A case control study for major trauma in geriatric patients

Modified physiologic criteria for the field triage scheme: Efficacy of major trauma recognition in different age groups in Asia

BACKGROUND

Major trauma is a leading cause of unexpected death globally, with increasing age-adjusted death rates for unintentional injuries. Field triage schemes (FTSs) assist emergency medical technicians in identifying appropriate medical care facilities for patients. While full FTSs may improve sensitivity, step-by-step field triage is time-consuming. A simplified FTS (sFTS) that uses only physiological and anatomical criteria may offer a more rapid decision-making process. However, evidence for this approach is limited, and its performance in identifying all age groups requiring trauma center resources in Asia remains unclear.

METHODS

We conducted a multinational retrospective cohort study involving adult trauma patients admitted to emergency departments in the included countries from 2016 to 2020. Prehospital and hospital data were reviewed from the Pan-Asia Trauma Outcomes Study database. Patients aged ≥18 years transported by emergency medical services were included. Patients lacking data regarding age, sex, physiological criteria, or injury severity scores were excluded. We examined the performance of sFTS in all age groups and fine-tuned physiological criteria to improve sFTS performance in identifying high-risk trauma patients in different age groups.

RESULTS

The sensitivity and specificity of the physiological and anatomical criteria for identifying major trauma (injury severity score ≥ 16) were 80.6% and 58.8%, respectively. The modified sFTS showed increased sensitivity and decreased specificity, with more pronounced changes in the young age group. Adding the shock index further increased sensitivity in both age groups.

CONCLUSIONS

sFTS using only physiological and anatomical criteria is suboptimal for Asian adult patients with trauma of all age groups. Adjusting the physiological criteria and adding a shock index as a triage tool can improve the sensitivity of severely injured patients, particularly in young age groups. A swift field triage process can maintain acceptable sensitivity and specificity in severely injured patients.

Analysis of Trauma Characteristics Between the Older and Younger Adult Patient from the Pan Asian Trauma Outcome Study Registry (PATOS)

OBJECTIVE

Asia is experiencing a demographic shift toward an aging population at an unrivaled rate. This can influence the characteristics and outcomes of trauma. We aim to examine different characteristics of older adult trauma patients compared to younger adult trauma patients and describe factors that affect the outcomes in Asian countries.

METHODS

This is a retrospective, international, multicenter study of trauma across participating centers in the Pan Asian Trauma Outcome Study (PATOS) registry, which included trauma cases aged ≥18 years, brought to the emergency department (ED) by emergency medical services (EMS) from October 2015 to November 2018. Data of older adults (≥65 years) and younger adults (<65 years) were analyzed and compared. The primary outcome measure was in-hospital mortality, and secondary outcomes were disability at discharge and hospital and intensive care unit (ICU) length of stays.

RESULTS

Of 39,804 trauma patients, 10,770 (27.1%) were older adults. Trauma occurred more among older adult women (54.7% vs 33.2%, p < 0.001). Falls were more frequent in older adults (66.3% vs 24.9%, p < 0.001) who also had higher mean Injury Severity Score (ISS) compared to the younger adult trauma patient (5.4 ± 6.78 vs 4.76 ± 8.60, p < 0.001). Older adult trauma patients had a greater incidence of poor Glasgow Outcome Scale (GOS) (13.4% vs 4.1%, p < 0.001), higher hospital mortality (1.5% vs 0.9%, p < 0.001) and longer median hospital length of stay (12.8 vs 9.8, p < 0.001). Multiple logistic regression revealed age (adjusted odds ratio [AOR] 1.06, 95%CI 1.02-1.04, p < 0.001), male sex (AOR 1.60, 95%CI 1.04-2.46, p = 0.032), head and face injuries (AOR 3.25, 95%CI 2.06-5.11, p < 0.001), abdominal and pelvic injuries (AOR 2.78, 95%CI 1.48-5.23, p = 0.002), cardiovascular (AOR 2.71, 95%CI 1.40-5.22, p = 0.003), pulmonary (AOR 3.13, 95%CI 1.30-7.53, p = 0.011) and cancer (AOR 2.03, 95%CI 1.02-4.06, p = 0.045) comorbidities, severe ISS (AOR 2.06, 95%CI 1.23-3.45, p = 0.006), and Glasgow Coma Scale (GCS) ≤8 (AOR 12.50, 95%CI 6.95-22.48, p < 0.001) were significant predictors of hospital mortality.

CONCLUSIONS

Older trauma patients in the Asian region have a higher mortality rate than their younger counterparts, with many significant predictors. These findings illustrate the different characteristics of older trauma patients and their potential to influence the outcome. Preventive measures for elderly trauma should be targeted based on these factors.

The use of whole-body trauma CT should be based on mechanism of injury: A risk analysis of 3920 patients at a tertiary trauma centre

BACKGROUND

Mechanism of injury (MOI) plays a significant role in a decision to perform whole-body computed tomography (CT) imaging for trauma patients. Various mechanisms have unique patterns of injury and therefore form an important variable in decision making.

METHODS

Retrospective cohort study including all patients >18 years old who received a whole-body CT scan between 1 January 2019 and 19 February 2020. The outcomes were divided into CT 'positive' if any internal injuries were detected and CT 'negative' if no internal injuries were detected. The MOI, vital sign parameters, and other relevant clinical examination findings at presentation were recorded.

RESULTS

3920 patients met the inclusion criteria, of which 1591 (40.6%) had a positive CT. The most common MOI was fall from standing height (FFSH), accounting for 23.0%, followed by motor vehicle accident (MVA), accounting for 22.4%. Covariates significantly associated with a positive CT included age, MVA >60 km/h, motor bike, bicycle, or pedestrian accident >30 km/h, prolonged extrication >30 min, fall from height above standing, penetrating chest or abdominal injury, as well as hypotension, neurological deficit, or hypoxia on arrival. FFSH was shown to reduce the risk of a positive CT overall, however, sub-analysis of FFSH in patients >65 years showed a significant association with a positive CT (OR 2.34, p < 0.001) compared to <65 years.

CONCLUSIONS

Pre-arrival information including MOI and vital signs have significant impact on identifying subsequent injuries with CT imaging. In high energy trauma, we should consider the need for whole-body CT based on MOI alone regardless of the clinical examination findings. However, for low-energy trauma, including FFSH, in the absence of clinical examination findings which support an internal injury, a screening whole-body CT is unlikely to yield a positive result, particularly in the age group <65yo.

Age as the Impact on Mortality Rate in Trauma Patients

Background

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

Objectives

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

Materials and Methods

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

Results

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

Conclusion

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

Mechanism of injury, injury patterns and associated injuries in patients operated for chest wall trauma

PURPOSE

Chest wall injuries are common in blunt trauma and associated with significant morbidity and mortality. The aim of this study was to determine the most common mechanisms of injury (MOI), injury patterns, and associated injuries in patients who undergo surgery for chest wall trauma.

METHODS

This was a retrospective study of trauma patients with multiple rib fractures and unstable thoracic cage injuries who were managed surgically at Sahlgrenska University Hospital during the period September 2010-September 2017. The MOI, injury severity score (ISS), new injury severity score (NISS), thoracic and associated injuries were recorded. Patients were categorized according to age (years): groups I (15‒44), II (45‒64) and III ( > 64). Unstable thoracic cage injuries were classified as sternal, anterior, lateral and posterior flail chest.

RESULTS

Two hundred and eleven trauma patients with a mean age (years) of 58.2 ± 15.6, mean ISS 23.6 ± 11.0, and mean NISS 34.1 ± 10.6 were included in the study. Traffic accidents were the most common MOI in Group I (62%) and falls in Group III (59%). The most common flail segments were lateral and posterior. Sternal and anterior flail segments were more common with bilateral injuries and traffic accidents, particularly frontal collisions. Injuries in at least three body regions were also more associated with traffic accidents. Diaphragmatic injury was seen in 18% of patients who underwent thoracotomy.

