The effect of age, severity, and mechanism of injury on risk of death from major trauma in Western Australia

The outcomes of the most severe polytrauma patients: a systematic review of the use of high ISS cutoffs for performance measurement

BACKGROUND

This systematic review aimed to describe the outcomes of the most severely injured polytrauma patients and identify the consistent Injury Severity Score based definition of utilised for their definition. This could provide a global standard for trauma system benchmarking.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist was applied to this review. We searched Medline, Embase, Cochrane Reviews, CINAHL, CENTRAL from inception until July 2022. Case reports were excluded. Studies in all languages that reported the outcomes of adult and paediatric patients with an ISS 40 and above were included. Abstracts were screened by two authors and ties adjudicated by the senior author.

RESULTS

7500 abstracts were screened after excluding 13 duplicates. 56 Full texts were reviewed and 37 were excluded. Reported ISS groups varied widely between the years 1986 and 2022. ISS groups reported ranged from 40-75 up to 51-75. Mortality varied between 27 and 100%. The numbers of patients in the highest ISS group ranged between 15 and 1451.

CONCLUSIONS

There are very few critically injured patients reported during the last 48 years. The most critically injured polytrauma patients still have at least a 50% risk of death. There is no consistent inclusion and exclusion criteria for this high-risk cohort. The current approach to reporting is not suitable for monitoring the epidemiology and outcomes of the critically injured polytrauma patients.

LEVEL OF EVIDENCE

Level 4-systematic review of level 4 studies.

Time trend analysis of Injury Severity score of adult trauma patients with emergent CT examination

PURPOSE

Controversy exists about whole-body computed tomography (CT) as a primary screening modality for suspected multiple trauma patients. Therefore, the aim of this study was to analyze time trends of CT examinations for trauma patients in relation to the Injury Severity Score (ISS).

METHODS

We retrospectively analyzed 561 adult trauma patients (mean age = 54 years) who were admitted to the trauma room of our hospital, immediately followed by a CT examination, in 2009, 2013 und 2017. Review of electronic patient charts was performed to determine the cause of injury. ISS was either calculated upon hospital charts and CT imaging reports or documented in the TraumaRegister DGU® for trauma patients with ICU treatment or ISS ≥ 16.

RESULTS

An increasing number of CT examinations of acute trauma patients were performed at our hospital with 117 patients in 2009 compared to 192 in 2013 and 252 in 2017. Their mean age increased (50 years in 2009, 54 in 2013 and 55 in 2017;p = 0.046), whereas their mean ISS decreased over time (15.2 in 2009 compared to 12.1 in 2013 and 10.6 in 2017;p = 0.001), especially in women (15.1 in 2009, 11.8 in 2013 and 7.4 in 2017;p = 0.001 both), younger age groups (18 to 24 years:15.6 in 2009, 6.5 in 2013 and 8.9 in 2017; p = 0.033 and 25 to 49 years:15.0 in 2009, 11.2 in 2013 and 8.3 in 2017;p = 0.001) as well as motor vehicle collision (MVC) victims (16.2 in 2009, 11.8 in 2013 and 6.1 in 2017; p < 0.001). Trauma patients with a high ISS were especially more likely of older age (OR 1.02,p < 0.001) and with the type of incident being a fall (< 3 m: OR3.84,p < 0.001;>3 m: OR6.22,p < 0.001) compared to MVC.

CONCLUSION

Previous studies suggesting a benefit of primary whole-body CT for trauma patients might not reflect the current patient population with decreasing ISS. Especially females, younger age groups and MVC patients might benefit from stricter selection criteria for receiving whole-body CT. Our results also emphasize the importance of prevention of fall or tumble for elderly people.

