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Terhalle L, Arntz L, Hoffmann F, Arnold I, Hafner L, Picking-Pitasch L, Zuppinger J, Delport Lehnen K, Leuppi J, Somasundaram R, Nickel CH, Bingisser R. Nonspecific stress biomarkers for mortality prediction in older emergency department patients presenting with falls: a prospective multicenter observational study. Intern Emerg Med 2024:10.1007/s11739-024-03693-6. [PMID: 38960969 DOI: 10.1007/s11739-024-03693-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 06/21/2024] [Indexed: 07/05/2024]
Abstract
BACKGROUND Older patients presenting to the emergency department (ED) after falling are increasingly prevalent. Falls are associated with functional decline and death. Biomarkers predicting short-term mortality might facilitate decisions regarding resource allocation and disposition. D-dimer levels are used to rule out thromboembolic disease, while copeptin and adrenomedullin (MR-proADM) may be used as measures of the patient`s stress level. These nonspecific biomarkers were selected as potential predictors for mortality. METHODS Prospective, international, multicenter, cross-sectional observation was performed in two tertiary and two regional hospitals in Germany and Switzerland. Patients aged 65 years or older presenting to the ED after a fall were enrolled. Demographic data, Activities of Daily Living (ADL), and D-dimers were collected upon presentation. Copeptin and MR-proADM levels were determined from frozen samples. Primary outcome was 30-day mortality; and secondary outcomes were mortality at 90, 180, and 365 days. RESULTS Five hundred and seventy-two patients were included. Median age was 83 [IQR 78, 89] years, 236 (67.7%) were female. Mortality overall was 3.1% (30 d), 5.4% (90 d), 7.5% (180 d), and 13.8% (365 d), respectively. Non-survivors were older, had a lower ADL index and higher levels of all three biomarkers. Elevated levels of MR-proADM and D-dimer were associated with higher risk of mortality. MR-proADM and D-dimer showed high sensitivity and low negative likelihood ratio regarding short-term mortality, whereas copeptin did not. CONCLUSION D-dimer and MR-proADM levels might be useful as prognostic markers in older patients presenting to the ED after a fall, by identifying patients at low risk of short-term mortality. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02244983.
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Affiliation(s)
- Lukas Terhalle
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland.
| | - Laura Arntz
- Emergency Department, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Felix Hoffmann
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Isabelle Arnold
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Livia Hafner
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | | | - Joanna Zuppinger
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
- Emergency Department, Cantonal Hospital Basel-Landschaft, Liestal, Switzerland
| | - Karen Delport Lehnen
- Emergency Department, Cantonal Hospital Basel-Landschaft Campus Bruderholz, Binningen, Switzerland
| | - Jörg Leuppi
- Medical Faculty, University of Basel and Cantonal Hospital Baselland, Liestal, Switzerland
| | - Rajan Somasundaram
- Emergency Department, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Christian H Nickel
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Roland Bingisser
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
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Shih RD, Alter SM, Wells M, Solano JJ, Engstrom G, Clayton LM, Hughes PG, Goldstein L, Lottenberg L, Ouslander JG. The Florida Geriatric Head Trauma CT Clinical Decision Rule. J Am Geriatr Soc 2024. [PMID: 38959158 DOI: 10.1111/jgs.19057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 05/24/2024] [Accepted: 06/05/2024] [Indexed: 07/05/2024]
Abstract
BACKGROUND Several clinical decision rules have been devised to guide head computed tomography (CT) use in patients with minor head injuries, but none have been validated in patients 65 years or older. We aimed to derive and validate a head injury clinical decision rule for older adults. METHODS We conducted a secondary analysis of an existing dataset of consecutive emergency department (ED) patients >65 years old with blunt head trauma. The main predictive outcomes were significant intracranial injury and Need for Neurosurgical Intervention on CT. The secondary outcomes also considered in the model development and validation were All Injuries and All Intracranial Injuries. Predictor variables were identified using multiple variable logistic regression, and clinical decision rule models were developed in a split-sample derivation cohort and then tested in an independent validation cohort. RESULTS Of 5776 patients, 233 (4.0%) had significant intracranial injury and an additional 104 (1.8%) met CT criteria for Need for Neurosurgical Intervention. The best performing model, the Florida Geriatric Head Trauma CT Clinical Decision Rule, assigns points based on several clinical variables. If the points totaled 25 or more, a CT scan is indicated. The included predictors were arrival via Emergency Medical Services (+30 points), Glasgow Coma Scale (GCS) <15 (+20 points), GCS <14 (+50 points), antiplatelet medications (+17 points), loss of consciousness (+16 points), signs of basilar skull fracture (+50 points), and headache (+20 points). Utilizing this clinical decision rule in the validation cohort, a point total ≥25 had a sensitivity and specificity of 100.0% (95% CI: 96.0-100) and 12.3% (95% CI: 10.9-13.8), respectively, for significant intracranial injury and Need for Neurosurgical Intervention. CONCLUSIONS The Florida Geriatric Head Trauma CT Clinical Decision Rule has the potential to reduce unnecessary CT scans in older adults, without compromising safe emergency medicine practice.