CONCLUSIONS

The MOI associated with multiple rib fractures differs according to the age of the patient and is associated with different chest wall injury patterns and extra-thoracic injuries.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Mortality Factors in Geriatric Blunt Trauma Patients: Creation of a Highly Predictive Statistical Model for Mortality Using 50,765 Consecutive Elderly Trauma Admissions from the National Sample Project

Elderly patients are at high risk for mortality after injury. We hypothesized that trauma benchmarking efforts would benefit from development of a geriatric-specific model for risk-adjusted analyses of trauma center outcomes. A total of 57,973 records of elderly patients (age older than 65 years), which met our selection criteria, were submitted to the National Trauma Database and included within the National Sample Project between 2003 and 2006. These cases were used to construct a multivariable logistic regression model, which was compared with the American College of Surgeons Committee on Trauma's Trauma Quality Improvement Project's (TQIP) existing model. Additional spline regression analyses were performed to further objectively quantify the physiologic differences between geriatric patients and their younger counterparts. The geriatric-specific and TQIP mortality models shared several covariates: age, Injury Severity Score, motor component of the Glasgow Coma Scale, and systolic blood pressure. Our model additionally used temperature and the presence of mechanical ventilation. Our geriatric-specific regression mode generated a superior c-statistic as compared with the TQIP approximation (0.85 vs 0.77; P = 0.048). Spline analyses demonstrated that elderly patients appear to be less likely to tolerate relative hypotension with higher observed mortality at initial systolic blood pressures of 90 to 130 mmHg. Although the TQIP model includes a single age component, these data suggest that each variable needs to be adjusted for age to more accurately predict mortality in the elderly. Clearly, a separate geriatric model for predicting outcomes is not only warranted, but necessary.

Death by Decade: Establishing a Transfusion Ceiling for Futility in Massive Transfusion

BACKGROUND

Age and massive transfusion are predictors of mortality after trauma. We hypothesized that increasing age and high-volume transfusion would result in progressively elevated mortality rates and that a transfusion "ceiling" would define futility.

METHODS

The Trauma Quality Improvement Program (TQIP) database was queried for 2013-2016 records and our level I trauma registry was reviewed from 2013 to 2018. Demographic, mortality, and blood transfusion data were collected. Patients were grouped by decade of life and by packed red blood cell (pRBC) transfusion requirement (zero units, 1-3 units, or ≥4 units) within 4 h of admission.

RESULTS

TQIP analysis demonstrated an in-hospital mortality risk that increased linearly with age, to an odds ratio of 10.1 in ≥80 y old (P < 0.01). Mortality rates were significantly higher in older adults (P < 0.01) and those with more pRBCs transfused. In massively transfused patients, the transfusion "ceiling" was dependent on age. Owing to the lack granularity in the TQIP database, 230 patients from our institution who received ≥4 units of pRBCs within 4 h of admission were reviewed. On arrival, younger patients had significantly higher heart rates and more severe derangements in lactate levels, base deficits, and pH compared with older patients. There were no differences among age groups in injury severity score, systolic blood pressure, or mortality.

CONCLUSIONS

In massively transfused patients, mortality increased with age. However, a significant proportion of older adults were successfully resuscitated. Therefore, age alone should not be considered a contraindication to high-volume transfusion. Traditional physiologic and laboratory criteria indicative of hemorrhagic shock may have reduced reliability with increasing age, and thus providers must have a heightened suspicion for hemorrhage in the elderly. Early transfusion requirements can be combined with age to establish prognosis to define futility to help counsel families regarding mortality after traumatic injury.

Polytrauma in Older Adults Leads to Significantly Increased TIMP-1 Levels in the Early Posttraumatic Period

Background

Patients after polytrauma regularly suffer from posttraumatic immune system destabilization, which closely influences the further clinical development. Increasing age has recently been identified as an isolated risk factor for an adverse outcome after major trauma. Higher rates and intensity of acute inflammation following severe injury suggest that deregulated inflammation may contribute to these higher rates of posttraumatic morbidity and mortality in older adults. MMP-9 and TIMP-1 have been found to play a major role in posttraumatic immune disorder in a previous genome-wide mRNA analysis.

Objective

The aim of this study was to evaluate the differences in serum protein dynamics in older and younger polytraumatized adults.

Methods

Blood samples were drawn immediately within 90 minutes after trauma and subsequently after 6, 12, 24, 48, and 72 h. Serum levels of TIMP-1 and MMP-9 were quantified using ELISA. Age groups were divided according to a cutoff of 60 years.

Results

60 polytrauma patients (ISS > 16) were included (<60 years, n = 49; ≥60 years, n = 49; ≥60 years, n = 11). Serum TIMP-1 and MMP-9 levels showed a highly significant serum dynamic in young and old polytrauma patients (p < 0.001). Patients ≥ 60 years showed significantly higher overall TIMP-1 levels (p < 0.001). Patients ≥ 60 years showed significantly higher overall TIMP-1 levels (p = 0.008). TIMP-1 levels showed a significant maximum after 72 h in the older study population. MMP-9 levels were nonsignificantly higher during the whole observational period in older polytrauma patients when compared to younger patients.

Conclusion

The posttraumatic immune response is characterized by significantly higher TIMP-1 levels in older polytrauma patients. This significant association between TIMP-1 levels and patients' age indicates a more extensive immune dysregulation following major trauma in older adults.

Implementation of new standard operating procedures for geriatric trauma patients with multiple injuries: a single level I trauma centre study

BACKGROUND

The demographic changes towards ageing of the populations in developed countries impose a challenge to trauma centres, as geriatric trauma patients require specific diagnostic and therapeutic procedures. This study investigated whether the integration of new standard operating procedures (SOPs) for the resuscitation room (ER) has an impact on the clinical course in geriatric patients. The new SOPs were designed for severely injured adult trauma patients, based on the Advanced Trauma Life Support (ATLS) and imply early whole-body computed tomography (CT), damage control surgery, and the use of goal-directed coagulation management.

METHODS

Single-centre cohort study. We included all patients ≥65 years of age with an Injury Severity Score (ISS) ≥ 9 who were admitted to our hospital primarily via ER. A historic cohort was compared to a cohort after the implementation of the new SOPs.

RESULTS

We enrolled 311 patients who met the inclusion criteria between 2000 and 2006 (group PreSOP) and 2010-2012 (group SOP). There was a significant reduction in the mortality rate after the implementation of the new SOPs (P = .001). This benefit was seen only for severely injured patients (ISS ≥ 16), but not for moderately injured patients (ISS 9-15). There were no differences with regard to infection rates or rate of palliative care.

CONCLUSIONS

We found an association between implementation of new ER SOPs, and a lower mortality rate in severely injured geriatric trauma patients, whereas moderately injured patients did not obtain the same benefit.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03319381, retrospectively registered 24 October 2017.

Relationship between age and injury severity in traffic accidents involving elderly pedestrians

OBJECTIVE

This study aimed to examine whether injury severity differs with respect to age among elderly pedestrians involved in traffic accidents and identify factors affecting injury severity.

METHODS

Using emergency department-based injury in-depth surveillance data, we analyzed the data of patients aged ≥60 years who were victims of pedestrian traffic accidents during 2011 to 2016. The pedestrians' ages were divided into 5-year age strata beginning at 60 years. In a multivariate analysis, injury severity was classified as severe to critical or mild to moderate.

RESULTS

The analysis included 10,449 patients. All age groups had a female predominance, and accidents most frequently occurred during the early morning. Multivariate analyses revealed that compared to the 60 to 64 years group, the odds ratios for incurring a severe injury were 1.18 (95% confidence interval [CI], 1.02 to 1.37) for the 65 to 69 years group, 1.42 (95% CI, 1.23 to 1.64) for the 70 to 74 years group, 1.70 (95% CI, 1.45 to 1.98) for the 75 to 79 years group, and 1.83 (95% CI, 1.56 to 2.15) for the ≥80 years group.

