patients in their 50s, performance of the revised GCS categories mirrored the standard GCS categorization (3-8, 9-12, 13-15); all other revised GCS categories were heavily modified by age. Model validation demonstrated the revised GCS categories statistically significantly outperformed the standard GCS categories at predicting mortality (AUC: 0.800 vs 0.755, p<0.001). The revised GCS categorization also outperformed the standard GCS categories for mortality within pre-specified subpopulations: blunt mechanism, isolated TBI, falls, non-transferred patients.

Discussion

We propose the revised age-adjusted GCS categories will improve severity assessment and provide a more uniform early prognostic indicator of mortality following traumatic brain injury.

Level of evidence

III epidemiologic/prognostic.

An Aging-Related Single-Nucleotide Polymorphism is Associated With Altered Clinical Outcomes and Distinct Inflammatory Profiles in Aged Blunt Trauma Patients

The contribution of individual genetic determinants of aging to the adverse clinical outcomes and altered inflammation mediator networks characteristic of aged trauma patients is unknown. The AA genotype of the aging-related single-nucleotide polymorphism (SNP) rs2075650 in TOMM40 has been associated with longevity, while the AG and GG genotypes are associated with an increased risk of Alzheimer disease. Here, we studied the effect of rs2075650 on clinical outcomes and dynamic biomarker patterns after traumatic injury. Genomic DNA was obtained from blunt trauma patients admitted to the ICU and examined for 551,839 SNPs using an Illumina microarray kit. Plasma was sampled from each patient three times within the first 24 h and daily from day 1 to 7 then assayed for 31 biomarkers using Luminex. Aged patients (65-90 years) were segregated into AA (n = 77) and AG/GG (n = 17) genotypes. Additional comparisons were made with matched groups of young patients (18-30 years), controlling for injury severity score (ISS) and sex ratio, and also segregated into AA (n = 56) and AG/GG (n = 19) genotypes. Aged patients with the AA genotype had a significantly lower requirement for ventilation and fewer days on mechanical ventilation, as well as significantly higher levels of one mediator and lower levels of two mediators. Dynamic Bayesian Network inference revealed IL-23 as a central node in each network regardless of age or genotype, with MIG and IP-10 also as key mediators in the networks of the aged patients. These findings suggest that an aging-related SNP, rs2075650, may influence clinical outcomes and inflammation networks in aged patients following blunt trauma, and thus may serve as a predictive outcome biomarker in the setting of polytrauma.

Geriatric Skiers: Active But Still at Risk, a National Trauma Data Bank Study

BACKGROUND

Downhill skiing accounts for a large portion of geriatric sport-related trauma. We assessed the national burden of geriatric versus nongeriatric ski trauma.

MATERIALS AND METHODS

Adults presenting to level 1/2 trauma centers after ski-associated injuries from 2011 to 2015 were identified from the National Trauma Data Bank by ICD-9 code. We compared demographics, injury patterns, and outcomes between geriatric (age ≥65 y) and nongeriatric adult skiers (age 18-64 y). A multiple regression analysis assessed for risk factors associated with severe injury (Injury Severity Score >15).

RESULTS

We identified 3255 adult ski trauma patients, and 16.7% (543) were geriatric. Mean ages for nongeriatric versus geriatric skiers were 40.8 and 72.1 y, respectively. Geriatric skiers more often suffered head (36.7 versus 24.3%, P < 0.0001), severe head (abbreviated injury scale score >3, 49.0 versus 31.5%, P < 0.0001) and thorax injuries (22.2 versus 18.1%, P = 0.03) as compared with nongeriatric skiers. Geriatric skiers were also more often admitted to the ICU (26.5 versus 14.9%, P < 0.0001), discharged to a facility (26.7 versus 11.6%, P < 0.0001), and suffered higher mortality rates (1.3 versus 0.4%, P = 0.004). Independent risk factors for severe injury included being male (OR: 1.68, CI: 1.22-2.31), helmeted (OR: 1.41, CI: 1.07-1.85), and having comorbidities (OR: 1.37, CI: 1.05-1.80). Geriatric age was not independently associated with severe injury.

CONCLUSIONS

At level 1/2 trauma centers, geriatric age in ski trauma victims was associated with unique injury patterns, higher acuity, increased rates of facility care at discharge, and higher mortality as compared with nongeriatric skiers. Our findings indicate the need for specialized care after high impact geriatric ski trauma.

