A five-year experience with severe injuries in elderly patients

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.

Rotational thromboelastometry values across age groups in all trauma patients presenting to a level 1 trauma centre: An observational study

OBJECTIVES

To describe rotational thromboelastometry (ROTEM) values (FIBTEM A5, EXTEM A5 and EXTEM CT) across age groups and assess for a statistical trend; and to determine whether any trend in ROTEM values is affected by severity of injury and packed red blood cells (PRBC) requirement.

METHODS

Retrospective observational study at a level 1 trauma centre in Queensland, Australia. A total of 1601 consecutive trauma patients presenting to the ED. ROTEM data described included FIBTEM A5, EXTEM A5 and EXTEM CT. These values are described by age group (≤30 years, 31-45 years, 46-60 years, 61-75 years and >75 years), Injury Severity Score (ISS) category (<12, ≥12, <25 and ≥25) and number of PRBCs transfused in the first 24 h of admission (0 units, 1-4 units, 5-9 units and ≥10 units).

RESULTS

The median age of participants was 37 years (interquartile range [IQR] 25-54 years), with 48.2% of patients had severe trauma (ISS >12) and 13.2% receiving at least one unit of PRBC in the first 24 h of admission. Median (IQR) values for FIBTEM A5, EXTEM A5 and EXTEM CT were 13 mm (10-16 mm), 45 mm (40-49 mm) and 62 s (56-71 s), respectively. A test for trend over progressive age groups showed an increase in FIBTEM A5 (P < 0.001) and EXTEM A5 values (P < 0.001) and a decrease in EXTEM CT values (P < 0.001).

CONCLUSION

The present study demonstrated a pattern of increasing coagulability, as defined by ROTEM, with increasing age group in trauma patients, even among the severely injured. Further investigation is required to determine the clinical impact of these findings on both the ROTEM-guided management and longitudinal outcomes of these patients and whether an age-specific approach is beneficial.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level III.

STUDY TYPE

Prognostic/Therapeutic/Diagnostic Test/Economic/Decision.

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

Objectives

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

Material and Methods

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

Results

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

Conclusion

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

Elderly trauma associated with high-risk recreational activity: A population-based study, United States, 2010 through 2016

BACKGROUND

Understanding trends in prevalence and etiology is critical to public health strategies for prevention and management of injury related to high-risk recreation in elderly Americans.

METHODS

The National Emergency Department Sample from 2010 through 2016 was queried for patients with a principal diagnosis of trauma (ICD-9 codes 800.0-959.9) and who were 55 years and older. High-risk recreation was determined from e-codes a priori. Primary outcome measures were mortality and total hospital charges.

RESULTS

Of the 29,491,352 patient cohort, 458,599 (1.56%) engaged in high-risk activity, including those age 85 and older. High-risk cases were younger (median age 61 vs 70) and majority male (71.87% vs 39.24%). The most frequent activities were pedal cycling (45.81%), motorcycling (29.08%), and off-road vehicles (9.13%). Brain injuries (8.82% vs 3.88%), rib/sternal fractures (13.35% vs 3.53%), and cardiopulmonary injury (5.25% vs 0.57%) were more common among high-risk cases. Mortality (0.75% vs 0.40%) and total median hospital charges ($3,360 vs $2,312) were also higher for high-risk admissions, where the odds of mortality increased exponentially per year of age (odds ratio, 1.06; 99.5% CI, 1.05-1.08). High-risk recreation was associated with more than $1 billion in total hospital charges and more than 100 deaths among elderly Americans per year.

CONCLUSION

Morbidity, mortality, and resource utilization due to high-risk recreation extend into the ninth decade of life. The patterns of injury described here offer opportunities for targeted injury prevention education to minimize risk among this growing segment of the United States population.

A retrospective cohort study of 27,049 polytraumatized patients age 60 and above: identifying changes over 16 years

Aim

In this study, we establish an overview of changes we observed in demographics of older severe trauma patients from 2002 to 2017.

Findings

Trauma mechanism, as well as injury pattern, changed over time. We found length of stay and mortality decreased despite an increase in patient age.

Message

We ascribe this observation mainly to increased use of diagnostic tools and improved treatment algorithms and underline the importance of the implementation of specialized geriatric trauma centers allowing interdisciplinary care.

Purpose

The number of severely injured patients exceeding the age of 60 has shown a steep increase within the last decades. These patients present with numerous co-morbidities, polypharmacy, and increased frailty requiring an adjusted treatment approach. In this study, we establish an overview of changes we observed in demographics of older severe trauma patients from 2002 to 2017.

Methods

A descriptive analysis of the data from the TraumaRegister DGU^® (TR-DGU) was performed. Patients admitted to a level one trauma center in Germany, Austria and Switzerland between 2002 and 2017, aged 60 years or older and with an injury severity score (ISS) over 15 were included. Patients were stratified into subgroups based on the admission: 2002–2005 (1), 2006–2009 (2), 2010–2013 (3) and 2014–2017 (4). Trauma and patient characteristics, diagnostics, treatment and outcome were compared.

