Functional outcomes in octogenarian trauma

Trauma in the Geriatric and the Super-Geriatric: Should They Be Treated the Same?

INTRODUCTION

There is paucity of studies comparing the characteristics of trauma in geriatrics and super-geriatrics. We aimed to explore the injury characteristics and outcomes of older adult trauma patients on a nationwide scale.

METHODS

This is a retrospective analysis of 2017-2019 American College of Surgeons Trauma Quality Improvement Program. We included moderate to severely injured (Injury Severity Score >8) older adult (≥65 y) trauma patients. Patients were stratified into geriatric (65 y ≤ Age <80 y) and super-geriatric (Age ≥80 y). Outcomes included interventions, complications, failure-to-rescue, withdrawal of support treatment, and mortality.

RESULTS

We identified 269,208 patients (geriatric = 57%; super-geriatric = 43%). Both groups had similar vital signs and Injury Severity Score (geriatric = 9[9-12] versus super-geriatric = 9[9-11]). The super-geriatric were more likely to have falls (71% versus 89%, P < 0.001), while the geriatric were more likely to have Motor vehicle collision (17% versus. 7%, P < 0.001). On multivariate analyses, geriatric patients were more likely to be treated at a Level I Trauma Center (adjusted Odds Ratio [aOR] = 1.1, P < 0.001), undergo hemorrhage control surgery (aOR = 1.5, P < 0.001), be admitted to the intensive care unit (aOR = 1.15, P < 0.001), or intubated (aOR = 1.4, P < 0.001). However, they were less likely to have withdrawal of support treatment (aOR = 0.37, P < 0.001) compared to the super-geriatric. Furthermore, geriatric patients were more likely to develop major complications (aOR = 1.08, P < 0.01). However, they had lower odds of failure-to-rescue (aOR = 0.69, P < 0.001) and in-hospital mortality (aOR = 0.56, P < 0.001) compared to the super-geriatric.

CONCLUSIONS

Significant differences exist in injury patterns, interventions, and outcomes between the geriatric and super-geriatric. Future studies and guidelines may need to classify older adults into geriatric and super-geriatric categories to facilitate tailored care and overall improvement of management strategies for older populations.

Characteristics and Clinical Outcomes of Elderly Patients with Trauma Treated in a Local Trauma Center

Purpose: This study aimed to investigate the characteristics of elderly patients who visited a non-regional trauma center to examine the effects of old age on the clinical outcomes of patients.Methods: The medical charts of 159 patients with trauma who visited the National Health Insurance Service Ilsan Hospital between March 2020 and February 2022 were retrospectively analyzed.Results: Of the 159 patients, 41 were assigned to the elderly patient group (EPG) and 118 were assigned to the non-elderly patient group (NEPG). The average age of patients in each group was 75.5 and 38.2 years in the EPG and the NEPG, respectively. Comparing the injury mechanism between the two groups, pedestrian traffic accidents (TA) were the most common (24.4%), followed by slipping (19.5%), motorcycle TA, and bicycle TA (14.6%) in EPG. In the NEPG, motorcycle TA (28.0%) was the most common, followed by car TA (27.1%), and fall injury (16.9%), with a significant difference between the two groups (<i>p</i> < 0.001). The significant differences between the two groups were the injury severity score (ISS; <i>p</i> = 0.004), severe trauma (<i>p</i> = 0.045), intensive care unit admission (<i>p</i> = 0.028), emergency operation (<i>p</i> = 0.034), and mortality (<i>p</i> = 0.013). The statistically significant risk factors for mortality were old age (<i>p</i> = 0.024) and chest injury (<i>p</i> = 0.013).Conclusion: Patients in the EPG compared with the NEPG group showed different injury mechanisms. The EPG has a higher severity and mortality rate than the NEPG.

Developing a measure of overall intensity of injury care: A latent class analysis

BACKGROUND

While injury is a leading cause of death and debility in older adults, the relationship between intensity of care and trauma remains unknown. The focus of this analysis is to measure the overall intensity of care delivered to injured older adults during hospitalization.

METHODS

We used Centers for Medicare and Medicaid Services Medicare fee-for-service claims data (2013-2014), to identify emergency department-based claims for moderate and severe blunt trauma in age-eligible beneficiaries. Medical procedures associated with care intensity were identified using a modified Delphi method. A latent class model was estimated using the identified procedures, intensive care unit length of stay, demographics, and injury characteristics. Clinical phenotypes for each class were explored.

RESULTS

A total of 683,398 cases were classified as low- (73%), moderate- (23%), and high-intensity care (4%). Greater age and reduced injury severity were indicators of lower intensity, while males, non-Whites, and nonfall mechanisms were more common with high intensity. Intubation/mechanical ventilation was an indicator of high intensity and often occurred with at least one other procedure or an extended intensive care unit stay.

CONCLUSION

This work demonstrates that, although heterogeneous, care for blunt trauma can be evaluated using a single novel measure.

LEVEL OF EVIDENCE

For prognostic/epidemiological studies, level III.

Creation of skin grafts from traumatic avulsed skin

As the proportion of geriatric patients increases, so too does the incidence of geriatric trauma. Trauma centres must develop protocols to reduce the risk of complications from injuries in this specialised patient population. From a soft tissue standpoint, open wounds tend to heal slower in these patients and have a significant impact on their quality of life. In this case report, we describe our protocol for managing traumatic skin tears using a combination of traumatic skin grafts and minced expansion grafts with photographic documentation of the healing from significant wounds in an elderly patient involved in a high-energy blunt traumatic injury.

Octogenarian and Nonagenarians Are at a Higher Risk for Experiencing Adverse 30-Day Outcomes Following ORIF of Ankle Fractures

Introduction:

Despite an increasing number of elderly individuals undergoing surgical fixation for ankle fractures, few studies have investigated peri-operative outcomes and safety of surgery in an octogenarian and nonagenarian population (age >80 years).

Materials and Methods:

The 2012-2017 American College of Surgeons database was queried for patients undergoing open reduction internal fixation for isolated uni-malleolar, bi-malleolar and tri-malleolar ankle fractures. The study cohort was divided into 3 comparison groups (age <65 years, 65-75 and >80). Multi-variate regression analyzes were used to compare the independent effect of varying age groups on 30-day post-operative outcomes while controlling for baseline clinical characteristics and co-morbidity burdens.