Branching Out: A Retrospective Review of Tree Fall-Related Trauma

Introduction Falls from trees (FFTs), although rare, represent a significant public health concern due to the severe consequences they can impose. Such incidents, while statistically uncommon across the wider population, have the potential to cause drastic, lasting alterations in patients' lives. The severity of these events is often substantial, highlighted by high Injury Severity Scores (ISSs) and prolonged hospital length of stay (LOS), which brings to light the urgent need for preventive strategies and heightened awareness. Our study aims to present a current epidemiological understanding of the patterns, nature, and severity of injuries caused by FFTs. Additionally, it provides an analysis and comparison of data obtained from a de-identified trauma database of patients presenting after FFTs. Methods This review presents data from a trauma registry system detailing trauma admissions from March 31, 2016, to December 27, 2021, at the Desert Regional Medical Center in Palm Springs, California, United States, a designated Level 1 trauma center. Throughout this period of nearly five years and eight months, a total of 3,148 patients were recorded to have visited the emergency department due to falls. Specifically, the study zeroes in on the subset of patients who were admitted after experiencing FFTs. From the comprehensive retrospective examination, it was noted that among the 3,148 fall incidents, there were 50 cases that involved FFTs. Results This retrospective analysis focused on 50 patients treated at the emergency department after FFTs, with a predominantly male demographic profile of 49 (98%) and an average age of 44 years. Hospitalization was required for the vast majority (44%), with approximately one-third necessitating ICU care. Surgical procedures were necessary for 35 (70%) of these cases. Upon discharge, 36 (72% of patients) were able to return home. Vertebral fractures were the most frequent injury, present in 24 (22% of admissions), followed closely by soft tissue injuries at 23 (21%). The mean ISS was 11, although those with extended hospital stays of over 10 days had higher ISS scores of 16, in contrast to an ISS of 10 for those with shorter stays. Conclusions FFTs constitute a lesser-known category of trauma-related injuries in the broader spectrum of fall-related incidents. Although relatively infrequent, these incidents result in significant injury burdens. The objective of this review is to compile and summarize the existing body of literature on FFTs. It involves an in-depth analysis of admission, discharge, and demographic data related to FFTs, highlighting the significant consequences associated with such accidents. Additionally, this review incorporates an analysis of a specialized dataset dedicated to injuries resulting from FFTs, facilitating a comparative assessment against current research in this field.

Predictors of Mortality in Extracorporeal Membrane Oxygenation Support Patients Following Major Trauma

INTRODUCTION

The usage of extracorporeal membrane oxygenation (ECMO) in trauma patients has increased significantly within the past decade. Despite increased research on ECMO application in trauma patients, there remains limited data on factors predicting morbidity and mortality outcome. Therefore, the primary objective of this study is to describe patient characteristics that are independently associated with mortality in ECMO therapy in trauma patients, to further guide future research.

METHODS

This retrospective study was conducted using the Trauma Quality Improvement Program database from 2010 to 2019. All adult (age ≥ 16 y) trauma patients that utilized ECMO were included. A Significant differences (P < 0.05) in demographic and clinical characteristics between groups were calculated using an independent t-test for normal distributed continuous values, a Mann-Whitney U test for non-normal distributed values, and a Pearson chi-square test for categorical values. A multivariable regression model was used to identify independent predictors for mortality. A survival flow chart was constructed by using the strongest predictive value for mortality and using the optimal cut-off point calculated by the Youden index.

RESULTS

Five hundred forty-two patients were included of whom 205 died. Multivariable analysis demonstrated that the female gender, ECMO within 4 h after presentation, a decreased Glasgow Coma Scale, increased age, units of blood in the first 4 h, and abbreviated injury score for external injuries were independently associated with mortality in ECMO trauma patients. It was found that an external abbreviated injury score of ≥3 had the strongest predictive value for mortality, as patients with this criterion had an overall 29.5% increased risk of death.

CONCLUSIONS

There is an ongoing increasing trend in the usage of ECMO in trauma patients. This study has identified multiple factors that are individually associated with mortality. However, more research must be done on the association between mortality and noninjury characteristics like Pao2/Fio2 ratio, acute respiratory distress syndrome classification, etc. that reflect the internal state of the patient.

Erhöhtes Alter, kardiovaskuläre Nebenerkrankungen, COPD und Diabetes mellitus bedingen eine Übersterblichkeit in der septischen Unfallchirurgie

Hintergrund Die konstante Überalterung der Bevölkerung in Deutschland führt u.a. zu einer Zunahme des durchschnittlichen Alters hospitalisierter Patienten. Hiermit einher gehen eine reduzierte physiologische Reserve und ein reduzierter körpereigener Abwehrmechanismus und folglich eine gesteigerte Infekt- und Komplikationsanfälligkeit. Die Altersentwicklung der septischen Unfallchirurgie ist im Vergleich zur Unfallchirurgie wenig erforscht. Zudem ist der Einfluss des Alters, verschiedener Vorerkrankungen, aber auch der des Alkohol- und Nikotinkonsums auf die Mortalität in der septischen Unfallchirurgie unzureichend untersucht.