Geriatric ATV and snowmobile trauma at a rural level 1 trauma center: A blow to the chest

INTRODUCTION

As the population ages, trauma centers are seeing a significant volume of injured geriatric patients. However, there is limited data on geriatric off-roading incidents. We investigated the injury patterns, severity and outcomes of geriatric versus younger adult all-terrain vehicle (ATV) and snowmobile related trauma with the hypothesis that geriatric patients will have higher mortality and worsened outcomes.

METHODS

The trauma registry at a New England Level 1 trauma center was queried by ICD 9/10 code for adult ATV and/or snowmobile-related trauma from 2011-2019. Data reviewed included demographic, admission, injury, and outcomes data including injury severity score (ISS), abbreviated injury scale (AIS) score, hospital disposition, and mortality. Patients were stratified by age into younger adults (18-64 years old) versus geriatric (65 years and older). Univariate analysis was performed to compare groups.

RESULTS

Over the study period, we identified 390 adult ATV or snowmobile-related trauma patients, of whom 38 were geriatric. The mean ages for the younger adult vs. geriatric cohorts were 41(SD 13) and 73(SD 5), respectively. The majority of patients were male (77%). Compared to younger adults, geriatric patients were more often unhelmeted (66 v 38%, p=0.004) and more likely to present after ATV as opposed to snowmobile trauma (71 v 51%, p=0.028). Geriatric patients more often sustained both any chest trauma (68 v 41%, p=0.003) and severe chest trauma (AIS≥3, 55 v 31%, p=0.022), and more often required tube thoracostomy (26 v 12%, p=0.042). Geriatric patients were also more often discharged to a facility (39 v 14%, p<0.001) compared to younger patients. There were no differences between age cohorts regarding arrival Glasgow coma scale scores, ISS>15, length of stay, ventilator days, complications, or mortality.

CONCLUSIONS

Following ATV or snowmobile-related trauma, geriatric patients were more likely to sustain severe chest trauma and to require additional care upon hospital discharge as compared to younger adults. Primary prevention should focus on encouraging helmet and chest protective clothing use in this geriatric population.

A Multi-Institutional Analysis of Damage Control Laparotomy in Elderly Trauma Patients: Do Geriatric Trauma Protocols Matter?

BACKGROUND

Trauma centers are receiving increasing numbers of older trauma patients. There is a lack of literature on the outcomes for elderly trauma patients who undergo damage control laparotomy (DCL). We hypothesized that trauma centers with geriatric protocols would have better outcomes in elderly patients after DCL.

METHODS

A retrospective chart review of consecutive adult trauma patients with DCL at 8 level 1 trauma centers was conducted from 2012 to 2018. Patients aged 40 or older were included. Age ≥ 55 years was defined as elderly. Demographics, injury information, clinical outcomes, including mortality, and complications were recorded. Univariate and multivariate analyses were performed.

RESULTS

A total of 379 patients with DCLs were identified with an average age of 54.8 ± 0.4 years with 39.3% (n = 149/379) of patients aged ≥ 55. Geriatric protocols or a consulting geriatric service was present at 37.5% (n = 3/8) of institutions. Age ≥ 55 was a significant risk factor for in-hospital mortality (OR 2, 95% CI 1.0-4.0, P = .04). Institutions without dedicated geriatric trauma protocols/services had higher overall in-hospital mortality on both univariate (57.9% vs 34.3%, P = .02) and multivariate analyses (OR 2.1, 95% CI 1.3-3.4, P < .001).

CONCLUSIONS

Surgical management of older trauma patients remains a challenge. Geriatric protocols or dedicated services were found to be associated with improved outcomes. Future efforts should focus on standardizing the availability of these resources at trauma centers.

One-year mortality in geriatric trauma patients: Improving upon the geriatric trauma outcomes score utilizing the social security death index

BACKGROUND

Geriatric Trauma Outcomes Score (GTOS) predicts in-patient mortality in geriatric trauma patients and has been validated in a prospective multicenter trial and expanded to predict adverse discharge (GTOS II). We hypothesized that these formulations actually underestimate the downstream sequelae of injury and sought to predict longer-term mortality in geriatric trauma patients.

METHODS

The Parkland Memorial Hospital Trauma registry was queried for patients 65 years or older from 2001 to 2013. Patients were then matched to the Social Security Death Index. The primary outcome was 1-year mortality. The original GTOS formula (variables of age, Injury Severity Score [ISS], 24-hour transfusion) was tested to predict 1-year mortality using receiver operator curves. Significant variables on univariate analysis were used to build an optimal multivariate model to predict 1-year mortality (GTOS III).