Results:

A total of 19,585 patients were included: 5.3% were >80 years, 18.1% were 65-79 years, and 76.6% were <65 years. When compared to the non-geriatric population, individuals >80 years were at a significantly Abstract: higher risk of 30-day wound complications (OR 1.84; p = 0.019), pulmonary complications (OR 3.88; p < 0.001), renal complications (OR 1.96; p = 0.015), septic complications (OR 3.72; p = 0.002), urinary tract infections (OR 2.24; p < 0.001), bleeding requiring transfusion (OR 1.90; p = 0.025), mortality (or 7.44; p < 0.001), readmissions (OR 1.65; p = 0.004) and non-home discharge (OR 13.91; p < 0.001).

Discussion:

Octogenarians undergoing ankle fracture fixation are a high-risk population in need of significant pre-operative surgical and medical optimization. With the majority of patients undergoing non-elective ORIF procedures, it is critical to anticipate potential complications and incorporate experienced geriatric providers early in the surgical management of these patients.

Conclusions:

Octogenarians and nonagenarians are fundamentally distinct and vulnerable age groups with a high risk of complications, readmissions, mortality and non-home discharges compared to other geriatric (65-79 years) and non-geriatric (<65 years) patients. Pre-operative counseling and risk-stratification are essential in this vulnerable patient population.

Urinary Titin N-Fragment Evaluation in a Randomized Controlled Trial of Beta-Hydroxy-Beta-Methylbutyrate for Acute Mild Trauma in Older Adults

The effects of beta-hydroxy-beta-methylbutyrate (HMB) complex administration and the significance of titin, a biomarker of muscle injury, in elderly minor trauma patients in acute phase has not been established. In this single-center, randomized controlled study, trauma patients aged ≥ 70 years with an injury severity score < 16 were included. Titin values on days 1 and 3 were measured and the intervention group received HMB complex (2.4 g of HMB + 14 g of glutamine + 14 g of arginine) and the control group received glutamine complex (7.2 g of protein including 6 g of glutamine). The cross-sectional area of the rectus femoris (RFCSA) on ultrasound, grip strength, and the Barthel Index were assessed on the first day of rehabilitation and after 2 weeks. We analyzed 24 HMB and 25 control participants. Titin values on day 3 correlated with grip strength (r = -0.34, p = 0.03) and the Barthel Index (r = -0.39, p = 0.01) at follow-up. HMB complex supplementation had no effect on the RFCSA (2.41 vs. 2.45 cm², p = 0.887), grip strength (13.3 vs. 13.1 kg, p = 0.946), or the Barthel Index (20.0 vs. 50.0, p = 0.404) at follow-up. Titin values might associate with subsequent physical function. Short-term HMB complex supplementation from acute phase did not ameliorate muscle injury.

Maxillofacial fractures in females: a 5-year retrospective review

BACKGROUND

This retrospective study reviews the maxillofacial fractures (MF) over a 5-year period at the National Maxillofacial Unit, St James Hospital Dublin, with an emphasis on female patients.

MATERIALS AND METHODS

The trauma database was analysed from January 2015 to December 2019. The following demographic details were recorded: patient age and gender, mechanism of injury, and facial fracture sites. This retrospective study did not require approval from the local IRB.

RESULTS

A total of 4761 patients had facial fractures during the study: 1125 (24%) female, 3636, (76%) male. Females had 1190 facial fractures, with two fracture peaks: 20-39 years and 70-89 years. In males, the majority of fractures occurred between 20 and 39 peaking at 20-29 years and tailed off thereafter. In the females the most common fracture sites were zygomatic 402 (34%), nasal 311(26%), orbital (22%), and mandibular 141(12%). There were also smaller percentages of frontal (0.8%), maxillary (4%), and Le Fort fractures (1%). Two hundred and sixty-two (23%) females were managed surgically and 853 (77%) non-surgically.

CONCLUSION

This study confirms maxillofacial fractures are less common in females. The female age distribution demonstrates two peaks, one in early adult and a second in old age. This may be explained by females living longer and independently and at risk for falls. The most commonly reported fracture aetiology in females was "falls." This raises concerns as to whether "falls" are used to explain an assault. There is an informal concern amongst maxillofacial surgeons that females presenting with facial trauma may be the victims of domestic violence, which may be denied by the victims.

Characteristics, injuries, and clinical outcomes of geriatric trauma patients in Japan: an analysis of the nationwide trauma registry database

Geriatric trauma is a major socio-economic problem, especially among the aging Japanese society. Geriatric people are more vulnerable to trauma than younger people; thus, their outcomes are often severe. This study evaluates the characteristics of geriatric trauma divided by age in the Japanese population. We evaluated trauma characteristics in patients (n = 131,088) aged ≥ 65 years by segregating them into 2 age-based cohorts: age 65–79 years (65–79 age group; n = 70,707) and age ≥ 80 years (≥ 80 age group; n = 60,381). Clinical characteristics such as patient background, injury mechanism, injury site and severity, treatment, and outcome were examined. Injuries among men were more frequent in the 65–79 age group (58.6%) than in the ≥ 80 age group (36.3%). Falls were the leading cause of trauma among the 65–79 age group (56.7%) and the ≥ 80 age group (78.9%). In-hospital mortality was 7.7% in the 65–79 age group and 6.6% in the ≥ 80 age group. High fall in the ≥ 80 age group showed 30.5% mortality. The overall in-hospital mortality was 11.8% (the 65–79 age group, 12.3%; the ≥ 80 age group, 11.2%). Most hospitalized patients were transferred to another hospital (the 65–79 age group, 52.5%; the ≥ 80 age group, 66.2%). We demonstrated the epidemiological characteristics of Japanese geriatric trauma patients. The overall in-hospital mortality was 11.8%, and fall injury in the ≥ 80 age group required caution of trauma care.

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.

Measurement of mobility and physical function in hospitalised trauma patients: A systematic review of instruments and their measurement properties

Introduction

It is well recognised that organised trauma systems reduce trauma patient mortality. As established systems mature, there is an increasing need to better understand the patient recovery trajectory. Mobility and physical function are key aspects of recovery, but the optimal instruments for measurement in the acute hospital setting remain unclear.