Methode 2014/15 (Exam1) wurden 345 Patienten der septischen Unfallchirurgie in die Studie eingeschlossen. 2017/18 (Exam2) erfolgte das 3-Jahres-Follow-up. Die Befragungen (Exam1 und 2) umfassten demografische Parameter, Nebenerkrankungen, die Medikamenteneinnahme, Alkohol- und Nikotinkonsum sowie verschiedene Parameter zur Morbidität. Hieraus wurde das Sterberisiko in der septischen Unfallchirurgie in Abhängigkeit von den verschiedenen Risikofaktoren (Alter, Nebenerkrankungen, Medikamenteneinnahme und Noxen) berechnet. Zudem wurde die Entwicklung des Patientenalters in der Unfallchirurgie sowie speziell in der septischen Unfallchirurgie zwischen 2010 und 2019 ausgewertet.

Ergebnisse 2014/15 (Exam1) wurden 345 Patienten in die Studie eingeschlossen. Hiervon konnten 2017/18 274 (79,4%) telefonisch erreicht werden. 36 (10,4%) lehnten eine Nachbefragung ab. 20 (8,4%) der 238 verbleibenden Probanden waren bereits verstorben, 218 (63,2%) nahmen erneut teil. Zwischen 2010 (n = 492) und 2019 (n = 885) nahm die Patientenzahl der septischen Unfallchirurgie in unserer Abteilung um 79,9% zu, wobei besonders der Anteil der unter 65-Jährigen anstieg. Ab dem 60. Lebensjahr stieg die Sterbewahrscheinlichkeit (60. Lj: 0,0377 vs. 70. Lj: 0,1395) sprunghaft an; wobei in der septischen Unfallchirurgie die eines 60-Jährigen der Sterbewahrscheinlichkeit eines 80-Jährigen der Normalbevölkerung entsprach. Nikotin- (p = 0,93) und Alkoholkonsum (p = 0,344) zeigten keinen signifikanten Einfluss auf die Sterblichkeit, während kardiale Vorerkrankungen (p = 0,01), die COPD (p = 0,01), der Diabetes mellitus (p = 0,05) und die pAVK (p = 0,01) mit einer signifikant erhöhten Sterblichkeit einhergingen.

Schlussfolgerung Das Alter, kardiale Vorerkrankungen, aber auch die COPD, der Diabetes mellitus und die periphere arterielle Verschlusskrankheit gehen mit einer signifikant erhöhten Sterblichkeit in der septischen Unfallchirurgie einher. Eine exponentielle Zunahme des Sterblichkeitsrisikos besteht zwischen dem 50. und 60. Lebensjahr, wobei das Risiko zu versterben eines 60-jährigen Patienten der septischen Unfallchirurgie dem eines 80-jährigen aus der Normalbevölkerung entspricht.

A National Assessment of Legacy vs New Generation Medicaid Data

OBJECTIVE

To compare performance of Medicaid legacy, Medicaid new generation, and Medicare claims on data analytic tasks DATA SOURCES: Medicaid Analytic eXtract (MAX) claims (legacy) of 100% beneficiaries in 2011 (all states except Idaho), 2012 (all states), 2013 (28 states), and 2014 (17 states); 2016 Transformed Medicaid Statistical Information System Analytic Files (TAF) claims (new generation) of 100% beneficiaries from all states; Medicare claims of 20% beneficiaries in 2011-2014, 2016.

STUDY DESIGN

We focused on the chain of events that starts with an out-of-hospital medical emergency and ends with hospital death or survival to discharge. We developed six data quality indicators to assess ambulance variables; linkage between claims; external cause of injury code reporting; and death reporting on hospital discharge status codes. For the latter, we estimated injury severity and modeled its association with death in the Medicare population. We used the model to compare reported vs expected deaths by injury severity in the Medicaid population. Datasets were compared by state and fee-for-service vs managed care.