Results

In total 27,049 patients with an average age of 73.9 years met the inclusion criteria. The majority were males (64%), and the mean ISS was 27.4. The proportion of patients 60 years or older [(23% (1) to 40% (4)] rose considerably over time. Trauma mechanisms changed over time and more specifically low falls (< 3 m) rose from 17.6% (1) to 40.1% (4). Altered injury patterns were also identified. Length-of-stay decreased from 28.9 (1) to 19.5 days (4) and the length-of-stay on ICU decreased from 17.1 (1) to 12.7 days (4). Mortality decreased from 40.5% (1) to 31.8% (4).

Conclusion

Length of stay and mortality decreased despite an increase in patient age. We ascribe this observation mainly to increased use of diagnostic tools, improved treatment algorithms, and the implementation of specialized trauma centers for older patients allowing interdisciplinary care.

Is There Any Difference in the Outcome of Geriatric and Non-Geriatric Severely Injured Patients?-A Seven-Year, Retrospective, Observational Cohort Study with Matched-Pair Analysis

Geriatric trauma is expected to increase due to the lifestyle and activity of the aging population and will be among the major future challenges in health care. Therefore, the aim of this study was to investigate differences between polytraumatized geriatric and non-geriatric patients regarding mortality, length-of-stay and complications with a matched pair analysis. We included patients older than 17 years with an Injury Severity Score (ISS) of 16 or more admitted to our level 1 trauma center between January 2008 and December 2015. The cohort was stratified into two groups (age < 70 and ≥ 70 years). One-to-one matching was performed based on gender, ISS, mechanism of injury (penetrating/blunt), Glasgow coma scale (GCS), base excess, and the presence of coagulopathy (international normalized ratio (INR) ≥ 1.4). Outcome was compared using the paired t-test and McNemar-test. A total of 1457 patients were identified. There were 1022 male (70%) and 435 female patients. Three hundred and sixty-four patients (24%) were older than 70 years. Matching resulted in 57 pairs. Mortality as well as length-of-stay were comparable between geriatric and non-geriatric polytraumatized patients. Complication rate (34% vs. 56%, p = 0.031) was significantly higher in geriatric patients. This indicates the possibility of similar outcomes in geriatric polytraumatized patients receiving optimal care.

Differences in Injury Pattern and Mortality between Hong Kong Elderly and Younger Patients

Background

The rapidly aging population in Hong Kong is causing an impact on our health care system. In Hong Kong, 16.5% of emergency department trauma patients are aged ≥65 years.

Objective

We aim to compare factors associated with trauma and differences in trauma mortality between elderly (≥65 years) and younger adult patients (15 to 64 years) in Hong Kong.

Methods

A retrospective observational study was performed using trauma registry data from the Prince of Wales Hospital, a 1200–bed acute hospital which is a regional trauma centre.

Results

A total of 2172 patients (331 [15.2%] elderly and 1841 [84.8%] younger) were included. Male patients predominated in the younger adult group but not in the elderly group. Compared with younger patients, elderly patients had more low falls and pedestrian-vehicle crashes and sustained injuries to the head, neck and extremities more frequently. The odds ratio (OR) for death following trauma was 5.5 in the elderly group (95% confidence interval [CI] 3.4–8.9, p>0.0001). Mortality rates increased progressively with age (p>0.0001) and were higher in the elderly at all levels of Injury Severity Score (ISS). Age ≥65 years independently predicted mortality (OR=5.7, 95% CI 3.5–9.3, p>0.0001). The elderly had a higher co-morbidity rate (58.6% vs. 14.1%; p>0.01). There was a lower proportion of trauma call activations for the elderly group (38.6% vs. 53.3%; p>0.01).

Conclusion

Elderly trauma patients differ from younger adult trauma patients in injury patterns, modes of presentation of significant injuries and mortality rates. In particular, the high mortality of elderly trauma requires renewed prevention efforts and aggressive trauma care to maximise the chance of survival.

The Tragically Hip: Trauma in Elderly Patients

Old age is a risk factor for poor outcome in trauma patients, as a result of undertriage and the presence of occult life-threatening injuries. The mechanisms of injury for geriatric trauma differ from those in younger patients, with a much higher incidence of low-impact trauma, especially falls from a low height. Frailty is a risk factor for severe injury after minor trauma, and caring for these patients require a multidisciplinary team with both trauma and geriatric expertise. With early recognition and aggressive management, severe injuries can still be associated with good outcomes, even in very elderly patients.

Intensive care and invasive ventilation in the elderly patient, implications of chronic lung disease and comorbidities

Aims: Elderly patients have an increasing prevalence of illness that requires consideration of critical care and invasive ventilatory support. Although critical care of even the very elderly can provide value, with increasing age the potential risks of treatment and diminishing returns with respect to quality and quantity of life result in a need for careful evaluation. Variable combinations of impaired organ function, active disease and residual pathology from past disease and injury all affect critical care, with the consequence that the elderly are a very heterogeneous population. Recognizing that critical care is a limited resource, it is important to identify patients who may be at increased risk or least likely to benefit from treatment. Patients with functional impairments, nutritional deficiencies and multiple comorbidities may be at highest risk of poor outcomes. Those with very severe disease, extreme age and requirements for prolonged ventilatory support have high in-hospital mortality. Functional impairments, comorbidities and severity of illness are usually more important considerations than chronologic age. The objective of this review is to identify how common problems of the elderly affect critical care and decisions concerning use of invasive ventilatory support.