Methods

A systematic review was undertaken to identify and describe mobility and physical function instruments scored by direct patient assessment, in adult trauma patients in an acute hospital setting. Databases were searched with no date restrictions. Instruments that were specific to subgroups or related to individual conditions, diseases or joints were excluded. The consensus-based standards for the selection of health measurement instruments checklist was used to assess risk of bias where relevant. Clinimetric properties were reported where possible, including reliability, validity and responsiveness.

Results

Fourteen thousand one hundred and fourteen articles were identified with 37 eligible for final review, including six instruments. None had been specifically designed for use in a heterogeneous range of trauma patients. The Functional Independence Measure was the most commonly cited (n = 10 studies), with evidence of construct validity, responsiveness and minimal floor/ceiling effects (<3%). The Acute Care Index of Function (n = 1 study) was found to be valid and responsive whilst the modified Iowa Level of Assistance (n = 2 studies) was reliable and responsive, but ceiling effects ranged from 26% to 37%. Little clinimetric data were available for other measures.

Conclusion

Evidence from a few studies show promise for the use of the Functional Independence Measure, Acute Care Index of Function and modified Iowa Level of Assistance to measure mobility and physical function in trauma patients, however comprehensive clinimetric data are lacking. Future research should test these scores in specifically designed clinimetric property studies in defined trauma patient populations. This would enable the identification of a gold standard measure for evaluating treatment effectiveness, enabling benchmarking between centres, allow prediction of recovery pathways and optimise trauma patient outcomes.

Early Predictors of Mortality in Geriatric Patients With Trauma

OBJECTIVE

To identify variables that predict mortality in geriatric patients with trauma.

DESIGN

Retrospective review.

SETTING

Level I trauma center.

PATIENTS/PARTICIPANTS

A total of 147 geriatric patients with trauma (age ≥65) with a predicted probability of survival of 10%-75% based on the Trauma Score-Injury Severity Score (TRISS).

MAIN OUTCOME MEASUREMENTS

Patients were divided into 2 cohorts: survivors and nonsurvivors. The following variables available at presentation were analyzed: age, mechanism of injury, temperature, systolic blood pressure, pulse rate, shock index, respiratory rate, Glasgow Coma Scale (GCS) score, base deficit, and hematocrit (HCT). The Injury Severity Score (ISS) and TRISS were calculated for both cohorts.

RESULTS

Of the 147 patients analyzed, 84 (57%) died during the index hospitalization and 63 (43%) survived. The mean age of nonsurvivors was significantly higher than that of survivors (78.6 vs. 76.1 years; P < 0.04). A greater number of nonsurvivors (72.6%) sustained injuries as a result of a low-energy mechanism compared with survivors (54%; P = 0.02). GCS, temperature, and respiratory rate were significantly lower for nonsurvivors, whereas base deficit was higher (P < 0.05). The TRISS was predictive of survival (TRISS 0.27 vs. 0.53, P < 0.001), but the distinguishing capacity of the TRISS to predict mortality was limited (area under the receiver operator curve; 0.67; 95% confidence interval 0.58-0.76; P < 0.0001).

CONCLUSIONS

Older age, lower GCS, and a low-energy mechanism of injury are associated with a higher mortality rate in this at-risk geriatric trauma population. Early identification of predictors of mortality may help care providers more accurately assess injury burden in geriatric patients.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Optimizing physical activity among older adults post trauma: Overcoming system and patient challenges

BACKGROUND

By 2050 it is anticipated that close to half (40%) of all trauma patients will be over the age of 65. Recovery for these individuals is more complicated than among younger individuals. Early mobilization has been shown to improve outcomes. Unfortunately, there are many challenges to early mobilization. The Function Focused Care Intervention was developed to overcome these challenges.

PURPOSE

The purpose of this paper was to describe the initial recruitment of the first 25 participants and delineate the challenges and successes associated with implementation of this intervention.

RESULTS

Overall recruitment rates were consistent with other studies and the intervention was implemented as intended. Most patients were female, white and on average 79 years of age. Optimizing physical activity of patients was a low priority for the nurses with patient safety taking precedence. Patients spent most of the time in bed. Age, depression and tethering were the only factors that were associated with physical activity and functional outcomes of patients.

CONCLUSION

Ongoing work is needed to keep patients physically active in the immediate post trauma recovery period.

Health status and return to work in trauma patients at 3 and 6 months post-discharge: an Australian major trauma centre study

INTRODUCTION

The aim of this study was to describe post-discharge outcomes, and determine predictors of 3 and 6 months health status outcomes in a population of trauma patients at an inner city major trauma centre.

METHODS

This was a prospective cohort study of adult trauma patients admitted to this hospital with 3 and 6 months post-discharge outcomes assessment. Outcome measures were the Physical Component Scores (PCS) and Mental Component Scores (MCS) of the Short Form 12, EQ-5D, and return to work (in any capacity) if working prior to injury. Repeated measures mixed models and generalised estimating equation models were used to determine predictors of outcomes at 3 and 6 months.

RESULTS

One hundred and seventy-nine patients were followed up. Patients with lower limb injuries reported lower mean PCS scores between 3 and 6 months (coefficient -4.21, 95 % CI -7.58, -0.85) than those without lower limb injuries. Patients involved in pedestrian incidents or assaults and those with pre-existing mental health diagnoses reported lower mean MCS scores. In adjusted models upper limb injuries were associated with reduced odds of return to work at 3 and 6 months (OR 0.20, 95 % CI 0.07, 0.57) compared to those without upper limb injuries.

DISCUSSION

Predictors of poorer physical health status were lower limb injuries and predictors of mental health were related to the mechanism of injury and past mental health. Increasing injury severity score and upper limb injuries were the only predictors of reduced return to work. The results provide insights into the feasibility of routine post-discharge follow-up at a trauma service level.

Mechanism of Injury Differentiates Risk Factors for Mortality in Geriatric Trauma Patients

OBJECTIVES

To evaluate the relationship between mechanism of injury and mortality in geriatric trauma patients and the ability of existing injury severity indices (ISIs) to assess mortality.

DESIGN

Retrospective review.

SETTING

Urban level 1 trauma center.

PARTICIPANTS

Four thousand five hundred forty-five trauma patients age ≥55 presenting between 2008 and 2011.

INTERVENTION

Low-energy (LE-GTP) and high-energy (HE-GTP) geriatric trauma patient cohorts were created based on ICD-9 injury codes. Existing ISIs were evaluated for their ability to predict in-hospital mortality using the area under the receiver-operating characteristic curve (AUROC).