CONCLUSION

In this study of emergency department-based data, we found that injury severity increased with age among elderly victims of traffic accidents. Furthermore, injury severity varied with respect to sex, time and location of the accident, and type of vehicle involved. Therefore, measures intended to reduce and prevent traffic accidents involving elderly pedestrians should consider these findings.

Trauma in elderly patients: a study of prevalence, comorbidities and gender differences

AIM

Trauma, in geriatric patients, increases with age, and is a leading cause of disability and institutionalization, resulting in morbidity and mortality. The aim of our study was to analyse the prevalence of trauma, the related risk factors, mortality and sex differences in the prevalence in a geriatric population.

PATIENTS AND METHOD

We observed 4,554 patients (≥65 years) with home injuries or car accidents. Patients were evaluated with ISS (Injury Severity Score) and major trauma with ATLS (Advanced Trauma Life Support). The instrumental investigation was in the first instance, targeted X-Ray or whole-body CT.

RESULTS

In over four years of study we treated 4,554 geriatric: 2,809 females and 1,745 Males. When the type of trauma was analysed the most common was head injury, followed by fractures of lower and upper limbs. In our experience hospitalization mainly involved patients over 80. In all patients mortality during assessment was 0.06%.

DISCUSSION

The geriatric patient is often defined as a "frail elderly", for the presence of a greater "injury sensitivity". This is due to the simultaneous presence of comorbidity, progressive loss of full autonomy and exposure to a high risk of traumatic events. Optimal management of the trauma patient can considerable reduce mortality and morbidity.

CONCLUSIONS

Falls and injuries in geriatric age are more frequent in women than in men. Among typical elder comorbidities, osteoporosis certainly causes a female preponderance in the prevalence of fractures. Our discharge data demonstrate that disability, which requires transfer to health care institutions, has a greater effect on women than men.

Sternal fractures in children: An analysis of the National Trauma Data Bank

PURPOSE

The purpose of this study was to describe the epidemiology and evaluate the clinical significance of traumatic sternal fractures.

METHODS

Patients age ≤18 years with sternal fractures in the National Trauma Database research datasets from 2007-2014 were identified. Patient demographics, injuries, procedures, and outcomes were analyzed using descriptive statistics and logistic regression.

RESULTS

Three thousand one hundred sixty patients with sternal fracture were identified. Ninety percent of injuries occurred in patients between 12 and 18 years old. Median injury severity score (ISS) was 17 [9,29]. Exploratory thoracotomy was performed in 1%. Thirty-nine percent were admitted to the intensive care unit (ICU). On multivariate regression, predictors of ICU stay >1 day were increasing ISS, lack of the use of protective devices, decreasing Glasgow Coma Score (GCS), tachycardia, and pulmonary contusion. Median hospital length of stay was 4 [2, 9] days. In-hospital mortality was 8%. Predictors of mortality were lower GCS, increasing ISS, decreasing oxygen saturation, hypotension, and cardiac arrest. Use of protective devices and seat belts did not affect mortality.

CONCLUSION

Sternal fractures in patients increase in incidence with age, and poor outcomes are impacted by associated injuries and complications. The presence of a sternal fracture should trigger a careful diagnostic evaluation.

LEVEL OF EVIDENCE

III STUDY TYPE: Treatment Study.

Trauma in the elderly patient

Major Trauma Centres and Emergency Departments are treating an increasing number of elderly trauma patients in the UK. Elderly patients, defined as those over the age of 65 years, are more susceptible to injury from lesser mechanisms of trauma than younger adults. The number of elderly trauma cases is rising yearly, accounting for >25% of all major trauma nationally. The elderly have different physiological reserves and a different response to trauma due to premorbid frailty, co-existing conditions and prescribed medication. These factors need to be appreciated in trauma triaging, radiological assessment and clinical management. A lower threshold for trauma-call activation is recommended, including a lower threshold for advanced imaging. We will review general principles of trauma in the elderly, outline injury patterns in this age group and illustrate the radiological features per anatomical site, from head to pelvis and the extremities. We advocate using contrast-enhanced computed tomography as the primary diagnostic imaging modality as concern about intravenous contrast agent-induced nephropathy is relatively minor. Prompt investigation and diagnosis leads to timely appropriate treatment, therefore the radiologist can discerningly improve morbidity and mortality in this vulnerable group.

End-of-Life Decision-Making for Patients With Geriatric Trauma Cared for in a Trauma Intensive Care Unit

BACKGROUND

The geriatric trauma population is growing and fraught with poor physiological response to injury and high mortality rates. Our primary hypothesis analyzed how prehospital and in-hospital characteristics affect decision-making regarding continued life support (CLS) versus withdrawal of care (WOC). Our secondary hypothesis analyzed adherence to end-of-life decisions regarding code status, living wills, and advanced directives.

MATERIALS AND METHODS

We performed a retrospective review of patients with geriatric trauma at a level I and level II trauma center from January 1, 2007, to December 31, 2014. Two hundred seventy-four patients met inclusion criteria with 144 patients undergoing CLS and 130 WOC.

RESULTS

A total of 13 269 patients with geriatric trauma were analyzed. Insurance type and injury severity score (ISS) were found to be significant predictors of WOC ( P = .013/.045). Withdrawal of care patients had shorter time to palliative consultation and those with geriatrics consultation were 16.1 times more likely to undergo CLS ( P = .026). Twenty-seven (33%) patients who underwent CLS and 31 (24%) patients who underwent WOC had a living will, advanced directive, or DNR order ( P = .93).

CONCLUSIONS

Of the many hypothesized predictors of WOC, ISS was the only tangible independent predictor of WOC. We observed an apparent disconnect between the patient's wishes via living wills or advanced directives "in a terminal condition" and fulfillment during EOL decision-making that speaks to the complex nature of EOL decisions and further supports the need for a multidisciplinary approach.

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.

Regional Anesthesia in Patients of Aged 99 Years in Clopidogrel Use

The risk of neuraxial block in patients treated with antiplatelet drugs are uncertain. Elderly patients often have low physiological reserve, delaying surgery can lead to a high rate of morbidity and mortality. The aim of this paper is to present a case of a patient with 99 years using clopidogrel undergoing regional anesthesia for surgical treatment of hip fracture without complications.

What are the differences in injury patterns of young and elderly traffic accident fatalities considering death on scene and death in hospital?

Older traffic participants have higher risks of injury than the population up to 65 years in case of comparable road traffic accidents and further, higher mortality rates at comparable injury severities. Rib fractures as risk factors are currently discussed. However, death on scene is associated with hardly survivable injuries and might not be a matter of neither rib fractures nor age. As 60% of traffic accident fatalities are estimated to die on scene, they are not captured in hospital-based trauma registries and injury patterns remain unknown. Our database comprises 309 road traffic fatalities, autopsied at the Institute of Legal Medicine Munich in 2004 and 2005. Injuries are coded according to Abbreviated Injury Scale, AIS© 2005 update 2008 [1]. Data used for this analysis are age, sex, site of death, site of accident, traffic participation mode, measures of injury severity, and rib fractures. The injury patterns of elderly, aged 65+ years, are compared to the younger ones divided by their site of death. Elderly with death on scene more often show serious thorax injuries and pelvic fractures than the younger. Some hints point towards older fatalities showing less frequently serious abdominal injuries. In hospital, elderly fatalities show lower Injury Severity Scores (ISSs) compared to the younger. The number of rib fractures is significantly higher for the elderly but is not the reason for death. Results show that young and old fatalities have different injury patterns and reveal first hints towards the need to analyze death on scene more in-depth.

Older Age, Comorbid Illnesses, and Injury Severity Affect Immediate Outcome in Elderly Trauma Patients

Introduction:

Trauma in elderly population is frequent and is associated with significant mortality, not only due to age but also due to complicated factors such as the severity of injury, preexisting comorbidity, and incomplete general assessment. Our primary aim was to determine whether age, Injury Severity Score (ISS), and preexisting comorbidities had an adverse effect on the outcome in patients aged 65 years and above following blunt trauma.