Impact of age on the clinical outcomes of major trauma

PURPOSE

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

METHODS

Review of the literature.

RESULTS

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

CONCLUSION

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

Predictors of mortality and prehospital monitoring limitations in blunt trauma patients

This study aimed at determining predictors of in-hospital mortality and prehospital monitoring limitations in severely injured intubated blunt trauma patients. We retrospectively reviewed patients' charts. Prehospital vital signs, Injury Severity Score (ISS), initial Glasgow Coma Scale (GCS), Revised Trauma Score (RTS), arterial blood gases, and lactate were compared in two study groups: survivors (n = 40) and nonsurvivors (n = 30). There were no significant differences in prehospital vital signs between compared groups. Nonsurvivors were older (P = 0.006), with lower initial GCS (P < 0.001) and higher ISS (P < 0.001), along with higher lactate (P < 0.001) and larger base deficit (BD; P = 0.006), whereas RTS (P = 0.001) was lower in nonsurvivors. For predicting mortality, area under the curve (AUC) was calculated: for lactate 0.82 (P < 0.001), for ISS 0.82 (P < 0.001), and for BD 0.69 (P = 0.006). Lactate level of 3.4 mmol/L or more was 82% sensitive and 75% specific for predicting in-hospital death. In a multivariate logistic regression model, ISS (P = 0.037), GCS (P = 0.033), and age (P = 0.002) were found to be independent predictors of in-hospital mortality. The AUC for regression model was 0.93 (P < 0.001). Increased levels of lactate and BD on admission indicate more severe occult hypoperfusion in nonsurvivors whereas vital signs did not differ between the groups.

Retrospective analysis of incidental non-trauma associated findings in severely injured patients identified by whole-body spiral CT scans

BACKGROUND

Whole-body Computed Tomography (CT) scan today is considered a crucial imaging technique in the diagnostic work-up of polytrauma patients implicating a potential survival benefit. Apart from prompt identification of life threatening injuries this imaging technique provides an additional benefit by diagnosing incidental non-trauma associated medical diseases. These incidental findings might be also life threatening and warrant urgent therapy. The downside of whole-body CT is a relatively high radiation exposure that might result in an increased life time cancer risk. The aim of this study was to investigate the frequency and type of non trauma associated incidental medical findings in relation to patient age and potential clinical relevance.

METHODS

Between January 1(st) 2011 and December 15th 2012, a total of 704 trauma patients were referred to our hospital's emergency room that triggered trauma room alarm according to our trauma mechanism criteria. Of these 534 (75.8%) received a whole-body CT according to our dedicated multiple trauma protocol. Incidental Findings (IF) were assigned in three groups according to their clinical relevance. Category 1: IF with high medical relevance (urgent life threatening conditions, unless treated) needing early investigations and intervention prior to or shortly after hospital discharge. Category 2: IF with intermediate or low medical relevance, warranting further investigations. Category 3: IF without clinical relevance.

RESULTS

Overall 231 IFs (43.3%) were identified, 36 (6.7%) patients had IFs with a high clinical relevance, 48 (9.0%) with a moderate or minor clinical relevance and 147 (27.5%) with no clinical relevance. The distribution of incidental findings with high or moderate relevance according to age showed an incidence of 2.6%, 6.6% and 8.8% for patients younger than 40 years, 40 to 60 years and older than 60 years, respectively.

CONCLUSION

Whole-body CT scans of trauma patients demonstrate a high rate of incidental findings. Potentially life-threatening, medical findings were found in approximately every 15th patient, predominantly aged over 40 years and presenting with minor to moderate injuries and an Injury Severity Score (ISS) of 10 or less.

A simple clinical risk nomogram to predict mortality-associated geriatric complications in severely injured geriatric patients

BACKGROUND

This study aimed to (1) identify inpatient complications associated with the greatest differential mortality risk between young and old patients with traumatic injury and (2) identify older patients at elevated risk for mortality-associated complications.

METHODS

Secondary analysis of more than 280,000 patients hospitalized for traumatic injury in 2001 to 2005 collected by the National Trauma Data Bank was performed. Predictor variables include 21 hospital complications. We used each complication to predict odds of hospital mortality, stratified by old (65+ years) versus young (18-64 years) age, controlling for age, sex, and preexisting condition count. We defined mortality-associated geriatric complications (MGCs) as complications associated with more than two times risk of mortality in older patients compared with younger patients. We then used age, comorbidity, and sex to predict development of MGCs or death.