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Affiliation(s)
- Richard D Shih
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
- Depatment of Emergency Medicine, Delray Medical Center, Delray Beach, Florida, USA
| | - Scott M Alter
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
- Depatment of Emergency Medicine, Delray Medical Center, Delray Beach, Florida, USA
- Depatment of Emergency Medicine, Bethesda Hospital East, Boynton Beach, Florida, USA
| | - Mike Wells
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
| | - Joshua J Solano
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
- Depatment of Emergency Medicine, Delray Medical Center, Delray Beach, Florida, USA
- Depatment of Emergency Medicine, Bethesda Hospital East, Boynton Beach, Florida, USA
| | - Gabriella Engstrom
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
| | - Lisa M Clayton
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
- Depatment of Emergency Medicine, Delray Medical Center, Delray Beach, Florida, USA
- Depatment of Emergency Medicine, Bethesda Hospital East, Boynton Beach, Florida, USA
| | - Patrick G Hughes
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
- Depatment of Emergency Medicine, Delray Medical Center, Delray Beach, Florida, USA
- Depatment of Emergency Medicine, Bethesda Hospital East, Boynton Beach, Florida, USA
| | - Lara Goldstein
- Department of Emergency Medicine, Memorial Healthcare System, Hollywood, Florida, USA
| | - Lawrence Lottenberg
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
- Department of Surgery, St. Mary's Medical Center, West Palm Beach, Florida, USA
| | - Joseph G Ouslander
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
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Colalillo JM. Geriatric emergency medicine: Complexity evolves with age. Emerg Med Australas 2024; 36:159-161. [PMID: 38155493 DOI: 10.1111/1742-6723.14367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 12/18/2023] [Indexed: 12/30/2023]
Affiliation(s)
- James M Colalillo
- Emergency Department, Fiona Stanley Hospital, Perth, Western Australia, Australia
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Vollrath JT, Schindler CR, Marzi I, Lefering R, Störmann P. Lung failure after polytrauma with concomitant thoracic trauma in the elderly: an analysis from the TraumaRegister DGU®. World J Emerg Surg 2022; 17:12. [PMID: 35197078 PMCID: PMC8867717 DOI: 10.1186/s13017-022-00416-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 02/08/2022] [Indexed: 11/19/2022] Open
Abstract
Background In developed countries worldwide, the number of older patients is increasing. Pulmonary complications are common in multiple injured patients with chest injuries. We assessed whether geriatric patients develop lung failure following multiple trauma with concomitant thoracic trauma more often than younger patients.
Methods A retrospective analysis of severely injured patients with concomitant blunt thoracic trauma registered in the TraumaRegister DGU® (TR-DGU) between 2009 and 2018 was performed. Patients were categorized into four age groups: 55–64 y, 65–74 y, 75–84 y, and ≥ 85 y. Adult patients aged 18–54 years served as a reference group. Lung failure was defined as PaO2/FIO2 ≤ 200 mm Hg, if mechanical ventilation was performed. Results A total of 43,289 patients were included, of whom 9238 (21.3%) developed lung failure during their clinical stay. The rate of posttraumatic lung failure was seen to increase with age. While lung failure markedly increased the length of hospital stay, duration of mechanical ventilation, and length of ICU stay independent of the patient’s age, differences between younger and older patients with lung failure in regard to these parameters were clinically comparable. In addition, the development of respiratory failure showed a distinct increase in mortality with higher age, from 16.9% (18–54 y) to 67.2% (≥ 85 y). Conclusion Development of lung failure in severely injured patients with thoracic trauma markedly increases hospital length of stay, length of ICU stay, and duration of mechanical ventilation in patients, regardless of age. The development of respiratory failure appears to be related to the severity of the chest trauma rather than to increasing patient age. However, the greatest effects of lung failure, particularly in terms of mortality, were observed in the oldest patients.