DATA EXTRACTION METHODS

Medicare and Medicaid beneficiaries with emergency ambulance transports PRINCIPAL FINDINGS: Medicare claims had high performance across indicators and states; MAX claims substantially underperformed on multiple indicators in most states. For example, most states reported external cause codes for over 90% of Medicare but less than 15% of Medicaid injury cases. Medicaid fee-for-service did not consistently perform better than Medicaid managed care. Compared with MAX, TAF claims performed significantly better on some indicators but continued to have poor external cause code reporting. Finally, MAX and TAF managed care records reported deaths at discharge in the range of expected deaths; however, fee-for-service claims might have underreported high-severity injury deaths.

CONCLUSIONS

New generation Medicaid claims performed better than legacy claims on some indicators, but much more improvement is needed to allow high-quality policy analysis.

Challenges in the PREHOSPITAL emergency management of geriatric trauma patients - a scoping review

BACKGROUND

Despite a widely acknowledged increase in older people presenting with traumatic injury in western populations there remains a lack of research into the optimal prehospital management of this vulnerable patient group. Research into this cohort faces many uniqu1e challenges, such as inconsistent definitions, variable physiology, non-linear presentation and multi-morbidity. This scoping review sought to summarise the main challenges in providing prehospital care to older trauma patients to improve the care for this vulnerable group.

METHODS AND FINDINGS

A scoping review was performed searching Google Scholar, PubMed and Medline from 2000 until 2020 for literature in English addressing the management of older trauma patients in both the prehospital arena and Emergency Department. A thematic analysis and narrative synthesis was conducted on the included 131 studies. Age-threshold was confirmed by a descriptive analysis from all included studies. The majority of the studies assessed triage and found that recognition and undertriage presented a significant challenge, with adverse effects on mortality. We identified six key challenges in the prehospital field that were summarised in this review.

CONCLUSIONS

Trauma in older people is common and challenges prehospital care providers in numerous ways that are difficult to address. Undertriage and the potential for age bias remain prevalent. In this Scoping Review, we identified and discussed six major challenges that are unique to the prehospital environment. More high-quality evidence is needed to investigate this issue further.

Tennis-related adult maxillofacial trauma injuries

Objectives: Tennis participation continues to increase amongst adults across the United States. The purpose of this study was to analyze trends in adult tennis-related facial injury epidemiology, demographics, diagnoses, and locations of injury. Materials and methods: The National Electronic Injury Surveillance System was evaluated for tennis-related facial injuries in adults from 2009 through 2018. Number of injuries were extrapolated, and data were analyzed for age, sex, specific injury diagnoses, locations, and discharge disposition. Descriptive statistics were used to present and describe variables of interest. Chi-squared testing (χ2) was performed to compare categorical variables. Results: During the study period, 342 tennis-related facial trauma ED visits were analyzed. Lacerations were the most common injury (45%), followed by contusions or abrasions (33.3%), concussions (11.7%), and fractures (8.5%). The most common sites of injury were the face (47.4%) and head (27.2%) regions. Males accounted for 62.0% of injuries, while females accounted for the remaining 38.0%. Patients between 34-65 years-old accounted for 47.7% of all injuries, and athletes over 65 years-old had the highest rate of fractures (10.1%). Conclusions: Facial trauma incurred secondary to tennis may follow patient-specific patterns. The incidence of tennis-related facial trauma is smaller compared to other sports, but the severity of such injuries remain a danger. Facial protection and enforcement in tennis is virtually absent, and these findings strengthen the need to educate athletes, families, and physicians on injury awareness and prevention.

Geriatric polytrauma patients should not be excluded from aggressive injury treatment based on age alone

Purpose

Age in severely injured patients has been increasing for decades. Older age is associated with increasing mortality. However, morbidity and mortality could possibly be reduced when accurate and aggressive treatment is provided. This study investigated age-related morbidity and mortality in polytrauma including age-related decisions in initial injury management and withdrawal of life-sustaining therapy (WLST).

Methods

A 6.5-year prospective cohort study included consecutive severely injured trauma patients admitted to a Level-1 Trauma Center ICU. Demographics, data on physiology, resuscitation, MODS/ARDS, and infectious complications were prospectively collected. Patients were divided into age subgroups (< 25, 25–49, 50–69, and ≥ 70 years) to make clinically relevant comparisons.