RESULTS

There were 3,262 patients who met inclusion. Inpatient mortality was 10.0% (324) and increased each year: 15.8%, 1 year; 17.8%, 2 years; and 22.6%, 5 years. The original GTOS equation had an area under the curve of 0.742 for 1-year mortality. Univariate analysis showed that patients with 1-year mortality had on average increased age (75.7 years vs. 79.5 years), ISS (11.1 vs. 19.1), lower GCS score (14.3 vs. 10.5), more likely to require transfusion within 24 hours (11.5% vs. 31.3%), and adverse discharge (19.5% vs. 78.2%; p < 0.0001 for all). Multivariate logistic regression was used to create the optimal equation to predict 1-year mortality: (GTOSIII = age + [0.806 × ISS] + 5.55 [if transfusion in first 24 hours] + 21.69 [if low GCS] + 34.36 [if adverse discharge]); area under the curve of 0.878.

CONCLUSION

Traumatic injury in geriatric patients is associated with high mortality rates at 1 year to 5 years. GTOS III has robust test characteristics to predict death at 1 year and can be used to guide patient centered goals discussions with objective data.

LEVEL OF EVIDENCE

Prognostic, level III.

The Challenges of Ultrasound-guided Thoracic Paravertebral Blocks in Rib Fracture Patients

Thoracic paravertebral blocks (TPVBs) provide an effective pain relief modality in conditions where thoracic epidurals are contraindicated. Historically, TPVBs were placed relying solely on the landmark-based technique, but the availability of ultrasound imaging makes it a valuable and practical tool during the placement of these blocks. TPVBs also provide numerous advantages over thoracic epidurals, namely, minimal hypotension, absence of urinary retention, lack of motor weakness, and remote risk of an epidural hematoma. Utilization of both landmark-based and ultrasound-guided techniques may increase the successful placement of a TPVB. This article reviews relevant sonoanatomy as it pertains to TPVBs. However, certain patient-related issues, including pneumothoraces, surgical emphysema, body habitus, and transverse process fractures, all may make imaging with ultrasound challenging. The changes noted on ultrasound imaging as a result of these issues will be further described in this review.

Association of Medicaid Expansion With Access to Rehabilitative Care in Adult Trauma Patients

Importance

Trauma is a leading cause of death and disability for patients of all ages, many of whom are also among the most likely to be uninsured. Passage of the Patient Protection and Affordable Care Act was intended to improve access to care through improvements in insurance. However, despite nationally reported changes in the payer mix of patients, the extent of the law's impact on insurance coverage among trauma patients is unknown, as is its success in improving trauma outcomes and promoting increased access to rehabilitation.

Objective

To use rigorous quasi-experimental regression techniques to assess the extent of changes in insurance coverage, outcomes, and discharge to rehabilitation among adult trauma patients before and after Medicaid expansion and implementation of the remainder of the Patient Protection and Affordable Care Act.

Design, Setting, and Participants

Quasi-experimental, difference-in-difference analysis assessed adult trauma patients aged 19 to 64 years in 5 Medicaid expansion (Colorado, Illinois, Minnesota, New Jersey, and New Mexico) and 4 nonexpansion (Florida, Nebraska, North Carolina, and Texas) states.

Interventions/Exposure

Policy implementation in January 2014.

Main Outcomes and Measures

Changes in insurance coverage, outcomes (mortality, morbidity, failure to rescue, and length of stay), and discharge to rehabilitation.

Results

A total of 283 878 patients from Medicaid expansion states and 285 851 patients from nonexpansion states were included (mean age [SD], 41.9 [14.1] years; 206 698 [36.3%] women). Adults with injuries in expansion states experienced a 13.7 percentage point decline in uninsured individuals (95% CI, 14.1-13.3; baseline: 22.7%) after Medicaid expansion compared with nonexpansion states. This coincided with a 7.4 percentage point increase in discharge to rehabilitation (95% CI, 7.0-7.8; baseline: 14.7%) that persisted across inpatient rehabilitation facilities (4.5 percentage points), home health agencies (2.9 percentage points), and skilled nursing facilities (1.0 percentage points). There was also a 2.6 percentage point drop in failure to rescue and a 0.84-day increase in average length of stay. Rehabilitation changes were most pronounced among patients eligible for rehabilitation coverage under the 2-midnight (8.4 percentage points) and 60% (10.2 percentage points) Medicaid payment rules. Medicaid expansion increased rehabilitation access for patients with the most severe injuries and conditions requiring postdischarge care (eg, pelvic fracture). It mitigated race/ethnicity-, age-, and sex-based disparities in which patients use rehabilitation.