Methods:

We included 1027 patients aged ≥65 years who were admitted to our Level I Trauma Center following blunt trauma. Patients’ charts were reviewed for demographics, ISS, mechanism of injury, preexisting comorbidities, Intensive Care Unit and hospital length of stay, complications, and in-hospital mortality.

Results:

The mean age of injured patients was 78.8 ± 8.3 years (range 65–109). The majority of patients had mild injury severity (ISS 9–14, 66.8%). Multiple comorbidities (≥3) were found in 233 patients (22.7%). Mortality during the hospitalization stay (n = 35, 3.4%) was associated with coronary artery disease, renal failure, dementia, and warfarin use (P < 0.05). Chronic anticoagulation treatment was recorded in 13% of patients. The addition of a single comorbidity increased the odds of wound infection to 1.29 and sepsis to 1.25. Both age and ISS increased the odds of death as −1.08 and −2.47, respectively.

Conclusions:

Our analysis shows that age alone in elderly trauma population is not a robust measure of outcome, and more valuable predictors such as injury severity, preexisting comorbidities, and medications are accounted for adverse outcome. Trauma care in this population with special considerations should be tailored to meet their specific needs.

Predictors of Mortality in Trauma Patients Aged 80 years or Older

The population of the United States is predicted to age dramatically over the next few decades; as such older patients will comprise an increasing proportion of the injured populations. Due to multiple comorbidities and frailty, the old and very old are at greater risk for mortality than younger patients. To identify predictors of inhospital mortality in these patients, we performed a retrospective cohort study at our Level 1 trauma center. Between April 2009 and October 2014, we identified 193 trauma patients aged 80 years and older admitted to the intensive care unit. The mean age was 86 years old (4.9) and a majority of patients were white (57%) and male (54%). Univariate analysis found Injury Severity Score ( P < 0.01), initial Glasgow Coma Scale ( P < 0.01), admission pH ( P = <0.01), admission lactate ( P < 0.01), the need for mechanical ventilation ( P < 0.01), and Geriatric Trauma Outcome Score ( P < 0.01) to be predictors of mortality. Multivariate analysis identified length of mechanical ventilation [odds ratio (OR) = 0.73, 95% confidence interval (CI) = 0.60–0.90, P < 0.01], admission lactate (OR = 1.74, 95% CI = 1.21–2.51, P < 0.01), and the need for mechanical ventilation (OR = 18.2, 95% CI = 3.33–99.8, P < 0.01) as independent predictors of mortality. These predictors can help guide clinical decisions and should prompt early discussion of goals of care. The association between mechanical ventilation and mortality is confounded by withdrawal of care.

On equal footing: Trends in ankle/foot injuries for men vs. women

OBJECTIVES

The objective of the current study was to examine trends in ankle/foot (A/F) injuries during the period 2001-2014, in order to determine whether the incidence of these injuries has changed and whether a previously identified difference in risk by gender still existed. In addition, other driver and crash-related risk factors were examined separately for men and women.

METHODS

Passenger vehicle drivers aged 16+ were identified from NASS-CDS; weighted data were analyzed for model years 2001-2014. Model years (MY) were grouped as 2001-2004 (older) vs. 2005-2014 (newer), and drivers in frontal crashes were included. Ankle injuries included fractures and dislocations to the malleolus and distal tibia/fibula. Foot injuries included fractures and dislocations of the talus, calcaneus, and tarsal/metatarsal bones. Logistic regression models were constructed to identify risk factors, including MY, age, belt use, toepan/instrument panel intrusion, and body mass index (BMI) separately for each gender using odds ratios.

RESULTS

The incidence of A/F injuries declined significantly between older and newer MY, especially for women. Whereas before MY 2005, ankle and foot injury risk was significantly higher for women than men, risks for ankle injury are now virtually the same for both genders, and women are only 1.2 times more likely than men to sustain a foot injury in a frontal crash. From multivariable regression models, however, it is apparent that there are different risk factors for A/F injuries for men vs. women. Body weight was a significant factor for both groups, but for men it was a risk only for those extremely obese, whereas for women those who were categorized as overweight were also at increased risk. Age greater than 55 was also found to be a risk factor for foot injuries among women but not men. For men and women, toepan intrusion remained the most important factor for both foot and ankle injuries, with significantly higher odds ratios noted for men. Foot pedals were a more likely injury source for women, whereas the toepan was more likely for men. In addition, belt use was protective for ankle injuries in women but not men.

CONCLUSIONS

Significant declines in A/F injuries have been noted in recent years, especially for women, whose risks are now similar to those for men. However, significant risk factors remain for each gender, primarily related to body habitus (BMI) and toepan intrusion. Age was a risk factor for foot injuries among women, for whom the foot pedals were more likely to be an injury source. Toepan intrusion remains a major factor for both men and women, but, with the exception of 30+ cm of intrusion, odds ratios were primarily much higher for men in each category of intrusion.

A new kid on the block: Outcomes with Kcentra 1 year after approval

BACKGROUND

As the population ages, more trauma patients are admitted with coagulopathy. Fresh frozen plasma is effective in reversing coagulopathy caused by warfarin; however, it is not appropriate for all patients. Prothrombin complex concentrates (PCCs) are an alternative for patients who require emergent reversal, minimal-volume administration and who have a supratherapeutic international normalized ratio (INR). A four-factor PCC initially approved in Europe is now available in the United States. We sought to review our experience with Kcentra (4F-PCC) in the first year following Food and Drug Administration approval.

METHODS

All trauma patients admitted to an academic Level 1 trauma center between July 15, 2013, and July 15, 2014, who received 4F-PCC for reversal of warfarin-induced coagulopathy were reviewed. 4F-PCC was given as per protocol. Univariate analysis was performed to examine patient demographics, injury characteristics, coagulation studies, 4F-PCC dose, vitamin K use, transfusions, response to reversal, duration of reversal, complications, and mortality.

RESULTS

Twenty-six patients met study criteria. Of these patients, 34.6% were reversed because of intracranial hemorrhage. The mean INR decreased from 5.7 ± 6.1 (range, 1.6-30) to 1.5 ± 0.4 (range, 1.2-2.6) after 4F-PCC administration. One patient (3.8%) received concurrent fresh frozen plasma. For patients with an initial INR greater than 5.0, the mean INR decreased from 12.0 ± 8.2 to 1.6 ± 0.5. Forty-eight hours following 4F-PCC administration, mean INR for all patients remained 1.4 ± 0.4 (range, 1.0-2.6). Of the patients, 80.8% received vitamin K over this period. Fourteen patients had a pre-4F-PCC thromboelastogram; four were hypocoagulable. Two patients had repeat thromboelastograms after 4F-PCC was given, which demonstrated normal coagulation. Of the patients with intracranial hemorrhage, 66.7% showed radiographic progression of the initial insult on post-4F-PCC head computed tomography, while only 11.1% progressed clinically. In-hospital mortality was 0%. There were no thromboembolic complications.

CONCLUSION

4F-PCC effectively reverses elevated INRs in trauma patients with warfarin-induced coagulopathy, with results lasting more than 48 hours after administration.

LEVEL OF EVIDENCE

Therapeutic study, level V.

Epidemiologic Impact of Rapid Industrialization on Head Injury Based on Traffic Accident Statistics in Korea

Objective

The aim of the present study is to estimate the incidence trend of head injury and the mortality based on traffic accident statistics and to investigate the impacts of rapid industrialization and economic growth on epidemiology of head injury in Korea over the period 1970–2012 including both pre-industrialized and post-industrialized stages.

Methods

We collected data of head injury estimated from traffic accident statistics and seven hospital based reports to see incidence trends between 1970 and 2012. We also investigated the population structure and Gross National Income (GNI) per capita of Korea over the same period. The age specific data were investigated from 1992 to 2012.

Results

The incidence of head injury gradually rose in the 1970s and the 1980s but stabilized until the 1990s with transient rise and then started to decline slowly in the 2000s. The mortality grew until 1991 but gradually declined ever since. However, the old age groups showed rather slight increase in both rates. The degree of decrease in the mortality has been more rapid than the incidence on head injury.