MAIN OUTCOME MEASURES

Mortality.

RESULTS

The Trauma Score-Injury Severity Score (TRISS) was the most predictive ISI for both cohorts and was deemed to have moderate predictive capacity (AUROC: 0.82) in LE-GTP and excellent predictive capacity (AUROC: 0.91) in the HE-GTP. For, HE-GTP each 1-year increase in age was associated with a 12% increase risk of mortality versus 6% for LE-GTP. Preexisting conditions (PECs) were distributed differently between the cohorts with significantly more PECs in the LE-GTP (P < 0.01).

CONCLUSIONS

Existing ISIs have fair-to-moderate predictive capacity for in-hospital morality in LE-GTPs and moderate-to-excellent predictive capacity in HE-GTPs. LE-GTPs and HE-GTPs are distinct cohorts that should be evaluated separately. Combining the cohorts underestimates both the effect of age on HE-GTPs and the effect of PECs on LE-GTPs while overestimating the effect of PECs on HE-GTPs.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Implementation of a rib fracture triage protocol in elderly trauma patients

Elderly patients are highly susceptible to rib fractures after trauma. The use of a clinical pathway to determine resource allocation for patients with rib fractures has resulted in positive treatment outcomes. This retrospective study assessed the efficacy of a triage protocol involving trauma services on hospital length of stay in elderly patients with fractured ribs. Patients who had 3 or more ribs fractured experienced a statistically significant reduction in hospital length of stay after protocol implementation. We conclude that elderly patients with 3 or more rib fractures should be systematically referred to a trauma specialist.

Penetrating torso injuries in older adults: increased mortality likely due to "failure to rescue"

PURPOSE

Approximately 8 % of injuries in the elderly are from penetrating mechanisms. The natural history of potentially survivable penetrating torso wounds in the elderly is not well studied. Older adults with penetrating injuries to the torso may have worse outcomes than matched, younger patients due to a failure to rescue after complications.

METHODS

A retrospective chart review of all patients ≥55 (older) with a penetrating injury (GSW or SW) to the torso over 20 years was performed. All patients with a maximum AIS chest or abdomen >1 and <6 were included. A matched cohort (mechanism, AIS chest and abdomen, ISS and sex) of patients between the ages of 20-40 years (young) was created (3 young, 1 older). Differences in hemodynamics, complications, length of stay and mortality were analyzed.

RESULTS

105 older met inclusion criteria were compared to 315 young patients. Hemodynamic status was similar between the groups. Older patients required ICU care more often than younger patients, p < 0.05. Older patients required longer ICU stays, p < 0.001 and longer hospitalizations, p = 0.0012. More older patients (41.0 %) suffered post-injury complications compared to the young (26.4 %), p = 0.005. Older patients who suffered a complication had a higher mortality (30.2 %) than the young after a complication (10.8 %), p = 0.007.

CONCLUSIONS

While uncommon, penetrating injuries to older adults are associated with higher rates of post-injury complications and increased mortality. This may represent a "failure to rescue" and represent an opportunity for improved post-injury care in older adults who suffer potentially survivable penetrating torso injuries.

Injury patterns, severity and outcomes among older adults who sustained brain injury following a same level fall: a retrospective analysis

INTRODUCTION

The objectives of this study were to: identify the incidence and types of brain injuries; classify brain injury severity; identify additional injuries; and identify predictors of length of stay, mortality and trauma center admission.

METHODS

This secondary analysis used the NY State Inpatient Databases Healthcare Cost and Utilization Project. Inclusion criteria were: age 65 years and older, admitted to a hospital following a same level fall, primary hospital discharge diagnosis of traumatic brain injury. Descriptive and regression analyses were performed.

RESULTS

3331 patient records were analyzed. Intracranial hemorrhage accounted for 70% of the brain injuries. Younger age, higher household income, insurance status, ethnicity, patient location, increasing number of chronic diseases and diagnoses predicted trauma center admission. Age, trauma center admission, comorbidities, and brain injury severity predicted mortality. Age, race, major surgery, and number of diagnoses predicted length of stay.

DISCUSSION

Brain injuries are common sequelae from falls among older adults. Additional research is needed to understand sociodemographic factors that are associated with trauma center admission.

High-energy femur fractures increase morbidity but not mortality in elderly patients

BACKGROUND

Trauma centers are projected to have an increase in the number of elderly patients with high-energy femur fractures. Greater morbidity and mortality have been observed in these patients. Further clarification regarding the impact of high-energy femur fractures is necessary in this population.

QUESTIONS/PURPOSES

Our purpose was to assess the influence of high-energy femur fractures on mortality and morbidity in patients 60 years and older. Specifically, we asked (1) if the presence of a high-energy femur fracture increases in-hospital, 6-month, and 1-year mortality in patients 60 years and older, and (2) if there is a difference in morbidity (number of complications, intensive care unit [ICU] and total hospital length of stay, discharge disposition, accompanying fractures, and surgical intervention) between patients 60 years and older with and without high-energy femur fractures.

METHODS

A retrospective review of 242 patients was performed. Patients with traumatic brain injury or spine injury with a neurologic deficit were excluded. A control group, including patients admitted secondary to high-energy trauma without femur fractures, was matched by gender and Injury Severity Score (ISS). In-hospital mortality, 6-month and 1-year mortality, complications, ICU and total hospital length of stay, discharge disposition, accompanying fractures, surgical intervention, and covariates were recorded. Statistical analyses using Fisher's exact test, ANOVA, Kaplan-Meier estimates, and Cox regression models were performed to show differences in mortality (in-hospital, 6-month, 1-year), complications, length of ICU and total hospital stay, discharge disposition, surgical intervention, and accompanying fractures between elderly patients with and without femur fractures. The average ages of the patients were 72.8 years (± 9 years) in the femur fracture group and 71.8 years (± 9 years) in the control group. Sex, age, ISS, and comorbidities were homogenous between groups.

RESULTS

In-hospital (p = 0.45), 6-month (p = 0.79), and 1-year mortality (p = 0.55) did not differ in patients with and without high-energy femur fractures. Elderly patients with high-energy femur fractures had an increased number of complications (p = 0.029), longer total hospital length of stay (p = 0.039), were discharged more commonly to rehabilitation centers (p < 0.005), had more accompanying long bone fractures (p = 0.002), and were more likely to have surgery (p < 0.001). Average ICU length of stay was similar between the two groups (p = 0.17).