Conclusions and relevance

This multistate assessment demonstrated significant changes in insurance coverage and discharge to rehabilitation among adult trauma patients that were greater in Medicaid expansion than nonexpansion states. By targeting subgroups of the trauma population most likely to be uninsured, rehabilitation gains associated with Medicaid have the potential to improve survival and functional outcomes for more than 60 000 additional adult trauma patients nationally in expansion states.

The TRAAGIC score: early predictors of inpatient mortality in adult trauma patients

Background

Scoring systems are important in prognostication and decision-making in the management of trauma patients. However, they often include an extensive list of factors not easily recalled by clinicians on admission. Additionally, multivariable analyses examining predictors of mortality in these patients is lacking. This study aimed to develop and validate a mortality prediction score for adult trauma inpatients. The intention was to create a scoring tool that could be easily remembered and implemented by clinicians.

Methods

This is a retrospective analysis of 5175 adult trauma patients treated at a level 1 trauma centre in Hamilton, Ontario, from 2002 to 2013. For derivation of the score, logistic regression was applied to data collected from 2002 to 2006 to identify potential predictors. Variables with p ≤ 0.10 identified from univariable analysis were entered in the multivariable logistic regression. Statistical significance was set at a value of 0.05. The prediction performance of the score was then assessed and validated on data for trauma patients treated from 2007 to 2013. The discrimination ability and calibration of the validation model were assessed. Frequencies, odds ratios with 95% confidence intervals (CIs) and C-statistics were reported.

Results

The TRAAGIC prediction score (transfusion, age, airway, hyperglycemia, international normalized ratio, creatinine) showed a C-index of 0.85 (95% CI 0.83–0.87) in the derivation cohort. The TRAAGIC score had high discrimination and good calibration when applied to the validation cohort.

Conclusion

The TRAAGIC score is an easily remembered and straightforward toolthat can reasonably predict inpatient mortality for adult trauma patients.

Age-Dependent Association of Occult Hypoperfusion and Outcomes in Trauma

BACKGROUND

Occult hypoperfusion (OH), or global hypoperfusion with normal vital signs, is a risk factor for poor outcomes in elderly trauma patients. We hypothesized that OH is associated with worse outcomes than shock in both young and elderly trauma patients.

METHODS

We conducted a single-center cohort study of adult (16 years or older) trauma patients from 2016 to 2018 with base excess measured on arrival. Perfusion states were defined as shock if heart rate was >120 beats/min or systolic blood pressure was <90 mmHg; OH if base excess was < -2 mmol/L, heart rate was <120 beats/min, and systolic blood pressure was >90 mmHg; and normal for all others. Patients were stratified as young (younger than 55 years) or elderly (55 years or older). Bayesian regression was used to assess the relationship between arrival perfusion state and mortality or serious complication.

RESULTS

Of 3,126 included patients, 808 were elderly. Rates of shock (33% and 31%) and OH (25% and 23%) were similar in young and elderly patients, respectively. OH on arrival was associated with higher odds of mortality or serious complication than normal perfusion, regardless of age group. Compared with shock, OH was associated with an odds ratio of 1.21 (95% CI, 0.97 to 1.52, posterior probability 96%) for poor outcomes in elderly patients and an odds ratio of 0.52 (95% CI, 0.42 to 0.65, posterior probability <1%) for poor outcomes in younger patients. Findings were similar on sensitivity analysis, excluding shock patients with base excess ≥ -2 mmol/L.

CONCLUSIONS

In elderly but not younger patients, OH is associated with worse outcomes than shock. Although shock parameters might need to be redefined in elderly patients, more attention is necessary for the diagnosis and treatment of all hypoperfused states in this age group.

Mortality profile of geriatric trauma at a level 1 trauma center

Background:

The management of geriatric trauma patients is challenging because of the altered physiology and co-existent medical conditions. To study the in-hospital mortality profile of geriatric trauma victims and the parameters associated with the mortality, we conducted this retrospective analysis.

Methods:

In a retrospective review of geriatric trauma admissions (above 60 years) over a 3-year period, we studied the association of age, gender, comorbidities, mechanism of injury (MOI), Glasgow coma score (GCS), injury severity score (ISS), systolic blood pressure, and hemoglobin (Hb) level on admission with hospital mortality. Univariate and Multivariable logistic regression was used to estimate odds and find independent associated parameters. P < 0.05 was considered as statistically significant.