RESULTS

We defined seven infectious and six noninfectious complications as MGCs (adjusted relative risk reduction for death associated with old age [aRRR] with 95% confidence interval [CI]): abscess (aRRR, 4.1; 95% CI, 3.6-4.5), wound infection (aRRR, 3.5; 95% CI, 3.2-3.9), empyema (aRRR, 3.4; 95% CI, 3.1, 3.8), urinary tract infection (aRRR, 3.3; 95% 3.0-3.6), pneumonia (aRRR, 3.1; 95% CI, 2.8-3.5), bacteremia (aRRR, 2.8; 95% CI, 2.6-3.0), aspiration pneumonia (aRRR, 2.6; 95% CI, 2.2-3.0), reduction/fixation failure (aRRR, 3.6; 95% CI, 3.3-3.9), pressure ulcer (aRRR, 3.3; 95% CI, 3.1-3.6), deep venous thrombosis (aRRR, 3.2; 95% CI, 2.9-3.6), pneumothorax (aRRR, 3.1; 95% CI, 2.5-3.7), and compartment syndrome (aRRR, 2.2; 95% CI, 1.5-2.9). We developed a graphical nomogram based on sex, age, and number of preexisting conditions to predict risk of MGCs (c statistic, 0.74).

CONCLUSION

Older patients at risk for MGC development should be considered for targeted interventions to improve quality of care.

LEVEL OF EVIDENCE

Prognostic/epidemiologic study, level III.

Fatality and injury severity of older adult motor vehicle collisions in orange county, california, 1998-2007

INTRODUCTION

Injuries and fatalities in adult drivers 18-65 years of age have decreased in recent years due to safer vehicles, enhanced medical policies, and implementation of injury prevention policies. However, adult drivers over 65 years of age are continuing to suffer from motor vehicle collision-related injuries and fatalities at a more constant rate. A number of physiological factors contribute to the deterioration in visual acuity, slower reaction speeds, and decreased awareness in older drivers. The objective of this study was to examine injury severity and fatality rates in older drivers compared to their younger counterparts in Orange County, California.

METHODS

This study used the Statewide Integrated Traffic Record System data for Orange County for the years 1998-2007. Drivers were categorized into 4 age groups: 25-64, 65-74, 75-84, and older than 85 years of age. Injury severity was assessed by the investigating officer.

RESULTS

Of the 197,814 drivers involved in motor vehicle collisions, 178,481 (90.2%) were in the 25-64 age group; 11,397 (5.8%) were 65-74; 6,592 (3.3%) were 75-84; and 1,344 drivers (0.7%) were over 85. Those aged 25-64 had the lowest fatality rate per 100,000 people, 2.5, whereas those 75-84 had the highest fatality rate, 4.9. The percent of crashes involving a left turn increased with age, and the percent that were stopped in the road decreases with age. Change in injury collision involvement ratio in the 3 younger age groups decreased by 26% to 32%, but decreased by 18% among drivers aged 85 years and older.

CONCLUSION

The decrease in collision fatalities was greater in the 25-64-year-old group compared to the older adult population. This disparity highlights the need for further injury prevention efforts for older drivers.

Improving adjustments for older age in pre-hospital assessment and care

Population estimates projects a significant increase in the geriatric population making elderly trauma patients more common. The geriatric trauma patients experience higher incidence of pre-existing medical conditions, impaired age-dependent physiologic reserve, use potent drugs and suffer from trauma system related shortcomings that influence outcomes. To improve adjustments for older age in pre-hospital assessment and care, several initiatives should be implemented. Decision-makers should make system revisions and introduce advanced point-of-care initiatives to improve outcome after trauma for the elderly.

Geriatric Trauma Patients at a Suburban Level-I Trauma Center in Japan

Background:

Despite the increases in the aged population in Japan, there are little data on geriatric patients with traumatic injuries. A prospective clinical study was carried out to evaluate the use of the emergency medical services (emergency medical services) system, mechanisms of injury, and prehospital assessment and triage of elderly victims of trauma.

Patients and Methods:

From July 1996 through June 1997, a group of geriatric trauma (Group G, n = 22) and a control group of younger trauma patients (n = 173) were compared with respect to transfer method to an Emergency Center (direct or indirect), Revised Trauma Scores on the scene of the accident (revised trauma score-l) and on admission to the Emergency Center (revised trauma score-2), and outcome (survival).

Results:

The mean values for revised trauma score-l in the Control Group (Group C) were not different from those in Group G, but revised trauma score-2 of the indirect-transfer patients (indirectly transported patients) in Group G were significantly lower than were those for Group C. Group G mortality rates were significantly higher than were the control rates (p = 0.0001). The mortality rate of the indirectly transported patients subgroup was significantly lower than that of the direct transfer subgroup (directly transported patients) (30/68 vs. 5/70, p<0.0001) in the Group C, but mortality rate of the indirectly transported patients subgroup exceeded that of the directly transported patients subgroup of Group G (8/14 vs. 5/8).

Conclusion:

The data suggest that in geriatric-age patients, direct transfer patients have a lower mortality rate than do indirect transfer patients when controlled for injury severity score. Therefore, it seems that a different set of triage criteria should be developed and implemented for geriatric-age victims with trauma-induced injuries and that those who meet these more stringent criteria should be transferred directly to a Trauma Center.

Polytrauma in the elderly: predictors of the cause and time of death

BACKGROUND

Increasing age and significant pre-existing medical conditions (PMCs) are independent risk factors associated with increased mortality after trauma. Our aim was to review all trauma deaths, identifying the cause and the relation to time from injury, ISS, age and PMCs.

METHODS

A retrospective analysis of trauma deaths over a 6-year period at the study centre was conducted. Information was obtained from the Trauma Audit and Research Network (TARN) dataset, hospital records, death certificates and post-mortem reports. The time and cause of death, ISS, PMCs were analysed for two age groups (<65 years and >or= 65 years).