Results

391 patients (70% males) were included with median ISS of 29 (22–36), 95% sustained blunt injuries. There was no difference in injury severity, resuscitation, urgent surgeries, nor in ventilator days, ICU-LOS, and H-LOS between age groups. Adjusted odds of MODS, ARDS and infectious complications were similar between age groups. 47% of patients ≥ 70 years died, compared to 10–16% in other age groups (P < 0.001). WLST increased with older age, contributing to more than half of deaths ≥ 70 years. TBI was the most common cause of death and decision for treatment withdrawal in all age groups.

Conclusions

Patients ≥ 70 years had higher mortality risk even though injury severity and complication rates were similar to other age groups. WLST increased with age with the vast majority due to brain injury. More than half of patients ≥ 70 years survived suggesting geriatric polytrauma patients should not be excluded from aggressive injury treatment based on age alone.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00068-020-01567-y.

Clear Sinus Sign on Head CT Scan: Reliable Criterion to Exclude Paranasal Sinus Fracture

PURPOSE

The clear sinus sign has been described in facial computed tomography (CT) as an indication of the absence of fluid in the paranasal sinuses. It is a highly reliable criterion to exclude fracture involving the paranasal sinus wall. Very scarce data on this sign on head CT scan is currently available. We conducted the present study to assess the usefulness of the clear sinus sign on head CT scan to exclude paranasal sinus fracture.

MATERIALS AND METHODS

A retrospective cross-sectional review of the medical records and head and facial CT images was performed for 80 trauma patients with a total of 640 paranasal sinuses. The presence and absence of paranasal sinus fracture was recorded and analyzed.

RESULTS

The clear sinus sign was found in 207 paranasal sinuses (32.3%) on head CT, and none of these had a paranasal sinus fracture (P < .001).

CONCLUSIONS

The presence of the clear sinus sign on head CT scans is an excellent indication for exclusion of a paranasal sinus fracture in trauma patients.

Alcohol is a predictor of mortality in motor vehicle collisions

INTRODUCTION

It is well recognized that driving while intoxicated increases the probability of a motor-vehicle collision (MVC). The effect of alcohol on the chance of surviving the MVC is less clear.

METHOD

Using data from the Fatality Analysis Reporting System (FARS) we conducted analyses for the outcome of mortality using alcohol and other variables as predictors. We also selected alcohol positive (AP) and alcohol negative (AN) persons from the same MVC and vehicle to control for confounding characteristics.

RESULTS

The odds ratio (OR) for mortality for alcohol positive drivers was 2.57, (p < 0.001 for all the following OR). Other harmful predictive factors were age OR 1.01 per year, vehicle age OR 1.05 per year, male sex OR 1.23, avoidance maneuver OR 1.09, speed related OR 2.89, rollover mechanism OR 2.75, and collision with a fixed object OR 6.70. Protective factors were proper restraint use - OR 0.19 and collision with another moving vehicle, OR 0.21. In the multivariate analysis the OR of mortality for AP vs AN was 1.46. Proper restraint use (OR 0.27) remained protective along with collision with another moving vehicle. When AP and AN persons from the same MVC and the same vehicle were compared, the adjusted OR's for mortality were 1.46 and 2.08, respectively.

CONCLUSIONS

Alcohol is an independent predictor of mortality in an MVC. Proper restraint use is the strongest protective factor. This finding allows a more complete understanding of the risks of driving while intoxicated, not only a higher probability of an MVC, but decreased survival once the MVC occurs. Practical Applications: Identification of alcohol as an independent predictor of mortality in an accident may improve risk assessment and influence drivers to avoid driving while intoxicated.

A Novel Risk Score to Predict Post-Trauma Mortality in Nonagenarians

Background:

Nonagenarians represent a rapidly growing age group who often have functional limitations and multiple comorbidities, predisposing them to trauma.

Aims:

The purpose of this study was to identify patient characteristics, hospital complications, and comorbidities that predict in-hospital mortality in the nonagenarian population following trauma. We also sought to create a scoring system using these variables.

Settings and Design:

This study was a retrospective chart review.

Methods:

We reviewed the medical records of 548 nonagenarian trauma patients admitted to two Level I trauma centers from 2006 to 2015. Statistical analysis was performed using logistic regression and a machine learning model, which calculated significant variables and computed a scoring system.