CONCLUSIONS

High-energy femur fractures increased morbidity in patients 60 years and older; however, no increase in mortality was observed in our patients. Concomitant injuries may play a more critical role in this population. Additional studies are necessary to clarify the role of high-energy femur fracture mortality in this age group.

LEVEL OF EVIDENCE

Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Age and mortality after injury: is the association linear?

INTRODUCTION

Multiple studies have demonstrated a linear association between advancing age and mortality after injury. An inflection point, or an age at which outcomes begin to differ, has not been previously described. We hypothesized that the relationship between age and mortality after injury is non-linear and an inflection point exists.

METHODS

We performed a retrospective cohort analysis at our urban level I center from 2007 through 2009. All patients aged 65 years and older with the admission diagnosis of injury were included. Non-parametric logistic regression was used to identify the functional form between mortality and age. Multivariate logistic regression was utilized to explore the association between age and mortality. Age 65 years was used as the reference. Significance was defined as p < 0.05.

RESULTS

A total of 1,107 patients were included in the analysis. One-third required intensive care unit (ICU) admission and 48 % had traumatic brain injury. 229 patients (20.6 %) were 84 years of age or older. The overall mortality was 7.2 %. Our model indicates that mortality is a quadratic function of age. After controlling for confounders, age is associated with mortality with a regression coefficient of 1.08 for the linear term (p = 0.02) and a regression coefficient of -0.006 for the quadratic term (p = 0.03). The model identified 84.4 years of age as the inflection point at which mortality rates begin to decline.

CONCLUSIONS

The risk of death after injury varies linearly with age until 84 years. After 84 years of age, the mortality rates decline. These findings may reflect the varying severity of comorbidities and differences in baseline functional status in elderly trauma patients. Specifically, a proportion of our injured patient population less than 84 years old may be more frail, contributing to increased mortality after trauma, whereas a larger proportion of our injured patients over 84 years old, by virtue of reaching this advanced age, may, in fact, be less frail, contributing to less risk of death.

Exposure to therapy of older patients with trauma and factors that influence provision of therapy

BACKGROUND

Rehabilitation as soon as possible after trauma decreases sedentary behavior, deconditioning, length of stay, and risk of rehospitalization.

OBJECTIVE

The study objectives were to describe exposure of older patients with trauma to rehabilitation and to explore factors associated with the number and initiation of therapy sessions.

DESIGN

This was a retrospective study of data from electronic medical records.

METHODS

Randomly selected older patients with trauma were described with regard to demographics, trauma diagnoses, comorbidities, preadmission function, and exposure to therapy. Regression analyses explored factors associated with number of therapy sessions and days until therapy was ordered and completed.

RESULTS

Records for 137 patients were randomly selected from records for 1,387 eligible patients who had trauma and were admitted over a 2-year period to a level I trauma center. The 137 patients received 303 therapy sessions. The sample included 63 men (46%) and 74 women (54%) who were 78 (SD=10) years of age; most patients were white (n=115 [84%]). All patients had orders for therapy, although 3 patients (2%) were never seen. An increase in comorbidities was associated with an increase in therapy sessions, a decrease in the number of days until an order was written, but an increase in the number of days from admission to evaluation. Injury severity was associated with a decrease in the number of days from admission to an order being written. A postponed or canceled therapy session was associated with increases in the number of days from admission to evaluation and in the number of days from an order being written to evaluation.

LIMITATIONS

This study was a retrospective review of a small sample with subjective measures and several dichotomous variables.

CONCLUSIONS

Increased injury severity, increased numbers of comorbidities, and postponed or canceled therapy sessions were associated with decreased time from admission to therapy orders, increased time from admission and orders to evaluation, and increased number of therapy sessions.

Predictors of transfer to rehabilitation for trauma patients admitted to a level 1 trauma centre--a model derivation and internal validation study

OBJECTIVE

Determine the predictors of transfer to rehabilitation in a cohort of trauma patients and derive a risk score based clinical prediction tool to identify such patients during the acute phase of injury management.

METHODS

Trauma registry data at a single level one trauma centre were obtained for all patients aged between 15 and 65 years admitted due to injury between 2007 and 2011. Multivariable logistic regression with stepwise selection was performed to derive a prediction model for transfer to rehabilitation. The model was tested on a validation dataset using receiver operator characteristic analyses and bootstrap cross validation on the entire dataset. A clinical prediction risk score was developed based on the final model.

RESULTS

There were 4900 patients included in the study. Variables found to be the strongest predictors of rehabilitation after logistic regression with stepwise selection were pelvic injuries (OR 12.6 95% CI 6.2, 25.2 p<0.001), need for intensive care unit admission (OR 7.2 95% CI 4.2, 12.3 p<0.001) and neurosurgical operation (OR 10.5 95% CI 4.7, 23.1 p<0.001). After bootstrap cross validation the mean AUC was 0.86 (95% CI 0.84, 0.89). The model had a sensitivity of 89% and specificity of 64%.

CONCLUSION

Intensive unit admission, neurosurgical operation, pelvic injuries and other lower limb injuries were the most important predictors of the need for rehabilitation after trauma. The prediction model has good overall sensitivity, discrimination and could be further validated for use in clinical practice.

Evolution and complications of chest trauma

OBJECTIVE

To describe the clinical characteristics and risk factors of patients with chest trauma, and to evaluate their correlation with the development of complications.

METHODS

Descriptive, prospective and analytical study of a patient cohort with chest trauma who underwent follow-up for a period of 30 days. Excluded from the study were those patients with moderate to severe traumatic brain injury, long-bone fractures, abdominal trauma and patients requiring mechanical ventilation.

RESULTS

A total of 376 patients met the inclusion criteria, 220 of whom were males (58.5%). The most frequent causes of trauma were falls (218 cases; 57.9%) and motor vehicle accidents (57 cases; 15.1%). The most frequent type of trauma was rib contusion (248 cases; 65.9%) and rib fractures (61 cases; 16.2%). Complications were observed in 43 patients (11.4%), mainly hemothorax (13 cases), pneumothorax (9 cases), pneumonia (6 cases) and acute renal failure (4 cases). Four patients died due to pneumonia and hemothorax. Thirty-three patients were hospitalized (8.7%) and 10 (2.6%) required later re-admittance. The risk for complications increased significantly in patients with more than 2 rib fractures, in those over the age of 85 and in the presence of certain comorbidities, such as COPD and pathologies requiring anticoagulation therapy. The risk for re-admittance is higher in patients over the age of 60.