RESULTS

Patients >or= 65 years old were at an increased risk of death (OR 6.4, 95% CI 5.2-7.8, p < 0.001). Thirty-two patients with an ISS of >15 and died within the first 24 hours of admission, irrespective of age, from causes directly related to their injuries. Twelve patients with an ISS of <16, died after 13 days of medical conditions not directly related to their injuries (p = 0.01). Thirty four patients had significant PMCs, of which 11 were <65 years (34.4% of that age group) and 23 were >or= 65 years (95.8% of that age group) (p = 0.02). The risk of dying late after sustaining minor trauma (ISS <16) is increased if a PMC exists (OR 5.5, p = 0.004).

CONCLUSION

Elderly patients with minor injuries and PMCs have an increased risk of death relative to their younger counterparts and are more likely to die of medical complications late in their hospital admission.

Alcohol use and testing among older trauma victims in Maryland

BACKGROUND

Few studies have examined alcohol use in the older trauma population. The purpose of the present study was to examine blood alcohol level testing and results among older trauma patients.

METHODS

All patients aged 65 years or older directly admitted from the injury scene and entered into the Maryland Trauma Registry during a 6-year period were reviewed.

RESULTS

The annual proportion of directly admitted patients of age 65 or older increased by 44% from 1996 to 2000. Blood alcohol concentration (BAC) was measured for 66% of older patients; 9% were alcohol positive, and 81% had BAC > or = 80 mg/dL. Mean BAC was 165 mg/dL for all alcohol-positive patients. The highest mean BAC was noted in patients with fall-related injuries, followed by pedestrians struck, then by those in a motor vehicle crash. The most common cause of injury was motor vehicle crash (47%). Among all injury causes, patients with fall-related injuries had the greatest proportional increase from 28% in 1996 to 44% in 2000. Alcohol positive status was most frequent (13%) and mean BAC was highest among patients admitted because of fall-related injuries.

CONCLUSION

Identifying and addressing alcohol use problems remains an important injury prevention measure for the older trauma population.

Epidemiologia das lesões traumáticas de alta energia em idosos

O aumento proporcional de idosos na população mundial associado à melhoria nas condições de saúde e suporte preventivo para essa faixa etária, permite forma de vida mais ativa, expondo-os a risco mais elevado de acidentes e traumas de alta energia. Esses pacientes têm características fisiológicas, doenças associadas, padrão comportamental e complicações pós-operatórias que levam a resposta sistêmica diferente dos demais grupos etários. Esse trabalho avaliou prospectivamente 28 pacientes com idade superior a 65 anos - 16 mulheres e 12 homens. O mecanismo de trauma mais prevalente foi atropelamento, resultando principalmente, em fraturas dos membros inferiores. O tempo de internação foi superior ao de pacientes de faixas etárias inferiores e 90% dos casos apresentaram algum tipo de complicação clínica após a osteossíntese. A idade age isoladamente como fator preditivo positivo para tais complicações no paciente politraumatizado. As doenças prévias e a idade dos doentes não influenciaram o desenvolvimento de complicações ortopédicas. As lesões associadas às fraturas apresentaram correlação com o mecanismo de trauma. Estes pacientes normalmente precisam ser operados para tratamento definitivo de suas fraturas. O fato de serem mais idosos e apresentarem doenças anteriormente ao acidente não aumenta o período pré-cirúrgico.

Elderly Trauma Inpatients in New York State: 1994???1998

BACKGROUND

The aging of the population in the United States has led to an increase in geriatric trauma. This study aimed to examine the characteristics and outcomes of geriatric trauma patients in New York State.

METHODS

Four groups of elderly trauma patients (ages 40-64, 65-74, 75-84, and 85+ years) were contrasted with younger adults ages 13 to 39 years with respect to mechanism of injury, discharge disposition, hospital length of stay, comorbidities, and type of hospital in which they were treated. Also, the independent association of each group with in-hospital mortality was investigated for patients with blunt injuries using logistic regression.

RESULTS

There was a 17.6% increase between 1994 and 1998 in the number of traumatic injuries qualifying for the New York State Trauma Registry in the 75- to 84-year-old group and a 16.4% increase in the group ages 85 years or older, despite a decrease in traumatic injuries in other age groups. The majority of these injuries among the patients 75 years of age or older resulted from low falls (from the same level). The mortality rate rose substantially with age, from 5.1% to 5.9% to 9.4% to 12.3% to 15.8%, respectively, for the groups ages 13 to 39, 40 to 64, 65 to 74, 75 to 84, and 85 or more years. Also, fewer than 20% of the patients older than 75 years died within 1 day after admission to the hospital, as compared with 44% of the patients younger than 65 years. The groups ages 40 to 64, 65 to 74, 75 to 84, and 85 years or older were all independent (increasingly) significant predictors of mortality for all three mechanisms of injury investigated. The adjusted odds ratios for mortality relative to patients who were 13 to 39 years of age were 2.67, 8.41, 17.40, and 34.98, respectively, for the groups ages 40 to 64, 65 to 74, 75 to 84, and 85 years or older.