Conclusion

In Korea during the low income stage, rapid industrialization cause considerable increase in the mortality and the incidence of head injury. During the high income stage, the incidence of head injury gradually declined and the mortality dropped more rapidly than the incidence due to preventive measures and satisfactory medical care. Nevertheless, the old age groups revealed rather slight increase in both rates owing to the large population structure and the declining birth rate.

Causes of death differ between elderly and adult falls

BACKGROUND

As the population ages, mortality from falls will soon exceed that from all other forms of injury. Tremendous resources are focused on this problem, but how these patients die is unclear. To fill this gap, we tested the hypothesis that falls among the elderly are related to patient, rather than to injury factors when compared with falls among younger adults.

METHODS

From January 2002 to December 2012, 7,293 fall admissions were reviewed. Data are reported as mean ± SD if normally distributed or median (interquartile range) if not.

RESULTS

In 2002 to 2007, 25% of all falls were in elderly patients (≥65 years), but in 2008 to 2012, this proportion increased to 30% (p < 0.001). When comparing adult (n = 5,216) with elderly (n = 2,077) admissions, characteristics were as follow: Injury Severity Score (ISS) of 8 (4-13) versus 9 (5-17), length of stay (in days) of 3 (1-7) versus 6 (2-11), and mortality of 3.8% versus 13.7% (all p < 0.001). After controlling for variables associated with mortality using multiple logistic regression, elderly age was the strongest independent predictor of mortality (odds ratio, 8.18; confidence interval, 4.88-13.71). When comparing adult (n = 198) with elderly (n = 285) fatalities, ground-level falls occurred in 31% versus 91%, ISS was 27 (25-41) versus 25 (16-36), and length of stay (in days) was 2 (0-6) versus 4 (1-11) (all p < 0.001). Death occurred directly from fall in 82% versus 63%, from complications in 10% versus 20%, and from a fatal event preceding the fall in 8% vs. 17% (all p < 0.001).

CONCLUSION

The proportion of fall admissions in the elderly is growing in this trauma system. Elderly age is the strongest independent predictor of mortality following a fall. In those who die, death is less likely a direct effect of the fall.

LEVEL OF EVIDENCE

Epidemiologic study, level III.

Image segmentation and registration algorithm to collect thoracic skeleton semilandmarks for characterization of age and sex-based thoracic morphology variation

Thoracic anthropometry variations with age and sex have been reported and likely relate to thoracic injury risk and outcome. The objective of this study was to collect a large volume of homologous semilandmark data from the thoracic skeleton for the purpose of quantifying thoracic morphology variations for males and females of ages 0-100 years. A semi-automated image segmentation and registration algorithm was applied to collect homologous thoracic skeleton semilandmarks from 343 normal computed tomography (CT) scans. Rigid, affine, and symmetric diffeomorphic transformations were used to register semilandmarks from an atlas to homologous locations in the subject-specific coordinate system. Homologous semilandmarks were successfully collected from 92% (7077) of the ribs and 100% (187) of the sternums included in the study. Between 2700 and 11,000 semilandmarks were collected from each rib and sternum and over 55 million total semilandmarks were collected from all subjects. The extensive landmark data collected more fully characterizes thoracic skeleton morphology across ages and sexes. Characterization of thoracic morphology with age and sex may help explain variations in thoracic injury risk and has important implications for vulnerable populations such as pediatrics and the elderly.

Orthopedic Trauma and Aging: It Isn't Just About Mortality

The elderly (age 70+) patient with orthopedic trauma is a rapidly growing subset of patients in the United States. Due to increased medical comorbidities and decreased physiological reserve, morbidity and mortality after trauma may significantly differ from those patients younger than 70 years old. A retrospective review was performed to investigate the effect of age on orthopedic trauma. A total of 870 records of patients with orthopedic trauma from 2006 to 2009 at our Level One trauma center were reviewed. A database was created to include demographics, type and number of comorbid conditions at presentation, injuries, intensive care unit (ICU) and hospital length of stay, and description of the fracture. Patients aged 70 years and older had an increased number of comorbidities per person (3.3214-P < .0001). Length of stay in patients aged 70 years and older was not significantly greater than that of the younger patients. They spent an average of 14.76 days in the hospital compared to 13.42 days for the combined younger patients (P = .45), but they spent significantly (P < .0001) more of their stay in the ICU (52.74% vs 34.9% for the younger cohorts). The number of fractures per patient was lower (1.66) in the 70 and older age-group when compared to younger populations (P < .0001). The 70 and older group was more likely to have their injury due to a fall and less likely to have solid organ injuries. As the number of elderly patients increase, continued research in the management of elderly patients with trauma can lead to protocols and practice guidelines to improve outcomes.

Geriatric High-Energy Polytrauma With Orthopedic Injuries: Clinical Predictors of Mortality

Background:

The impact of orthopedic injuries in the elderly patient with multi-trauma and the effect of operative fixation on these injuries have not been thoroughly evaluated.

Methods:

We reviewed geriatric patients (aged 65 and older) between 2004 and 2010 at a level 1 trauma center who sustained high-energy polytrauma (injury and severity score [ISS] ≥ 16) with associated orthopedic injuries. Patients were excluded if they had severe head and spine injuries, died on arrival, or had low-energy mechanisms of injury. Logistic regression was conducted to identify factors that predict mortality.

Results:

There were 154 patients who comprised our study group with an average age of 76 years and an ISS of 23. There were 96 males and 58 females. Overall, 52 patients died within 1 year of their admission: 21 patients during their initial hospital stay and 31 patients within 1 year following admission. In all, 64 (42%) patients underwent operative stabilization of their orthopedic injuries. Increased mortality was seen (P < .05) in female patients, those with lower admission Glasgow coma score, and those who underwent orthopedic surgery. Patients had worse outcomes if they sustained femur (P = .014), clavicle, or scapular fractures (P = .027). Other factures associated with higher mortality included pelvic/acetabular injury requiring surgery (P = .019) or spine fractures treated nonoperatively (P = .014).

Conclusion:

The effect of orthopedic injuries on this geriatric polytrauma group contribute to worse outcomes when they included clavicle, scapula, and femur fractures. We also found that pelvic/acetabular fractures treated operatively and nonoperative spine fractures were associated with higher mortality rates. Risk/benefit consideration is suggested when contemplating operative intervention in these patients.

Lumbar Bone Mineral Density Phantomless Computed Tomography Measurements and Correlation with Age and Fracture Incidence

OBJECTIVE

Low bone quality is a contributing factor to motor vehicle crash (MVC) injury. Quantification of occupant bone mineral density (BMD) is important from an injury causation standpoint. The first aim of this study was to validate a technique for measuring lumbar volumetric BMD (vBMD) from phantomless computed tomography (CT) scans. The second aim was to apply the validated phantomless technique to quantify lumbar vBMD in Crash Injury Research and Engineering Network (CIREN) occupants for correlation with age, fracture incidence, and osteopenia/osteoporosis diagnoses.

METHODS

Quantitative CT (qCT) and dual-energy X-ray absorptiometry (DXA) were collected prospectively for 50 subjects and used to validate a technique to measure vBMD from 281 phantomless CT scans of CIREN occupants. Hounsfield unit (HU) measurements were collected from the L1-L5 vertebrae, right psoas major muscle, and anterior subcutaneous fat for all subjects and from 3 phantom ports with known mg/cc calcium hydroxyapatite values for the validation group. qCT calibration was accomplished using regressions between the phantom HU and mg/cc values to convert L1-L5 HU values to mg/cc. A phantomless calibration technique was developed where the fat and muscle HU values were linearly regressed against fat (-69 mg/cc) and muscle (77 mg/cc) to establish a conversion for L1-L5 HU measurements to mg/cc. vBMD calculated from qCT versus the phantomless method was compared for the 50 subjects to assess agreement and a mg/cc osteopenia threshold was established using DXA T-scores. CIREN HU measurements were converted to mg/cc using the phantomless technique and the mg/cc osteopenia threshold was used to compare vBMD to age, fracture incidence, and osteopenia comorbidity classifications in CIREN.