CONCLUSIONS

Patients with chest trauma who present certain comorbidities, are over the age of 85 and have more than 2 rib fractures may present more complications. These factors should be contemplated in the evaluation, management and follow-up of these subjects.

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.

Long-term survival after major trauma in geriatric trauma patients: the glass is half full

BACKGROUND

The objective is to examine the long-term survival status of geriatric trauma patients (GTPs) after major trauma.

METHODS

A 10-year retrospective review at a Level I trauma center was performed. GTP were defined as age ≥ 65 years, with Injury Severity Score ≥ 30. Primary endpoints: survival at hospital discharge and long-term survival and discharge status. Two groups were defined: Abbreviated Injury Score (AIS) head >3 (G1, n = 116) and AIS head ≤ 3 (G2, n = 29). For GTP surviving hospitalization, two subgroups were defined: AIS head >3 (SG1, n = 77) and AIS head ≤ 3 (SG2, n = 20). Comparisons were analyzed for exploratory purposes only by independent t-tests or Mann-Whitney rank sums tests as appropriate. Long-term survival was plotted by a Kaplan-Meier curve.

RESULTS

A total of 145 GTP met inclusion criteria. In-hospital mortality was 33%. Nonsurvivors had lower Glasgow Coma Scale score (6 vs. 14, p < 0.001), higher Injury Severity Score (38 vs. 34, p < 0.003), and lower Revised Trauma Score (5.97 vs. 7.84, p < 0.002). Hospital mortality for G1 was 34% (39 of 116) and for G2 was 31% (9 of 29). In group 1 (n = 116), 39 patients (34%) died while 77 (66%) survived a median of 29 months (interquartile range [IQR] = 6-62). In group 2 (n = 29), 9 patients (31%) died while 20 (69%) survived a median of 46.50 months (IQR = 26.75-79). For the 77 patients who were alive at discharge (subgroup 1, AIS >3), 25 (32%) died while 52 (68%) survived a median of 33 months (IQR = 10.50-72.75). For the 20 patients with AIS ≤ 3 (subgroup 2), 7 of 20 (35%) died while 13 (65%) survived a median of 49 months (IQR = 30.50-93.50). A total of 28 patients (19%) survived more than 5 years from the time of discharge. For these 65 GTPs who are currently alive at the time of follow-up, living status could be determined for 49 (75%) and 33 of 49 (67%) were living at home.

CONCLUSIONS

This study documents appreciable long-term survival for GTP with major injury including severe head injury. A substantial proportion of these patients was able to return home.

LEVEL OF EVIDENCE

III, prognostic/epidemiological study.

Early hospital care of severe traumatic brain injury

Head injury is one of the major causes of trauma-related morbidity and mortality in all age groups in the United Kingdom, and anaesthetists encounter this problem in many areas of their work. Despite a better understanding of the pathophysiological processes following traumatic brain injury and a wealth of research, there is currently no specific treatment. Outcome remains dependant on basic clinical care: management of the patient's airway with particular attention to preventing hypoxia; avoidance of the extremes of lung ventilation; and the maintenance of adequate cerebral perfusion, in an attempt to avoid exacerbating any secondary injury. Hypertonic fluids show promise in the management of patients with raised intracranial pressure. Computed tomography scanning has had a major impact on the early identification of lesions amenable to surgery, and recent guidelines have rationalised its use in those with less severe injuries. Within critical care, the importance of controlling blood glucose is becoming clearer, along with the potential beneficial effects of hyperoxia. The major improvement in outcome reflects the use of protocols to guide resuscitation, investigation and treatment and the role of specialist neurosciences centres in caring for these patients. Finally, certain groups are now recognised as being at greater risk, in particular the elderly, anticoagulated patient.

Research priorities for high-quality geriatric emergency care: medication management, screening, and prevention and functional assessment

BACKGROUND

Geriatric adults represent an increasing proportion of emergency department (ED) users and can be particularly vulnerable to acute illnesses. Health care providers have recently begun to focus on the development of quality indicators (QIs) to define a minimal standard of care.

OBJECTIVES

The original objective of this project was to develop additional ED-specific QIs for older patients within the domains of medication management, screening and prevention, and functional assessment, but the quantity and quality of evidence were insufficient to justify unequivocal minimal standards of care for these three domains. Accordingly, the authors modified the project objectives to identify key research opportunities within these three domains that can be used to develop QIs in the future.

METHODS

Each domain was assigned one or two content experts who created potential QIs based on a systematic review of the literature, supplemented by expert opinion. Candidate QIs were then reviewed by four groups: the Society for Academic Emergency Medicine (SAEM) Geriatric Task Force, the SAEM Geriatric Interest Group, and audiences at the 2008 SAEM Annual Meeting and the 2009 American Geriatrics Society Annual Meeting, using anonymous audience response system technology as well as verbal and written feedback.

RESULTS

High-quality evidence based on patient-oriented outcomes was insufficient or nonexistent for all three domains. The participatory audiences did not reach a consensus on any of the proposed QIs. Key research questions for medication management (three), screening and prevention (two), and functional assessment (three) are presented based on proposed QIs that the majority of participants accepted.

CONCLUSIONS

In assessing a minimal standard of care by which to systematically derive geriatric QIs for medication management, screening and prevention, and functional assessment, compelling clinical research evidence is lacking. Patient-oriented research questions that are essential to justify and characterize future QIs within these domains are described.