CONCLUSIONS

Trauma is a serious and escalating problem for the elderly, and increasing age is a significant risk factor for patient mortality.

Skeletal injury patterns in older females

Injury patterns in elderly patients are different from those in younger patients. With recent emphasis on osteoporosis and its effects, we looked at a continuous series of patients from one Level 1 trauma center regarding injury patterns by gender. For all patients older than 65 years, and including all mechanisms, older women were more likely to sustain forearm and wrist fractures than were older men. For the individual mechanism of motor vehicle collision there was a significant increase in the extremity Abbreviated Injury Scores in older women compared with older men. Similarly, older women were more likely to sustain lower leg fractures and distal upper extremity fractures than were older men. This raises the possibility that increased bone loss, as seen in older women, may be reflected in the injury patterns they sustained given the same mechanism. More work is warranted in this region to potentially diminish these effects.

Improving the TRISS Methodology by Restructuring Age Categories and Adding Comorbidities

BACKGROUND

The Trauma and Injury Severity Score (TRISS) methodology was developed to predict the probability of survival after trauma. Despite many criticisms, this methodology remains in common use. The purpose of this study was to show that improving the stratification for age and adding an adjustment for comorbidity significantly increases the predictive accuracy of the TRISS model.

METHODS

The trauma registry and the hospital administrative database of a regional trauma center were used to identify all blunt trauma patients older than 14 years of age admitted with International Classification of Diseases, Ninth Revision codes 800 to 959 from April 1993 to March 2001. Each individual medical record was then reviewed to ascertain the Revised Trauma Score, the Injury Severity Score, the age of the patients, and the presence of eight comorbidities. The outcome variable was the status at discharge: alive or dead. The study population was divided into two subsamples of equal size using a random sampling method. Logistic regression was used to develop models on the first subsample; a second subsample was used for cross-validation of the models. The original TRISS and three TRISS-derived models were created using different categorizations of Revised Trauma Score, Injury Severity Score, and age. A new model labeled TRISSCOM was created that included an additional term for the presence of comorbidity.

RESULTS

There were 5,672 blunt trauma patients, 2,836 in each group. For original TRISS, the Hosmer-Lemeshow statistic (HL) was 179.1 and the area under the receiver operating characteristic (AUROC) curve was 0.873. Sensitivity and specificity were 99.0% and 27.8%, respectively. For the best modified TRISS model, the HL statistic was 20.35, the AUROC curve was 0.902, the sensitivity was 99.0%, and the specificity was 27.8%. For TRISSCOM, the HL statistic was 14.95 and the AUROC curve was 0.918. Sensitivity and specificity were 99.0% and 29.7%, respectively. The difference between the two models almost reached statistical significance (p = 0.086). When TRISSCOM was applied to the cross-validation group, the HL statistic was 10.48 and the AUROC curve was 0.914. The sensitivity was 98.6% and the specificity was 34.9%.

CONCLUSION

TRISSCOM can predict survival more accurately than models that do not include comorbidity. A better categorization of age and the inclusion of comorbid conditions in the logistic model significantly improves the predictive performance of TRISS.

Trauma in the very elderly: a community-based study of outcomes at trauma and nontrauma centers

BACKGROUND

Little research has examined trauma outcomes in the very elderly (>80 years), the fastest growing subset of our geriatric population. Our objective was to describe demographics, mechanism of injury and injury severity of very elderly trauma patients and examine the association between trauma center (TC) verification and hospital mortality in this age group.

METHODS

Retrospective cohort study. Database consisted of a 1996 countywide trauma registry. Subjects consisted of patients > 80 years of age. The setting consisted of Level I (TCI) and Level II (TCII) trauma centers, and acute care (AC) hospitals. The z score analysis was performed using the Major Trauma Outcome Study and a county-specific risk/outcome equation. In addition, a logistic regression model examined hospital mortality (outcome variable) using age, ISS, arrival GCS, and TC verification as predictor variables. Statistical analysis included descriptive statistics; ANOVA; and forward stepwise logistic regression model (OR; 95% CI).

RESULTS

Four hundred fifty-five patients with a mean age of 85.9 (+/-4.8) years (range 80-101). Overall mortality was 9.9%. Using z score analysis, survival at TCII performed as predicted (-1.59), while AC performed less than predicted (-3.41). In the regression model, GCS (OR 0.68; CI 0.57-0.79), ISS (OR 1.1; CI 1.05-1.2) and AC setting (OR 3.2; CI 1.1-9.5) predicted hospital mortality. TCs had significantly better outcomes than AC hospitals in a subset of severely injured patients (ISS 21-45) (56% v 8% survival; p < 0.01).

CONCLUSION

Risk-adjusted outcomes, in this population, differed between TC and AC settings. Head injury, injury severity, and lack of TC verification are associated with hospital mortality in very elderly trauma patients.

Motor vehicle crash fatalities in the elderly: rural versus urban

BACKGROUND

The elderly contribute disproportionately to hospital trauma mortality and expense. This population and its traffic fatality rate are increasing. The purpose of this study was to determine how the effect of age on vehicle-related mortality is modified by population density.

