Overview and Outcomes

The burden of geriatric trauma at the University College Hospital, Ibadan, Nigeria

Background:

Aims and Objectives:

Materials and Methods:

Results:

Conclusion:

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.

Incidence and Impact of Risk Factors in Critically Ill Trauma Patients

There is a paucity of data describing the incidence of pre-existing diseases or risk factors and their effects in trauma patients. We conducted a prospective study to determine the incidence of such factors in critically ill trauma patients and to evaluate their impact on outcome. The study, performed over a 2-year period, examined the hospital course of all trauma patients admitted to the ICU. Multiple risk factors were evaluated and analyzed via multivariate regression analysis. Outcome was evaluated by infection rate, hospital length of stay, ventilator days, and mortality matched for age and Injury Severity Score (ISS). A total of 1172 patients (73% blunt injury) were enrolled over the study period. Of these, 873 (74.5%) were male. The mean age was 42.5 years with an ISS of 19.8. Tobacco use (24%) was the most common risk factor identified, followed by hypertension (HTN, 17%), coronary artery disease (9%), chronic obstructive pulmonary disease (COPD)/reactive airway disease (4%), non-insulin-dependent diabetes (NIDDM) (4%), insulin-dependent diabetes (IDDM) (3.2%), cancer (3%), liver disease (2%), and HIV/AIDS (1.4%). Of these risk factors, IDDM was found to be an independent risk factor for infection (0.004) and ventilator days (0.047), increasing age was found to be an independent risk factor for hospital length of stay (0.023) and mortality (<0.001), and HTN was found to be an independent risk factor for increased ventilator days (0.04). In addition, COPD/reactive airway disease was found to be an independent predictor of ventilator days, infection, and ICU days (P < 0.05). Thus, increased age, IDDM, COPD, and HTN are most predictive of outcome in critically ill trauma patients. With our aging population it is becoming increasingly important to identify pre-existing risk factors on admission in order to minimize their effects on outcome.

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.

Cognitive performance in multiple trauma patients 3 years after injury

OBJECTIVES

Patients with sequelae from multiple trauma commonly display cognitive disturbances, specifically in the areas of attention and memory. This study was designed to assess cognitive functioning 3 years after severe multiple trauma and to investigate how cognitive performance is related to head injury severity and psychological distress respectively.

METHODS

Sixty-eight multiple trauma patients were tested with a screening battery consisting of six neuropsychological tasks 3 years after injury. A measure of psychological distress (20-item General Health Questionnaire, or GHQ-20) was also administered.

RESULTS

Patients who neither showed signs of reduced consciousness on admission to the hospital nor reported significant psychological distress at follow-up tended to have normal test performance. In five of the six tasks, cognitive impairment was related to the severity of the traumatic brain injury as measured by the Glasgow Coma Scale (GCS). In both attention span tasks, patients designated as cases by the GHQ had significantly lower scores than noncase patients. These bivariate relationships were upheld in multiple regression analyses, in which age, sex, and GCS and GHQ scores were entered as independent variables. When patients with severe head injuries were excluded from the analyses, GCS scores still contributed to the variance in tests of verbal attention span and delayed recall, but performance on attentional tasks was more strongly related to psychological distress than to GCS scores.

CONCLUSIONS

Cognitive deficits in multiple trauma patients were related both to the severity of the traumatic brain injury and to the degree of psychological distress. The strength of the association between brain injury as indicated by GCS scores and cognitive performance differed between different tasks. Neuropsychological testing may assist in differentiating primary organic from secondary psychogenic impairments.

Postinjury multiple organ failure: a bimodal phenomenon

To better define the epidemiology of postinjury multiple organ failure (MOF), we prospectively evaluated 457 high-risk trauma patients who survived more than 48 hours. Overall, 70 (15%) developed MOF. In 27 (39%) patients, the occurrence was early, while in 43 (61%) patients the presentation was delayed. At presentation, early MOF had more cardiac dysfunction, while late MOF had greater hepatic failure. Indices of shock were more critical risk factors for early MOF, while advanced age was more important for late MOF. While early and late MOF had a similar high incidence of major infections, these appeared to be more important in precipitating late MOF. Finally, while mortality is similar, early MOF patients appear to succumb faster. In conclusion, postinjury MOF remains a significant challenge and appears to present in at least two patterns (i.e., early versus late). Better understanding of the relative roles of the dysfunctional inflammation and infections in early MOF versus late MOF may facilitate the development of new strategies for the prevention and treatment of morbid syndrome.