Results:

Out of 881 patients, 208 (23.6%) patients died in hospital. The most common MOI was fall (53.3%) followed by motor vehicle collision (31.1%) and other mechanisms (14.5%). The in-hospital mortality was significantly higher and adjusted odds ratio (OR) for mortality were higher for male gender (2.11 [1.04–4.26]), higher ISS (6.75 [2.07–21.95] for ISS >30), low GCS (<8) (4.6 [2.35–8.97]), low Hb (<9) (1.68 [0.79–3.55]), hypotension on admission (32.42 [10.89–96.52]) as compared to other groups. Adjusted OR was 3.19 (1.55–6.56); 7.67 (1.10–53.49); 1.13 (0.08–17.12) for co-existent cardiovascular, renal, and hepatic comorbidities, respectively.

Conclusion:

Male gender, higher ISS, low GCS, low Hb, hypotension on admission, co-existent cardiovascular, renal and hepatic comorbidities are associated with increased mortality in geriatric trauma patients.

Advanced mobile prehospital nursing care for elderly people post-trauma: integrative review

OBJECTIVE

to identify scientific evidences available on the literature on nursing interventions on advanced mobile prehospital care for elderly people post-trauma.

METHOD

an integrative review of literature on the databases PubMed, CINAHL, and LILACS, from 2012 to 2017.

RESULTS

a sample composed by 26 studies, grouped into six thematic categories: circulation with hemorrhage control (n=11); dysfunction, neurological state (n=7); airway with protection of the cervical spine (n=3); secondary evaluation (n=3); ventilation and breathing (n=1), and environment exposition/control (n=1).

CONCLUSION

Despite having identified nursing interventions, there was no description of specific nursing interventions related to advanced mobile prehospital care for elderly people post-trauma.

It is time for a change in the management of elderly severely injured patients! An analysis of 126,015 patients from the TraumaRegister DGU®

BACKGROUND

The number of elderly patients among the severely injured has been increasing continuously. It has been suggested that an increased life expectancy and a higher level of activity and mobility in older ages could explain this observation. Elderly trauma patients have relevant higher mortality rates and poorer functional outcomes. The reasons remain unclear. The aim of this study was to look for differences in the management of severely injured elderly patients compared to younger age groups and to evaluate their potential impact on outcome.

METHODS

The TraumaRegister DGU^® is a multicenter database that documents de-identified data of severely injured patients since 1993. Trauma cases documented between 2009 and 2016 with an ISS ≥ 9 were divided in four age groups. The groups were compared with respect to mechanism of injury, pattern of injury, severity of injury, management and outcome.

RESULTS

The analysis of 126,015 severely injured patients showed that 37.5% of the population were elderly patients (≥ 60 years). Their rate actually increased every year by 1.7%. The elderly trauma patients experience different mechanisms of injury (more low energy trauma) and different pattern of injuries (more brain trauma, less abdominal and extremity injuries). Evaluating the management of patients showed that elderly patients have lower intubation rates and less volume replacement in the prehospital setting. Diagnostic interventions like CT scans in the emergency room were performed more restrictively. Elderly trauma patients also received fewer surgical interventions for brain injuries, pelvic fractures and femur fractures. Their hospital mortality rates were higher.

CONCLUSIONS

Severely injured elderly patients are treated with a more "wait and see approach" resulting in higher mortality rates. We suggest that this population needs a more "aggressive management" to improve their outcome, if the wish to perform complete treatment including surgical procedures and intensive care medicine has not been excluded by the patients or their legal guardian.

Quantifying the burden of pre-existing conditions in older trauma patients: A novel metric based on mortality risk

INTRODUCTION

Pre-existing medical conditions (PEC) represent a unique domain of risk among older trauma patients. The study objective was to develop a metric to quantify PEC burden for trauma patients.

METHODS

A cohort of 4526 non-severe blunt-injured trauma patients aged 55 years and older admitted to a Level I trauma center between January 2006 and December 2012 were divided into development (80%) and test (20%) sets. Cox regression was used to develop the model based on in-hospital and 90-day mortality. Regression coefficients were converted into a point-based PEC Risk Score. Performance of the PEC Risk Score was compared in the test set with two other PEC-based metrics and three injury-based metrics. An external cohort of 2284 trauma patients admitted in 2013 was used to evaluate combined metric performance.