METHODS

FARS data for vehicle drivers and passengers were analyzed after linkage to census age-specific county population and area estimates. Characteristics of crash fatalities in the elderly (> or =65 years old) were compared with younger victims, for each quartile of county population density.

RESULTS

There were 5905 fatalities among the elderly, and 26,159 among the younger population, yielding annual rates (per 100,000) of 17.6 and 11.4. Rates were higher in counties with lower population density, but always higher among the elderly. Elderly fatal crash victims in all county quartiles were less likely to be male, unrestrained, riding with an intoxicated driver, or traveling over 60 MPH; all these risk factors were more frequent at lower population densities, regardless of age. Fatal crashes at intersections were more likely in the elderly, especially at higher population densities.

CONCLUSION

Older age and lower population density independently increase vehicle-related mortality. Differing characteristics in each category suggest different preventive strategies.

Low-impact falls: demands on a system of trauma management, prediction of outcome, and influence of comorbidities

BACKGROUND

Falls from a low height are an extremely common source of injury, the severity of which is often underestimated. As a result, low fall patients are usually not transferred to Level I trauma centers. There are surprisingly few systematic data relating to the demands made on systems of trauma care by patients with low falls. This study addresses this issue using information from a comprehensive national trauma database. The performance of TRISS methodology, and the factors associated with prolonged hospital stay, in low fall patients is also examined.

METHODS

The study included 31,419 patients. Patients with low falls (< 2 m) were compared with those suffering high falls (> or = 2 m), motor vehicle crashes, assault, sports injuries, and a group with unclassified injuries. Probability of survival was estimated using TRISS, and its performance in different types of injury was assessed using measures of discrimination and calibration. The influence of coexistent medical conditions on mortality and length of stay was investigated using logistic regression.

RESULTS

Low falls accounted for 45.5% of all admissions, and 43.9% of the total bed days. The low fall group was older (mean age, 61.6 years), and predominantly female (62.5%) in contrast to the other groups (both p < 0.001). There were fewer severely injured patients than in all of the other groups except sports injuries. The area under the receiver operating characteristic curve for TRISS applied to low falls (0.874) was less than that for high falls (0.969), motor vehicle crashes (0.973), assaults (0.960), sports (1.000), and unclassified injuries (0.965). Also, the calibration of the TRISS model was poor for patients with low falls. A logistic regression model derived from a training set of 5,000 patients gave slightly improved discrimination and markedly improved calibration when compared with TRISS. Although there was a strong relationship between the number of coexistent medical conditions and the risk of dying after a low fall, including data on comorbidities in a predictive model did not improve performance. Prolonged stay (defined as greater than the 90th centile, 23 days) was more likely in women (p < 0.005), or with advanced age (p < 0.001) or low initial calculated probability of survival (p < 0.001). Cardiovascular and central nervous system diseases and diabetes were associated with longer hospital stay (all p < 0.001). A logistic regression model using TRISS variables and comorbidity data gave poor prediction of prolonged stay. There was considerable variation in the length of stay between institutions.

CONCLUSION

Patients with low falls make considerable demands on a system of trauma care. TRISS methodology performs less well in this group than with other types of injury. Chronic medical conditions are associated with increased mortality and more prolonged stay after a low fall. Between-institutional variation in length of stay was considerable and this, along with the poor performance of predictive models derived from routinely collected clinical data, make it unlikely that length of stay could be used as a measure of institutional performance. More robust audit measures for patients with low falls are required.

[Factors related with accident risks in persons older than 65 years of age in the province of Guadalajara]

OBJECTIVES

We studied the factors that can increase the risk of accidents among elderly persons who had no cognitive deterioration in the province of Guadalajara, Spain.

METHODS

A cross-sectional, observational study was made in a primary care setting in which urban and rural areas were differentiated. A questionnaire (confirmed by a pilot study and analysis of the stability of responses using the kappa coefficient) was administered to a randomized, stratified sample in different stages. The sample was proportional in age, sex, and population centers. The variables studied were the cohabitants of the home, type of home, architectural barriers in the home, heating systems, periodic eye and ear checkups, use of corrective lenses and hearing aids, traffic safety, and sociodemographic variables. Data were analyzed using descriptive, analytical, and multivariant statistical procedures and logistical regression. The sample included 473 persons from rural areas and 477 persons from an urban area. The final study sample included 388 persons from rural areas and 392 persons from an urban area. The percentage of losses ranged from 16% (males from a rural area) to 26% (females from a rural area).

RESULTS

The type of home differed depending on the area. One-story homes predominated in rural areas. In every case, over 80% of the homes had 1 to 4 architectural barriers, particularly the absence of hand-bars in bathrooms, presence of rugs and carpets, changes in floor level, and stairs. The percentage of elderly persons who underwent eye or hearing checkups less than once a year was over 75% for eye checkups and over 90% for hearing checkups, regardless of the area. Although the use of seatbelts is obligatory, 3% to 7% of the elderly do not use them.

CONCLUSIONS

The prevalence of conditions that increase the risk of accidents for persons over 65 was high in our province. This study highlights the need for corrective measures.