Results:

The in-hospital mortality rate was 7.1% (n = 39). Significant predictors of mortality were cardiac comorbidity, neuro-concussion, New Injury Severity Score (ISS) 16+, striking an object, ISS 25–75, and pulmonary and cardiac complications. Significant variables were assigned a numeric value. A score of 5+ carried a 41.1% mortality risk, 79% sensitivity, and 91% specificity. A score of 10+ had an associated 81.8% mortality risk with 31% specificity and 99% sensitivity.

Conclusions:

Our findings identified reliable predictors of mortality in nonagenarian population posttrauma. The scoring system performs with good specificity and sensitivity and incrementally correlates with mortality risk.

Females fall more from heights but males survive less among a geriatric population: insights from an American level 1 trauma center

Background

Approximately one third of subjects ≥65 year old and half of subjects ≥80 years old sustain a fall injury each year. We aimed to study the outcomes of fall from a height (FFH) among older adults. We hypothesized that in an elderly population, fall-related injury and mortality are the same in both genders.

Methods

A retrospective analysis was conducted between January 2012 and December 2016 in patients who sustained fall injury at age of at least 60 years and were admitted into a Level 1 Trauma center. Patients were divided into 3 groups: Gp-I: 60–69, Gp-II: 70–79 and Gp-III: ≥80 years old. Data were analyzed and compared using Chi-square, one-way analysis of variance (ANOVA) and logistic regression analysis tests.

Results

Forty-three percent (3665/8528) of adult trauma patients had FFH and 59.5% (2181) were ≥ 60 years old and 52% were women. The risk of fall increased with age with an Odd ratio (OR) 1.52 for age 70–79 and an OR 3.40 for ≥80.

Females fell 1.2 times more (age-adjusted OR 1.24; 95% CI 1.05–1.45) and 47% of ≥80 years old suffered FFH. Two-thirds of FFH occurred at a height ≤ 1 m. Injury severity (ISS, NISS and GCS) were worse in Gp-II, lower extremities max Abbreviated Injury score (max AIS) was higher in Gp-III. Overall mortality was 8.7% (Gp-I 3.6% vs. 11.3% in Gp-II and 14% in Gp- III). Males showed higher mortality than females in the entire age groups (Gp-I: 4.6% vs 1%, Gp-II: 12.9% vs 4.2% and Gp-III: 17.3% vs 6.9% respectively). On multivariate analysis, shock index (OR 3.80; 95% CI 1.27–11.33) and male gender (OR 2.70; 95% CI 1.69–4.16) were independent predictors of mortality.

Conclusions

Fall from a height is more common in older adult female patients, but male patients have worse outcomes. Preventive measures for falls at home still are needed for the older adults of both genders.

Electronic supplementary material

The online version of this article (10.1186/s12877-019-1252-6) contains supplementary material, which is available to authorized users.

Aspirin for primary prevention of stroke in traumatic cerebrovascular injury: association with increased risk of transfusion

OBJECTIVE

Blunt traumatic extracranial carotid or vertebral artery injury (i.e., traumatic cerebrovascular injury [TCVI]) occurs in 1%-2% of all blunt trauma admissions, carries a 10% risk of thromboembolic ischemic stroke, and accounts for up to 9600 strokes annually in the US. Screening CT angiograms (CTAs) of patients with trauma has become ubiquitous in recent years, and patients with initially asymptomatic TCVI are commonly treated with antiplatelet agents to prevent stroke. Prophylaxis with antiplatelets is thought to be safer than anticoagulation, which carries a significant risk of hemorrhage in patients with trauma. However, the risk of hemorrhagic complications due to antiplatelets has not been assessed in this population.

METHODS

This is a retrospective cohort study of patients in whom a screening CTA was obtained after admission for blunt trauma at a Level 1 trauma center. Patients with CTAs indicating TCVI were treated routinely with 325 mg aspirin daily. The risk of transfusion > 24 hours after admission was compared according to CTA findings (CTA+ or CTA- for positive or negative findings, respectively) and aspirin treatment (ASA+ or ASA- for treatment or no treatment, respectively).