Mortality and cost outcomes of elderly trauma patients admitted to intensive care and the general wards of an Australian tertiary referral hospital

Mortality and cost outcomes of elderly intensive care unit (ICU) trauma patients were characterised in a retrospective cohort study from an Australian tertiary ICU Trauma patients admitted between January 2000 and December 2005 were grouped into three major age categories: aged > or =65 years admitted into ICU (n = 272); aged -65 years admitted into general ward (n = 610) and aged < 65 years admitted into ICU (n = 1617). Hospital mortality predictors were characterised as odds ratios (OR) using logistic regression. The impact of predictor variables on (log) total hospital-stay costs was determined using least squares regression. An alternate treatment-effects regression model estimated the mortality cost-effect as an endogenous variable. Mortality predictors (P < or = 0.0001, comparator: ICU > or = 65 years, ventilated) were: ICU < 65 not-ventilated (OR 0.014); ICU < 65 ventilated (OR 0.090); ICU age > or = 65 not-ventilated (OR 0.061) and ward > or = 65 (OR 0.086); increasing injury severity score and increased Charlson comorbidity index of 1 and 2, compared with zero (OR 2.21 [1.40 to 3.48] and OR 2.57 [1.45 to 4.55]). The raw mean daily ICU and hospital costs in A$ 2005 (US$) for age < 65 and > or = 65 to ICU, and > or = 65 to the ward were; for year 2000: ICU, $2717 (1462) and $2777 (1494); hospital, $1837 (988) and $1590 (855); ward $933 (502); for year 2005: ICU, $3202 (2393) and $3086 (2307); hospital, $1938 (1449) and $1914 (1431); ward $1180 (882). Cost increments were predicted by age < or = 65 and ICU admission, increasing injury severity score, mechanical ventilation, Charlson comorbidity index increments and hospital survival. Mortality cost-effect was estimated at -63% by least squares regression and -82% by treatment-effects regression model. Patient demographic factors, injury severity and its consequences predict both cost and survival in trauma. The cost mortality effect was biased upwards by conventional least squares regression estimation.

Older people and major trauma

Major traumatic injury is a leading cause of death in younger age groups, but increasingly older people are affected also. Adverse outcomes, both physical and psychological, are associated with injury in the older population. This review aims to locate and describe the evidence relating to older people and major trauma in order to inform policy, practice, research and education. The published research and systematic reviews fall into three main topics: mechanism of traumatic injury in older people, the effects of co-morbidities on older trauma patients and outcomes following serious traumatic injury in older people. The psychological impact of traumatic injury and the resulting functional alteration cannot be underestimated in this group of patients.

Elderly Patients with Pelvic Fracture: Interventions and Outcomes

We examined the outcome of elderly trauma patients with pelvic fractures. Patients 65 years of age and older (elderly) with pelvic fractures were retrospectively compared with patients younger than 65 years with pelvic fractures and also with elderly patients without fracture. Over the study period, 1223 patients sustained a pelvic fracture (younger than 65 years, n = 1066, 87.2%; elderly, n = 157,12.8%). These patients were also compared with 1770 elderly patients with blunt trauma without fracture. Although the pelvic fracture patients were equally matched for Injury Severity Score (21.2 ± 13.4 nonelderly vs 20.5 ± 13.6 elderly), hospital length of stay was increased in the elderly (12.5 ± 13.1 days vs 11.5 ± 14.1 days) and they had a higher mortality rate (20.4% [32 of 157] vs 8.3% 88 of 1066]). The elderly without fracture also had a higher mortality rate when compared with the younger patients (10.9% [191 of 1760]; P < 0.03). The elderly were more likely to die from multisystem organ failure (25.0% [eight of 32] vs 10.2% [nine of 88]), whereas the nonelderly group was more likely to die from exsanguination (45.5% [40 of 88] younger than 65 years vs 21.9% [seven of 32] 65 years or older; P < 0.05). Elderly patients with pelvic fracture have worse outcomes than their younger counterparts despite aggressive management at a Level I trauma center.

Management of trauma in the geriatric patient

PURPOSE OF REVIEW

The purpose of this review is to examine recent evidence on the role and significance of anesthesiologists in caring for elderly patients suffering from severe trauma.

RECENT FINDINGS

Recent findings suggest that early aggressive resuscitation and medical management interventions may lead to improved outcomes in elderly trauma patients.

SUMMARY

Data suggest that anesthesiologists should actively participate in the resuscitation and critical care management of patients soon after they have suffered significant trauma. Further research is needed to delineate specific areas of focus and intervention to allow for optimal care and outcomes.

Traumatic injury in the older adult from head to toe

This review demonstrates essential issues to consider when caring for older trauma patients, including baseline physical status, mental health, comorbidities, and risk factors for sequelae and future injuries. The impact of a traumatic injury on older adults is complex. Issues of normal aging, functional status, chronic health conditions, and response to treatment affect health care and related decisions. Studies that have examined outcomes for older trauma patients to date have been mainly descriptive or confined to a single institution, limiting our ability to generalize. Other studies, using large data sets, have provided some information regarding possible primary prevention strategies, yet have limitations in the individual level detail collected. Nevertheless, this review also demonstrates the dearth of available evidence-based recommendations that provides support to treatment protocols in this complex and diverse patient population. The lack of an evidence base to use in the management of older trauma patients demonstrates the critical need for research in this rapidly growing population. An example of one such area includes the use of pulmonary artery catheters in older trauma patients. Although evidence to date suggests that pulmonary artery catheters are of benefit in the management of patients with physiologic compromise, it is unclear whether using these published cardiac output management recommendations leads to improved outcomes. In light of newly published data suggesting equivocal benefit from use of pulmonary artery catheters, with increased side effects, this controversy is an important area for future research. Critical care nurses, with their emphasis on multidisciplinary, holistic practice, can expand their influence as essential members of the interdisciplinary team caring for older trauma patients by cultivating geriatric specialty knowledge. Older trauma patients would benefit greatly from this type of specialty nursing care during all phases of the recovery trajectory, particularly in terms of adequate symptom management and prevention of sequelae, as well as with timely and appropriate initiation of consultative services. Using the intersection of primary and secondary prevention as the overall guide for practice, critical care nurses and other health care providers who possess an understanding of aging processes and comorbid conditions can significantly improve outcomes for older adults with traumatic injuries.

Trauma and falls in the elderly

The number of people living longer and staying active continues to rise, resulting in an increase in the incidence of trauma-related vis-its by older persons to emergency departments. The elderly sustain a disproportionate share of fractures and serious injury, and represent a unique subset of patients with special needs and considerations. This article reviews the current literature on the management of elderly patients with trauma, including the physiologic changes of aging relevant to the management of trauma, injury patterns unique to geriatric victims of trauma, and aspects particular to resuscitation and general management of geriatric trauma victims. We include a discussion of the evaluation and management of falls in the elderly, including assessment of fall risk.