RESULTS

Linear regression of lumbar vBMD derived from the qCT versus phantomless calibrations showed excellent agreement (R(2) = 0.87, P <.0001). A 145 mg/cc threshold for osteopenia was established (sensitivity = 1, specificity = 0.57) and 44 CIREN occupants had vBMD below this threshold. Of these 44 occupants, 64% were not classified as osteopenic in CIREN, but vBMD suggested undiagnosed osteopenia. Age was negatively correlated with vBMD in both sexes (P <.0001) and CIREN occupants with less than 145 mg/cc vBMD sustained an average 1.7 additional rib/sternum fractures (P =.036).

CONCLUSIONS

Because lumbar vBMD was estimated from phantomless CT scans with accuracy similar to qCT, the phantomless technique can be broadly applied to both prospectively and retrospectively assess patient bone quality for research and clinical studies related to MVCs, falls, and aging.

Age- and sex-specific thorax finite element model development and simulation

OBJECTIVE

The shape, size, bone density, and cortical thickness of the thoracic skeleton vary significantly with age and sex, which can affect the injury tolerance, especially in at-risk populations such as the elderly. Computational modeling has emerged as a powerful and versatile tool to assess injury risk. However, current computational models only represent certain ages and sexes in the population. The purpose of this study was to morph an existing finite element (FE) model of the thorax to depict thorax morphology for males and females of ages 30 and 70 years old (YO) and to investigate the effect on injury risk.

METHODS

Age- and sex-specific FE models were developed using thin-plate spline interpolation. In order to execute the thin-plate spline interpolation, homologous landmarks on the reference, target, and FE model are required. An image segmentation and registration algorithm was used to collect homologous rib and sternum landmark data from males and females aged 0-100 years. The Generalized Procrustes Analysis was applied to the homologous landmark data to quantify age- and sex-specific isolated shape changes in the thorax. The Global Human Body Models Consortium (GHBMC) 50th percentile male occupant model was morphed to create age- and sex-specific thoracic shape change models (scaled to a 50th percentile male size). To evaluate the thoracic response, 2 loading cases (frontal hub impact and lateral impact) were simulated to assess the importance of geometric and material property changes with age and sex.

RESULTS

Due to the geometric and material property changes with age and sex, there were observed differences in the response of the thorax in both the frontal and lateral impacts. Material property changes alone had little to no effect on the maximum thoracic force or the maximum percent compression. With age, the thorax becomes stiffer due to superior rotation of the ribs, which can result in increased bone strain that can increase the risk of fracture. For the 70-YO models, the simulations predicted a higher number of rib fractures in comparison to the 30-YO models. The male models experienced more superior rotation of the ribs in comparison to the female models, which resulted in a higher number of rib fractures for the males.

CONCLUSION

In this study, age- and sex-specific thoracic models were developed and the biomechanical response was studied using frontal and lateral impact simulations. The development of these age- and sex-specific FE models of the thorax will lead to an improved understanding of the complex relationship between thoracic geometry, age, sex, and injury risk.

Physiologic field triage criteria for identifying seriously injured older adults

OBJECTIVE

To evaluate the ability of out-of-hospital physiologic measures to predict serious injury for field triage purposes among older adults and potentially reduce the undertriage of seriously injured elders to non-trauma hospitals.

METHODS

This was a retrospective cohort study involving injured adults 55 years and older transported by 94 emergency medical services (EMS) agencies to 122 hospitals (trauma and non-trauma) in 7 regions of the western United States from January 1, 2006 to December 31, 2008. We evaluated initial out-of-hospital Glasgow Coma Scale (GCS) score, systolic blood pressure (SBP), respiratory rate, heart rate, shock index (SBP ÷ heart rate), out-of-hospital procedures, mechanism of injury, and patient demographics. The primary outcome was "serious injury," defined as Injury Severity Score (ISS) ≥ 16, as a measure of trauma center need. We used multivariable regression models, fractional polynomials and binary recursive partitioning to evaluate appropriate physiologic cut-points and the value of different physiologic triage criteria.

RESULTS

A total of 44,890 injured older adults were evaluated and transported by EMS, of whom 2,328 (5.2%) had ISS ≥ 16. Nonlinear associations existed between all physiologic measures and ISS ≥ 16 (unadjusted and adjusted p ≤ 0.001 for all,), except for heart rate (adjusted p = 0.48). Revised physiologic triage criteria included GCS score ≤ 14; respiratory rate < 10 or > 24 breaths per minute or assisted ventilation; and SBP < 110 or > 200 mmHg. Compared to current triage practices, the revised criteria would increase triage sensitivity from 78.6 to 86.3% (difference 7.7%, 95% CI 6.1-9.6%), reduce specificity from 75.5 to 60.7% (difference 14.8%, 95% CI 14.3-15.3%), and increase the proportion of patients without serious injuries transported to major trauma centers by 60%.

CONCLUSIONS

Existing out-of-hospital physiologic triage criteria could be revised to better identify seriously injured older adults at the expense of increasing overtriage to major trauma centers.

Morphometric analysis of variation in the ribs with age and sex

Rib cage morphology changes with age and sex are expected to affect thoracic injury mechanisms and tolerance, particularly for vulnerable populations such as pediatrics and the elderly. The size and shape variation of the external geometry of the ribs was characterized for males and females aged 0-100 years. Computed tomography (CT) scans from 339 subjects were analyzed to collect between 2700 and 10 400 homologous landmarks from each rib. Rib landmarks were analyzed using the geometric morphometric technique known as Procrustes superimposition. Age- and sex-specific functions of 3D rib morphology were produced representing the combined size and shape variation and the isolated shape variation. Statistically significant changes in the size and shape variation (P < 0.0001) and shape variation (P < 0.0053) of all 24 ribs were found to occur with age in males and females. Rib geometry, location, and orientation varied according to the rib level. From birth through adolescence, the rib cage experienced an increase in size, a decrease in thoracic kyphosis, and inferior rotation of the ribs relative to the spine within the sagittal plane. From young adulthood into elderly age, the rib cage experienced increased thoracic kyphosis and superior rotation of the ribs relative to the spine within the sagittal plane. The increased roundedness of the rib cage and horizontal angling of the ribs relative to the spine with age influences the biomechanical response of the thorax. With the plane of the rib oriented more horizontally, loading applied in the anterior-posterior direction will result in increased deformation within the plane of the rib and an increased risk for rib fractures. Thus, morphological changes may be a contributing factor to the increased incidence of rib fractures in the elderly. The morphological functions derived in this study capture substantially more information on thoracic skeleton morphology variation with age and sex than is currently available in the literature. The developed models of rib cage anatomy can be used to study age and sex variations in thoracic injury patterns due to motor vehicle crashes or falls, and clinically relevant changes due to chronic obstructive pulmonary disease or other diseases evidenced by structural and anatomic changes to the chest.

Predictors of mortality in geriatric trauma patients: a systematic review and meta-analysis

BACKGROUND

The rate of mortality and factors predicting worst outcomes in the geriatric population presenting with trauma are not well established. This study aimed to examine mortality rates in severe and extremely severe injured individuals 65 years or older and to identify the predictors of mortality based on available evidence in the literature.

METHODS

We performed a systematic literature search on studies reporting mortality and severity of injury in geriatric trauma patients using MEDLINE, PubMed, and Web of Science.

RESULTS

An overall mortality rate of 14.8% (95% confidence interval [CI], 9.8-21.7%) in geriatric trauma patients was observed. Increasing age and severity of injury were found to be associated with higher mortality rates in this patient population. Combined odds of dying in those older than 74 years was 1.67 (95% CI, 1.34-2.08) compared with the elderly population aged 65 years to 74 years. However, the odds of dying in patients 85 years and older compared with those of 75 years to 84 years was not different (odds ratio, 1.23; 95% CI, 0.99-1.52). A pooled mortality rate of 26.5% (95% CI, 23.4-29.8%) was observed in the severely injured (Injury Severity Score [ISS] ≥ 16) geriatric trauma patients. Compared with those with mild or moderate injury, the odds of mortality in severe and extremely severe injuries were 9.5 (95% CI, 6.3-14.5) and 52.3 (95% CI, 32.0-85.5; p ≤ 0.0001), respectively. Low systolic blood pressure had a pooled odds of 2.16 (95% CI, 1.59-2.94) for mortality.