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Affiliation(s)
- Jan Tilmann Vollrath
- Department of Trauma, Hand, and Reconstructive Surgery, University Hospital Frankfurt am Main, Goethe University, Theodor-Stern-Kai 7, 60596, Frankfurt am Main, Germany.
| | - Cora Rebecca Schindler
- Department of Trauma, Hand, and Reconstructive Surgery, University Hospital Frankfurt am Main, Goethe University, Theodor-Stern-Kai 7, 60596, Frankfurt am Main, Germany
| | - Ingo Marzi
- Department of Trauma, Hand, and Reconstructive Surgery, University Hospital Frankfurt am Main, Goethe University, Theodor-Stern-Kai 7, 60596, Frankfurt am Main, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), Cologne Merheim Medical Center (CMMC), University of Witten/Herdecke, Cologne, Germany
| | - Philipp Störmann
- Department of Trauma, Hand, and Reconstructive Surgery, University Hospital Frankfurt am Main, Goethe University, Theodor-Stern-Kai 7, 60596, Frankfurt am Main, Germany
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Pedersen V, Lampart A, Bingisser R, Nickel CH. Accuracy of plain radiography in detecting fractures in older individuals after low-energy falls: current evidence. Trauma Surg Acute Care Open 2020; 5:e000560. [PMID: 33178895 PMCID: PMC7640585 DOI: 10.1136/tsaco-2020-000560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 10/04/2020] [Indexed: 11/08/2022] Open
Abstract
Background Older individuals sustaining low-energy falls (LEF) and presenting to the emergency department (ED) demand straightforward diagnostic measures for injury detection. Plain radiography (XR) series for diagnosis of fall-related injuries are standard of care, but frequently subsequent CT examination is required for diagnostic assurance. A systematic database search of diagnostic accuracy of XR for detection of fractures in older LEF patients was performed. Methods We searched PubMed, Embase, Cochrane Library, WHO International Clinical Trial Platform, and Clinical trials.gov databases from inception to January 2020 for studies including older patients (≥65 years) with LEF and obtaining CT examination and XR of the skeleton in an ED setting. Results From 8944 references screened, 11 studies met the criteria for inclusion. Performance of XR for detection of fractures of the pelvic ring and hip was analyzed in nine studies, two studies investigated XR performance to detect rib fractures, and two studies compared diagnostic accuracy of thoracolumbar spine XR. Sensitivity estimates ranged from 10% to 58% and specificity estimates from 55% to 100%. Clinical and statistical heterogeneity was significant among included studies, with an overall considerable risk of bias. Discussion High-quality evidence on accurate imaging strategies in older patients with LEF is lacking to date. XR is missing a reasonable amount of fractures of the pelvic ring, rib cage, and thoracic and lumbar spine. However, the utility of first-line CT imaging and the benefit of diagnosing every fracture is unknown, demanding high-quality prospective trials considering patient-oriented outcome as well.
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Affiliation(s)
- Vera Pedersen
- Department for General, Trauma and Reconstructive Surgery, University Hospital Munich, Munich, Germany
| | - Alina Lampart
- Department of Internal Medicine, Upper Valais Hospital Center Visp Location, Visp, Valais, Switzerland
| | - Roland Bingisser
- Emergency Department, University Hospital Basel, Basel, Switzerland
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Abstract
"Standing-level falls represent the most frequent cause of trauma-related death in older adults and a common emergency department (ED) presentation. However, these patients rarely receive guideline-directed screening and interventions during or following an episode of care. Reducing injurious falls in an aging society begins with prehospital evaluations and continues through definitive risk assessments and interventions that usually occur after ED care. Although ongoing obstacles to ED-initiated, evidence-based older adult fall-reduction strategies include the absence of a compelling emergency medicine evidence basis, innovations under way include validation of pragmatic screening instruments and incorporation of contemporary technology to improve fall detection rates."
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Nagaraj G, Hullick C, Arendts G, Burkett E, Hill KD, Carpenter CR. Avoiding anchoring bias by moving beyond 'mechanical falls' in geriatric emergency medicine. Emerg Med Australas 2018; 30:843-850. [PMID: 30091183 DOI: 10.1111/1742-6723.13129] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 06/12/2018] [Indexed: 12/14/2022]
Affiliation(s)
- Guruprasad Nagaraj
- Hornsby Ku-ring-gai Hospital, Sydney, New South Wales, Australia.,Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Carolyn Hullick
- Emergency Department, John Hunter Hospital, Newcastle, New South Wales, Australia.,School of Medicine and Public Health, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Glenn Arendts
- Department of Emergency Medicine, The University of Western Australia, Perth, Western Australia, Australia
| | - Ellen Burkett
- Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Keith D Hill
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
| | - Christopher R Carpenter
- Department of Emergency Medicine, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
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