RESULTS

The mean overall transfusion amount (number of units of packed red blood cells [PRBCs]) was 0.9 ± 2.1 for CTA+/ASA+ patients (n = 196) and 0.3 ± 1.60 for CTA-/ASA- patients (n = 2290) (p < 0.0001). In adjusted models, the overall relative risk (RR) of PRBC transfusion was 1.70 (1.32-2.20) for CTA+/ASA+ patients compared with CTA-/ASA- patients. Among age groups, participants whose ages were 50-69 years had the greatest significantly elevated RR (1.71, 95% CI 1.08-2.72) for CTA+/ASA+ patients compared with CTA-/ASA- patients.

CONCLUSIONS

Treatment with aspirin for the prevention of stroke in patients with initially asymptomatic TCVI carries a significantly increased risk of PRBC transfusion. Future studies are needed to determine if this risk is offset by a reduced risk of ischemic stroke.

Older age is associated with a reduced likelihood of ambulance transport to a trauma centre after major trauma in Perth

OBJECTIVE

To describe the characteristics and outcomes of older adult (≥65 years) major trauma patients in comparison with younger adults (16-64 years). To determine whether older age is associated with a reduced likelihood of transport (directly or indirectly) to a major trauma centre and whether this is associated with in-hospital mortality.

METHODS

A retrospective cohort study of major trauma patients transported to hospital by St John Ambulance paramedics in Perth, Western Australia, between 1 January 2013 and 31 December 2016. Multivariate logistic regression was used to test the relationship between age and major trauma centre transport. Multivariate logistic regression analysis using inverse probability of treatment weighting was used to determine if major trauma centre transport was associated with in-hospital mortality in older adults.

RESULTS

One thousand six hundred and twenty-five patients were included; of these 576 (35%) were ≥65 years. In comparison with younger adults, older adults had more falls as their mechanism of injury (n = 358 [62%] versus n = 102 [10%], P ≤ 0.001) and more major head injuries (n = 472 [82%] versus n = 609 [58%], P ≤ 0.001). Older adults had lower odds (adjusted odds ratio 0.52, 95% confidence interval [CI] 0.35-0.78) of major trauma centre transport and this was associated with 1.7 times the likelihood of in-hospital mortality (95% CI 1.04-2.7).

CONCLUSIONS

Older adults who were not transported to the trauma centre had an increased odds of in-hospital mortality. However, older age was associated with a significantly reduced likelihood of trauma centre transport. With the aging population, the development of specific prehospital triage criteria to enable the complexities of this higher-risk population to be identified is important.

The Evolution of Trauma in Los Angeles County Over More Than a Decade

OBJECTIVE

Explore trends in trauma incidence and mortality rates in Los Angeles County.

DESIGN

Data for patients treated at Los Angeles County trauma centers from 2000 to 2011 were analyzed for this study. Age-adjusted incidence and mortality rates were calculated by gender, race, injury type, injury severity, and mechanism of injury. Trends were assessed using linear regression to determine the annual percentage change (APC).

RESULTS

There were 223 773 patients included. The trauma incidence rate increased by 14.6% driven by an increase in blunt injury of 5.4% annually (P < .05). Penetrating injury decreased at -6.9% APC (P < .01). Mortality rate decreased at -11.5% APC (P < .01), with reduction in both blunt (-6.8% APC [P < .01]) and penetrating injuries (-16.7% APC [P < .01]). The trends in mortality persisted with stratification by age, gender, race, and injury severity score.

CONCLUSION

In this mature trauma system, the trauma incidence increased slightly from 2000 to 2011, while the mortality steadily declined. Public health officials in other areas could perform a similar self-evaluation to describe and monitor injury events and trends in their jurisdictions, a reassessment of priority and trauma system resource allocation, which will directly benefit the regional population.

Factors affecting mortality in older trauma patients-A systematic review and meta-analysis

INTRODUCTION

Major trauma in older people is a significant health burden in the developed world. The aging of the population has resulted in larger numbers of older patients suffering serious injury. Older trauma patients are at greater risk of death from major trauma, but the reasons for this are less well understood. The aim of this review was to identify the factors affecting mortality in older patients suffering major injury.

MATERIALS AND METHODS

A systematic review of Medline, Cinhal and the Cochrane database, supplemented by a manual search of relevant papers was undertaken, with meta-analysis. Multi-centre cohort studies of existing trauma registries that reported risk-adjusted mortality (adjusted odds ratios, AOR) in their outcomes and which analysed patients aged 65 and older as a separate cohort were included in the review.