CONCLUSION

Overall mortality rate among the geriatric population presenting with trauma is higher than among the adult trauma population. Patients older than 74 years experiencing traumatic injuries are at a higher risk for mortality than the younger geriatric group. However, the trauma-related mortality sustains the same rate after the age of 74 years without any further increase. Moreover, severe and extremely severe injuries and low systolic blood pressure at the presentation among geriatric trauma patients are significant risk factors for mortality.

LEVEL OF EVIDENCE

Systematic review and meta-analysis, level IV.

Emergency department visits by older adults for motor vehicle collisions

Introduction:

To describe the epidemiology and characteristics of emergency department (ED) visits by older adults for motor vehicle collisions (MVC) in the United States (U.S.).

Methods:

We analyzed ED visits for MVCs using data from the 2003–2007 National Hospital Ambulatory Medical Care Survey (NHAMCS). Using U.S. Census data, we calculated annual incidence rates of driver or passenger MVC-related ED visits and examined visit characteristics, including triage acuity, tests performed and hospital admission or discharge. We compared older (65+ years) and younger (18–64 years) MVC patients and calculated odds ratios (OR) and 95% confidence intervals (CIs) to measure the strength of associations between age group and various visit characteristics. Multivariable logistic regression was used to identify independent predictors of admissions for MVC-related injuries among older adults.

Results:

From 2003–2007, there were an average of 237,000 annual ED visits by older adults for MVCs. The annual ED visit rate for MVCs was 6.4 (95% CI 4.6–8.3) visits per 1,000 for older adults and 16.4 (95% CI 14.0–18.8) visits per 1,000 for younger adults. Compared to younger MVC patients, after adjustment for gender, race and ethnicity, older MVC patients were more likely to have at least one imaging study performed (OR 3.69, 95% CI 1.46–9.36). Older MVC patients were not significantly more likely to arrive by ambulance (OR 1.47; 95% CI 0.76–2.86), have a high triage acuity (OR 1.56; 95% CI 0.77–3.14), or to have a diagnosis of a head, spinal cord or torso injury (OR 0.97; 95% CI 0.42–2.23) as compared to younger MVC patients after adjustment for gender, race and ethnicity. Overall, 14.5% (95% CI 9.8–19.2) of older MVC patients and 6.1% (95% CI 4.8–7.5) of younger MVC patients were admitted to the hospital. There was also a non-statistically significant trend toward hospital admission for older versus younger MVC patients (OR 1.78; 95% CI 0.71–4.43), and admission to the ICU if hospitalized (OR 6.9, 95% CI 0.9–51.9), after adjustment for gender, race, ethnicity, and injury acuity. Markers of injury acuity studied included EMS arrival, high triage acuity category, ED imaging, and diagnosis of a head, spinal cord or internal injury.

Conclusion:

Although ED visits after MVC for older adults are less common per capita, older adults are more commonly admitted to the hospital and ICU. Older MVC victims require significant ED resources in terms of diagnostic imaging as compared to younger MVC patients. As the U.S. population ages, and as older adults continue to drive, EDs will have to allocate appropriate resources and develop diagnostic and treatment protocols to care for the increased volume of older adult MVC victims.

Defining geriatric trauma: when does age make a difference?

BACKGROUND

Injured elderly patients experience high rates of undertriage to trauma centers (TCs) whereas debate continues regarding the age defining a geriatric trauma patient. We sought to identify when mortality risk increases in injured patients as the result of age alone to determine whether TC care was associated with improved outcomes for these patients and to estimate the added admissions burden to TCs using an age threshold for triage.

METHODS

We performed a retrospective cohort study of injured patients treated at TCs and non-TCs in Pennsylvania from April 1, 2001, to March 31, 2005. Patients were included if they were between 19 and 100 years of age and had sustained minimal injury (Injury Severity Score < 9). The primary outcome was in-hospital mortality. We analyzed age as a predictor of mortality by using the fractional polynomial method.

RESULTS

A total of 104,015 patients were included. Mortality risk significantly increased at 57 years (odds ratio 5.58; 95% confidence interval 1.07-29.0; P = .04) relative to 19-year-old patients. TC care was associated with a decreased mortality risk compared with non-TC care (odds ratio 0.83; 95% confidence interval 0.69-0.99; P = .04). Using an age of 70 as a threshold for mandatory triage, we estimated TCs could expect an annual increase of approximately one additional admission per day.

CONCLUSION

Age is a significant risk factor for mortality in trauma patients, and TC care improves outcomes even in older, minimally injured patients. An age threshold should be considered as a criterion for TC triage. Use of the clinically relevant age of 70 as this threshold would not impose a substantial increase on annual TC admissions.

High-energy skeletal trauma in the elderly

Despite the increasing prevalence of high-energy skeletal trauma in the elderly (i.e., sixty years or older), there is a lack of prospective data regarding best care for these injuries.Elderly patients with multiple injuries are often undertriaged to trauma centers and underresuscitated.Aggressive early resuscitation can improve outcomes in elderly patients who have sustained skeletal trauma.Comanagement by orthopaedic surgeons and geriatricians of elderly patients with skeletal trauma can lead to a lower length of hospital stay, lower readmission rates, shorter time to operation, lower complication rates, and lower mortality.

Evaluation of a new elderly trauma triage algorithm

OBJECTIVES

Undertriage is common in patients 55 years and older and is even worse for those 65 and older. In 1999, the Florida legislature implemented a statewide trauma system, including a new Florida trauma triage algorithm (FTTA). This study examines how the new system affected prehospital triage in younger versus older patients.

METHODS

A retrospective review of appropriate triage was conducted at a regional level 2 trauma center during a 1-year period. Patients were considered to have major trauma if they were FTTA positive or had an Injury Severity Score (ISS) of ≥ 16. An internal trauma review panel examined hospital discharge data to assess triage accuracy. Odds ratios (ORs) and confidence intervals (CIs) were calculated.

RESULTS

A total of 49% of nontrauma patients 15 to 54 years old were seen at the trauma center compared with 83% of FTTA positive and 86% of patients with an ISS ≥ 16 (OR 2.88, 95% CI 2.44-3.41). For those with an ISS ≥ 16, the OR was 6.53 (95% CI 4.07-10.47). For patients 55 years and older, 52% of nontrauma patients were triaged to the trauma center versus 59% of FTTA positive and 64% of patients with ISS ≥ 16 (OR 1.03, 95% CI 0.93-1.15). Patients 55 years and older with an ISS ≥ 16 had only a slightly increased triage effect (OR 1.67, 95% CI 1.08-2.58) compared with those with an ISS 0 to 15 (OR 1.00, 95% CI 0.89-1.12).

CONCLUSIONS

Whereas FTTA appropriately triaged patients 15 to 54 years old to the trauma center, those 55 years old and older were much less likely to be triaged correctly. The reasons for this finding remain unknown, and further studies are needed to investigate and improve elderly triage.

Direct transport of geriatric trauma patients with pelvic fractures to a Level I trauma center within an organized trauma system: impact on two-week incidence of in-hospital complications

BACKGROUND

Undertriage of elderly trauma patients to tertiary trauma centers is well documented. This study evaluated the impact of directness of transport to a Level I trauma center on morbidity in geriatric trauma patients sustaining severe pelvic fractures.

METHODS

This was a retrospective cohort study of 87 geriatric trauma patients diagnosed with potentially unstable pelvic fractures, treated at a Level I trauma center between 2008 and 2010.