RESULTS

Total mortality was 9.4% and 9.1% in the development and test set, respectively. The final model included 12 PEC. In the test set, the PEC Risk Score (c-statistic: 79.7) was superior for predicting in-hospital and 90-day mortality compared with all other metrics. For in-hospital mortality alone, the PEC Risk Score similarly outperformed all other metrics. Combination of the PEC Risk Score and any injury-based metric significantly improved prediction compared with any injury-based metric alone.

CONCLUSION

Our 12-item PEC Risk Score performed well compared with other metrics, suggesting that the classification of trauma-related mortality risk may be improved through its use. Among non-severely injured older trauma patients, the utility of prognostic metrics may be enhanced through the incorporation of comorbidities.

Young and Aged Blunt Trauma Patients Display Major Differences in Circulating Inflammatory Mediator Profiles after Severe Injury

BACKGROUND

Aging is accompanied by alterations in immune functions. How these changes translate into levels of circulating inflammatory mediators and network expression after severe trauma is not well characterized. To address this, we compared time-dependent changes in the levels of an extensive biomarker panel in cohorts of severely injured young and aged adults.

STUDY DESIGN

Cohorts of young (18 to 30 years old, n = 115) and aged (65 to 90 years old, n = 101) blunt trauma patients admitted to the ICU with plasma sampled 3 times within the first 24 hours and daily from day 1 to day 7 were assayed for 30 inflammatory biomarkers using Luminex analyzer. Stringently matched groups controlling for sex ratio and Injury Severity Score (n = 56 young vs n = 56 aged) were generated. Data were analyzed using 2-way ANOVA, area under the curve analysis, Dynamic Bayesian Network inference, and Dynamic Network Analysis.

RESULTS

In the overall cohorts, the young group had a significantly higher Injury Severity Score, which was associated with higher circulating levels of 18 inflammatory mediators from admission to day 7. The aged group had higher levels of C-X-C motif chemokine ligand 10/interferon gamma-induced protein 10 and C-X-C motif chemokine ligand 9/monokine induced by gamma interferon. In groups that were matched for Injury Severity Score, the significantly higher levels of interferon gamma-induced protein 10 and monokine induced by gamma interferon persisted in the aged. Dynamic Bayesian Network revealed interferon gamma-induced protein 10 and monokine induced by gamma interferon as key mediators in the aged, and Dynamic Network Analysis revealed higher network complexity in the aged.

CONCLUSIONS

These findings indicate that differences in the early inflammatory networks between young and aged trauma patients are not simply a suppression of pro-inflammatory responses in the aged, but are characterized by a major shift in the mediator profile patterns with high levels of CXC chemokines in the aged.

Investigation of risk factors of geriatric patients with significant brain injury from ground-level fall: A retrospective cohort study in a local Accident and Emergency Department setting

Background:

Trauma was the fifth leading cause of death in Hong Kong in 2013.4 Injuries caused by falls ranked first in traumatic brain injury (TBI) cases among older adults (51%).5 Elderly trauma patients face an increased risk of adverse consequences6 from trauma compared with their younger counterparts, as advanced age itself is already a well-recognized risk factor for less favorable outcomes following trauma. Therefore, identifying factors associated with significant brain injury in geriatric patients in A&E triage is crucial in providing timely care to these patients.

Objectives:

To identify the risk factors for geriatric patients with significant brain injury from ground-level falls and to formulate their association of risk factors with significant brain injury as a consequence from ground-level falls.

Methods:

This was a retrospective study with data collected from the Clinical Data Analysis and Reporting System of Queen Mary Hospital from 1 January 2013 to 31 December 2015. A total of 1101 cases were identified.

Results:

There were 76% of the recruited patients with a normal computed tomography scan. However, the remaining 24% had computed tomography scans indicative of brain injury. Severe head injuries were scored 3 -8 on the Glasgow Coma Scale and moderate head injuries were scored 9 -12. Respectively, these were 20 times (p = 0.005) and 5 times (p = 0.002) more likely to have positive computed tomography findings than patients with a Glasgow Coma Scale score from 13 to 15. Patients with loss of consciousness were two times more likely to have a positive computed tomography result than those without loss of consciousness (p = 0.001). Although warfarin use is a well-established risk factor for intracranial hemorrhage after head injury, in our dataset, the result was not statistically significant. However, the use of new oral anti-coagulants was associated with positive computed tomography findings with patients taking new oral anti-coagulants 2.3 times more likely to have positive computed tomography findings compared with those with no anticoagulant use (p = 0.033).

Conclusions:

Early detection of patients with significant brain injury and aggressive management may prevent secondary injury from the complications of brain injury, hence improving patient mortality and morbidity, and reducing hospital stay and health care costs.