RESULTS

3609 papers were identified from the electronic databases, and 28 from manual searches. Of these, 15 papers fulfilled the inclusion criteria. Demographic variables (age and gender), pre-existing conditions (comorbidities and medication), and injury-related factors (injury severity, pattern and mechanism) were found to affect mortality. The 'oldest old', aged 75 and older, had higher mortality rates than younger patients, aged 65-74 years. Older men had a significantly higher mortality rate than women (cumulative odds ratio 1.51, 95% CI 1.37-1.66). Three papers reported a higher risk of death in patients with pre-existing conditions. Two studies reported increased mortality in patients on warfarin (cumulative odds ratio 1.32, 95% CI 1.05-1.66). Higher mortality was seen in patients with lower Glasgow coma scores and systolic blood pressures. Mortality increased with increased injury severity and number of injuries sustained. Low level falls were associated with higher mortality than motor vehicle collisions (cumulative odds ratio 2.88, 95% CI 1.26-6.60).

CONCLUSIONS

Multiple factors contribute to mortality risk in older trauma patients. The relation between these factors and mortality is complex, and a fuller understanding of the contribution of each factor is needed to develop a better predictive model for trauma outcomes in older people. More research is required to identify patient and process factors affecting mortality in older patients.

Hospital-based emergency department visits in children with motor vehicle traffic accidents: estimates from the nationwide emergency department sample

BACKGROUND

The purpose of this study is to provide nationally representative estimates of children visiting hospital-based emergency departments (ED) for motor vechicle traffic accidents (MVTA) in the United States during the year of 2008.

METHODS

Nationwide Emergency Department Sample for 2008 was used. All pediatric (age ≤18 years) ED visits with external cause for injury ICD-9-diagnostic codes for MVTA were selected. Outcomes examined included discharge status following ED visit and presence of concomitant injuries. Descriptive statistics was used to summarize the estimates.

RESULTS

Totally 604 027 hospital-based ED visits occurred in the United States among children (age ≤18 years) due to MVTA. Following an ED visit, 91% were discharged routinely, while 6% were admitted as inpatients into the same hospital. A total of 928 children died in the ED. A total of 34 004 ED visits required inpatient admission into the same hospital and 768 patients died during hospitalization. Mean charge per ED visit was $1887 and total ED charges across the United States were close to $970 million. Among those admitted into the same hospital following ED visit (n=34 004), the mean hospitalization charge was $53 726 and total hospitalization charge across the entire United States were $1.8 billion.

CONCLUSIONS

Study findings illustrate the burden associated with pediatric ED visits due to MVTA. Close to $970 million of hospital charges were incurred by children who made an ED visit due to a MVTA during 2008 and about $1.8 billion was incurred among those hospitalized following an ED visit.

Does progressive resistance and balance exercise reduce falls in residential aged care? Randomized controlled trial protocol for the SUNBEAM program

Introduction

Falls are common among older adults. It is reported that approximately 60% of residents of aged care facilities fall each year. This is a major cause of morbidity and mortality, and a significant burden for health care providers and the health system. Among community dwelling older adults, exercise appears to be an effective countermeasure, but data are limited and inconsistent among studies in residents of aged care communities. This trial has been designed to evaluate whether the SUNBEAM program (Strength and Balance Exercise in Aged Care) reduces falls in residents of aged care facilities.

Research question

Is the program more effective and cost-effective than usual care for the prevention of falls?

Design

Single-blinded, two group, cluster randomized trial.

Participants and setting

300 residents, living in 20 aged care facilities.

Intervention

Progressive resistance and balance training under the guidance of a physiotherapist for 6 months, then facility-guided maintenance training for 6 months.

Control

Usual care.

Measurements

Number of falls, number of fallers, quality of life, mobility, balance, fear of falling, cognitive well-being, resource use, and cost-effectiveness. Measurements will be taken at baseline, 6 months, and 12 months.

Analysis

The number of falls will be analyzed using a Poisson mixed model. A logistic mixed model will be used to analyze the number of residents who fall during the study period. Intention-to-treat analysis will be used.

Discussion

This study addresses a significant shortcoming in aged care research, and has potential to impact upon a substantial health care problem. Outcomes will be used to inform care providers, and guide health care policies.