RESULTS

Of the 87 patients, 39% (34 of 87) initially were transported to a nontertiary trauma center. After adjusting for presence of comorbidity and injury severity, the 2-week incidence of complications was 54% higher in transferred patients compared with those directly transported (rate ratio, 1.54; 95% confidence interval, .95-2.54). In particular, transferred patients had increased odds of developing pneumonia/systemic inflammatory response syndrome.

CONCLUSIONS

Despite lacking precision, results of this study suggest an increased risk of complications in transferred geriatric trauma patients with severe pelvic fractures compared with their directly transported counterparts.

Trauma centre outcome performance: a comparison of young adults and geriatric patients in an inclusive trauma system

BACKGROUND

Elderly trauma patients represent a unique clientele requiring specialised care but they rarely benefit from standardised care strategies within trauma systems. We aimed to evaluate whether trauma centres with lower/higher than expected mortality amongst patients <65 years of age have similar results for geriatric patients. A secondary objective was to compare transfer to level I/II trauma centres across age groups.

METHODS

The study was based on data from a Canadian provincial trauma registry (1999-2006). Outcome performance was evaluated with estimates of risk-adjusted 30-day mortality generated for each of the system's 57 adult trauma centres. Agreement in performance results was evaluated with correlation coefficients.

RESULTS

The study sample comprised 55,283 young adults (3.5% mortality) and 30,960 geriatric patients (8.2% mortality). The two age groups only had one out of six outliers in common. Hospital ranks amongst young adults were not correlated to those assigned amongst geriatric patients (r = 0.01, 95%CI -0.25;0.27). Correlation was also low for patients with major trauma (r = 0.20, 95%CI -0.06;0.44). Amongst patients with severe head injuries initially received in a level III/IV centre, 81% of young adults versus 71% of geriatric patients were transferred to a level I/II centre (p<0.0001).

CONCLUSIONS

Trauma centres that have low risk-adjusted mortality for young adults do not necessarily do so for geriatric patients. In addition, geriatric patients with severe head injuries are less likely to be treated in neurosurgical trauma centres. Further research is needed to identify determinants of inter-hospital variation in outcome for geriatric trauma patients.

The clinical features and outcome of crush patients with acute kidney injury after the Wenchuan earthquake: differences between elderly and younger adults

BACKGROUND

On May 12, 2008, a devastating earthquake hit Wenchuan county of China's Sichuan province. Acute kidney injury (AKI) is one of the most lethal but reversible complications of crush syndrome after an earthquake. However, little is known about the epidemiological features of elderly crush patients with AKI. The aim of the present study is to compare clinical features and outcome of crush related AKI between elderly and younger adults in the Wenchuan earthquake.

MATERIALS AND METHODS

A questionnaire was sent to 17 reference hospitals that treated the victims after the earthquake. Clinical and laboratory characteristics of crush patients with AKI were retrospectively analysed.

RESULTS

228 victims experienced crush related AKI, of which 211 were adults, including 45 elderly (age ≥ 65 years) and 166 younger adults (age, 15-64 years). Compared with the resident population, the percentage of patients was higher amongst elderly (19.7% versus 7.6%, P<0.001). The distribution of gender was similar in elderly and younger adults. Mean systolic blood pressure was higher in elderly groups. Although no statistical differences in number of injury and injury severity score were observed between elderly and younger adults, elderly victims had lower frequency of extremities crush injury; higher incidences of thoracic traumas, limb, rib, and vertebral fractures; lower serum creatinine, potassium and creatinine kinase levels; lower incidence of oliguria or anuria; lower dialysis requirement; underwent less fasciotomies and amputations, received less blood and plasma transfusions. Mortality were 17.8% and 10.2% in elderly and younger adults, respectively (P=0.165). Stratified analysis demonstrated the elderly receiving dialysis had higher mortality rate compared with younger patients (62.5% versus 10.5%, P<0.001). Multivariate logistic regression analysis indicated that need for dialysis and sepsis were independent risk factors for death in the elderly patients.

CONCLUSIONS

Elderly crush victims more frequently developed AKI in the Wenchuan earthquake, and they differ from younger adults in injury patterns and treatment modalities. The elderly patients with AKI requiring dialysis were at a relatively high risk of mortality.

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.

Recommendations for Uniform Reporting of Data following Major Trauma — The Utstein Style: An Initiative

The document is published in collaboration with the following organisations: the European Society of Emergency Medicine (Leuven); the European Resuscitation Council (Antwerpen); the Air Medical Physician Association (Salt Lake City, US); the German Interdisciplinary Association of Critical Care Medicine; and the German Society of Anaesthesiology and Intensive Care. The document is to be published jointly in the following journals: 1) Trauma Care (ITACCS); 2) Resuscitation; 3) Prehospital and Disaster Medicine; 4) European Journal of Emergency Medicine; 5) Trauma and Emergency Medicine Journal (SA); 6) Emergency Medicine(Norway); 7) JEUR; and 8) Notfall und Rettungsmedizin (Germany).

Evaluating age in the field triage of injured persons

STUDY OBJECTIVE

We evaluate trauma undertriage by age group, the association between age and serious injury after accounting for other field triage criteria and confounders, and the potential effect of a mandatory age triage criterion for field triage.

METHODS

This was a retrospective cohort study of injured children and adults transported by 48 emergency medical services (EMS) agencies to 105 hospitals in 6 regions of the western United States from 2006 through 2008. We used probabilistic linkage to match EMS records to hospital records, including trauma registries, state discharge databases, and emergency department databases. The primary outcome measure was serious injury, as measured by an Injury Severity Score greater than or equal to 16. We assessed undertriage (Injury Severity Score ≥16 and triage-negative or transport to a nontrauma center) by age decile and used multivariable logistic regression models to estimate the association (linear and nonlinear) between age and Injury Severity Score greater than or equal to 16, adjusted for important confounders. We also evaluated the potential influence of age on triage efficiency and trauma center volume.

RESULTS

Injured patients (260,027) were evaluated and transported by EMS during the 3-year study period. Undertriage increased for patients older than 60 years, reaching approximately 60% for those older than 90 years. There was a strong nonlinear association between age and Injury Severity Score greater than or equal to 16. For patients not meeting other triage criteria, the probability of serious injury was most notable after 60 years. A mandatory age triage criterion would have decreased undertriage at the expense of overtriage, with 1 patient with Injury Severity Score greater than or equal to 16 identified for every 60 to 65 additional patients transported to major trauma centers.

CONCLUSION

Trauma undertriage increases in patients older than 60 years. Although the probability of serious injury increases among triage-negative patients with increasing age, the use of a mandatory age triage criterion appears inefficient for improving field triage.

Elevated systolic blood pressure after trauma: tolerated in the elderly

BACKGROUND

We undertook the current study to determine the impact of elevated admission systolic blood pressure (SBP) on trauma patients without severe brain injury.

MATERIALS AND METHODS

We conducted a retrospective review of the Los Angeles County Trauma System database to identify all patients with moderate to severe injuries (injury severity score >9) admitted between 2003 and 2008. Patients with head abbreviated injury score >3 were excluded. We divided the remaining patients into three age cohorts and conducted multivariate regression modeling at increasing SBP thresholds to identify independent predictors of mortality.

RESULTS

A total of 23,931 patients met inclusion criteria. Overall mortality was 8.6% and it increased with age across the three groups. The admission SBP thresholds associated with significantly increased mortality in the young and middle-aged were >190 mm Hg (AOR 1.5, P = 0.04) and >180 mm Hg (AOR 1.5, P = 0.01), respectively. In the elderly, no admission SBP threshold was associated with significantly increased mortality. Interestingly, several elevated admission SBP thresholds were associated with significantly reduced mortality in the elderly (>150 mm Hg AOR 0.6, P < 0.01; >160 mm Hg AOR 0.6, P < 0.01; and >170 mm Hg AOR 0.7, P = 0.02).

CONCLUSIONS

The admission SBP thresholds that predicted higher mortality for the young and middle-aged were >190 mm Hg and >180 mm Hg, respectively. Elderly trauma patients tolerated higher admission SBP than their younger counterparts and multiple elevated SBP thresholds were associated with significantly reduced mortality in the elderly.