Ultrasound: Impact on Diagnostic Peritoneal Lavage, Abdominal Computed Tomography, and Resident Training

Our objective was to determine the impact of abdominal ultrasound (US) on 1) the use of diagnostic peritoneal lavage (DPL) and abdominal computed tomography (ACT) for diagnosing blunt abdominal trauma (BAT) and on 2) surgical resident training. The study design was a retrospective chart review. Patients sustaining BAT who had ACT or DPL done during the 1-year period before the introduction of US (pre-US) were compared with those from a 1-year period beginning 6 months after US (post-US). Data collected included diagnostic modality, demographic data, mortality, associated injuries, length of stay, mechanism of injury, and number of exploratory laparotomies. Of 128 patients in the pre-US group, 35 patients (27%; P < 0.001) underwent DPL, 0 patients (0%; P < 0.001) received US, and 92 patients (72%) received ACT, with positive results for 31 patients (34%). Exploratory laparotomy was performed on 35 patients (27%) in the pre-US group. Of 140 patients in the post-US group, 8 patients (6%; P < 0.001) underwent DPL, 120 patients (85%; P < 0.001) received US, and 108 patients (77%) received ACT, with positive results for 44 patients (42%). Exploratory laparotomy was performed on 22 patients (15%; P < 0.001) in the post-US group. Resident experience with DPL before and after the introduction of US and availability of US for graduated residents was documented. Chi-square and Fisher's exact test were used for statistical analysis. Resident experience changed from 22 to 3 DPLs per year in the pre- and post-US groups, respectively. Ten per cent of graduating residents had US available for use after leaving this institution. US replaced DPL and resulted in slightly more positive ACT scans in assessing BAT at our institution. Paradoxically, only 10 per cent of graduating residents had US available after leaving this institution. Until the use of US for diagnosing BAT has widespread use in the community, we must question our adequacy of resident preparation for diagnosing BAT.

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

BACKGROUND

Elderly patients suffer higher mortality rates after trauma than younger patients. This increased mortality is attributable to age, preexisting disease, and complications as well as injury severity.

METHODS

Records from 5,139 adult patients from a Level I trauma center were retrospectively reviewed. Injury Severity Score (ISS), Revised Trauma Score (RTS), early mortality (<24 hours), and late mortality (>24 hours) were determined for elderly (> or =65 years) and younger (16-64 years) patients. Preexisting diseases and complications were identified by International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis coding.

RESULTS

Mortality in elderly patients was twice that in younger patients despite equivalent injury severity (p < 0.001), and elderly patients were more likely to suffer later death than younger patients (p < 0.005). The prevalence of preexisting disease was greater in the elderly, as was the incidence of complications. Using logistic regression, ISS, RTS, preexisting cardiovascular or liver disease, the development of cardiac, renal, or infectious complications, and geriatric status were all independently predictive of late mortality (p < 0.05).

CONCLUSION

Elderly trauma patients more frequently suffer late mortality than younger patients because of the combination of injury and increased preexisting disease and complications after injury. Aggressive treatment of the elderly trauma patient is warranted; however, in the face of significant preexisting disease or complications, survival is less likely. Predictive models of survival can be developed, taking into account preexisting disease and complications as well as admission parameters such as age, ISS, and RTS, and specific risk of mortality quantitated.

Trauma patients 75 years and older: long-term follow-up results justify aggressive management

BACKGROUND

Long-term survival rate and functional status after trauma for one of the fastest growing segments of the population, patients 75 years and older, is poorly documented.

METHODS

Trauma patients 75 years and older who were discharged from our Level I trauma center between June 1988 and July 1992 (n = 279) were contacted by mail or phone. Public death records were used to identify patients who had died. A stepwise logistic regression analysis was performed to determine predictors of poor outcome (death within 6 months). Main outcome measures included mortality and self-assessed functional status.

RESULTS

A minimum 4-year follow-up was obtained for 81% of the 279 study patients. The mean follow-up period was 5.4 +/- 1.1 years. Mean age at time of injury was 81 +/- 5 years (range, 75-101 years); mean Injury Severity Score was 9.4 +/- 7.7. At follow-up, 132 patients (47%) had died, 93 patients (33%) were contacted, and 54 patients (19%) could not be located. Twelve percent of patients survived less than 6 months after discharge. Poor survival was predicted by preexisting diseases (dementia, p = 0.001; hypertension, p = 0.02; and chronic obstructive pulmonary disease, p = 0.05) and not by age or severity of injury. The mean age of patients still living was 85 +/- 3.9 years (range, 79-99 years), and 77 of 93 patients were living in an independent setting (33 alone, 44 with spouse or family); of these, 57% reported no difficulties in performing 12 of 14 activities of daily living.

CONCLUSION

Despite higher than expected mortality after discharge, aggressive management of trauma patients 75 years and older is justified by the favorable long-term outcome.

Occupational fatalities among older workers in the United States: 1980-1991

Workers aged 65 and older had a workplace fatality rate of 2.6 times that of workers aged 16 to 64 for 1980 through 1991 (14.1 per 100,000 vs 5.4), according to National Traumatic Occupational Fatalities (NTOF) data. The highest rates were in mining, agriculture, and construction. Compared with younger workers, older men were at an elevated risk for fatalities caused by machines, and older women for fatal falls and homicide. Prevention efforts should focus on older workers in agricultural settings, as well as those at increased risk of workplace falls or violence.