Functional Status and Quality of Life in Survivors of Injury Treated at Tertiary Trauma Centers: What Are We Neglecting?

BACKGROUND

The purpose of this study was to describe the functional status and quality of life (QOL) of patients at 12 months after injury.

METHODS

Retrospective study consisting of patients treated at three tertiary trauma centers for injuries. Functional capacity (FC) was measured using the Sickness Impact Profile and QOL was measured using the Medical Outcomes Study Short Form (MOS SF-36) at approximately 12 months after the date of injury.

RESULTS

There were 144 patients that fulfilled the study inclusion and exclusion criteria. The mean duration of follow-up was 1.3 years, with a range of 0.8 to 1.5 years. Age and gender were not associated with the FC or QOL. The mean(standard deviation) Injury Severity Score (ISS) was 18.9(9.4), whereas ISS category distribution was 1 to 11 (22.9%), 12 to 24 (50.0%), and 25 to 49 (27.1%). Patients with an ISS of 25 to 49 had significantly worse physical (p = 0.008) and total (p = 0.023) Sickness Impact Profile scores and had more physical functioning (p = 0.096), emotional role functioning (p = 0.080), and energy (p = 0.017) impairments when compared with those with an ISS less than 24. Patients injured in motor vehicle collisions had significantly impaired psychosocial function (p = 0.031), whereas those injured in falls had reduced quality of life scores for physical function (p = 0.089), physical role (p = 0.066), and mental health (p = 0.081).

CONCLUSION

Patients who survive injuries experience residual impairments in FC and QOL for as long as 1 year after injury. Changes to the long-term management of these patients should be considered.

A Feasibility Study of Methodological Issues and Short-Term Outcomes in Seriously Injured Older Adults

• Background For any given traumatic injury, older adults experience a longer hospitalization, more complications, and higher mortality than do younger patients.

• Objectives To prospectively identify problems in designing follow-up studies in seriously injured older adults without head injury and to examine outcomes after serious trauma in older adults who were sent to a level I trauma center.

• Methods A short-term descriptive follow-up design was used in which each patient served as his or her baseline. Eligible patients had injuries that required admission to an intensive care unit, a hospital length of stay longer than 72 hours, or surgery. Patients with isolated hip fractures, central nervous system injuries, and burn injuries were excluded. Data were collected by using standardized instruments during the acute hospital stay and 3 months after discharge from the hospital.

• ResultsDuring a representative 2-month period, 21% of a potential 77 subjects died in the hospital, 44% had cognitive impairment that precluded participation, and 17% declined to participate. Twenty older adults (mean age 73.5 years) who were injured in motor vehicle crashes (45%), falls (35%), or pedestrian accidents (15%) or who had gunshot wounds (5%) were enrolled. Ten percent died after discharge. Levels of physical disability at 3 months after discharge were higher than those before the injury (score on Sickness Impact Profile physical subscale 24.5 vs 10.9, P = .02), and psychological distress (Impact of Event Scale score 20.9) remained elevated.

• Conclusion Mortality, disability, and posttraumatic psychological distress after discharge are problems in seriously injured older adults.

Differences in survival, length of stay, and discharge disposition of older trauma patients admitted to trauma centers and nontrauma center hospitals

PURPOSE

To examine the relationship of level of care (trauma center [TC], nontrauma center [NTC] hospitals) on three outcomes: survival, length of stay, and discharge disposition.

DESIGN

Retrospective secondary analysis of a subset of data (1,418 patients age 65 to 99 years) from a large statewide study in which the purpose was to compare admission patterns (TCs and NTCs) of motor vehicle (MV) trauma patients according to age and sex. The New Jersey UB-92 Patient Discharge Data for 2000 were used in this analysis.

METHODS

Demographic and clinical variables were compared using descriptive data, independent samples t tests, Pearson chi square, and Mann-Whitney U analyses. Logistic regression and multiple regression analyses were performed to examine relationships between level of care and three outcome variables, survival, length of stay, and discharge disposition, while controlling for age and severity of injury.

RESULTS

NTC admission was the only predictor of survival and discharge to home, but injury severity was the strongest predictor of length of stay, followed by NTC care. The odds of survival and discharge home decreased slightly as age and injury severity increased.

CONCLUSIONS

This analysis indicated preliminary evidence that level of care influences survival, length of stay, and discharge disposition. Studies are warranted for researchers to examine the influence of postinjury variables, including complications, stress reaction, and depression on outcomes.

An association between Emergency Medicine residencies and improved trauma patient outcome

A study was done to compare trauma patient outcome at American College of Surgeons (ACS) Level l Trauma Centers with Emergency Medicine residency programs (EMRP+) to those without (EMRP-). Ten Level l Trauma Centers were reviewed from the ACS National Trauma Database (5 centers with and 5 without EM residency programs). Of 18,591 trauma patient records, 8679 were identified as EMRP-, and 9912 as EMRP+. After deleting incomplete data sets, 6621 EMRP- and 6150 EMRP+ records remained. Comparisons between patient age, gender, TRISS, complications, deaths, hospital, ICU and ventilator days, and numbers of burns, penetrating and blunt trauma were performed using t-test and chi-square analysis. Despite having a statistically significant older patient population, with more burn and penetrating trauma patients requiring longer ICU stays and longer ventilatory support (p < 0.0001), Emergency Medicine Residency program hospitals had a significantly lower complication rate (5.14% vs. 11.04%, respectively, p < 0.0001), death rate (4.704% vs. 5.479%, respectively, p = 0.0013), and shorter overall hospital stays (Mean 4.94 days, SD +/- 8.74 vs. 6.35 days, SD +/- 11.22, respectively, p < 0.0001) than EMRP- hospitals. The presence of Emergency Medicine residency programs at ACS Level I Trauma Centers is associated with improved trauma patient outcomes.

Relationship of age, injury severity, injury type, comorbid conditions, level of care, and survival among older motor vehicle trauma patients

The purpose of this secondary data analysis was to compare age, injury severity, injury types, selected comorbidities, level of care (at trauma center [TC] and non-trauma center [NTC] hospitals), and survival among older motor vehicle trauma patients (N = 1,478). Patients admitted to both levels of care had similar comorbid conditions. TC patients had a higher injury severity, whereas NTC patients had a greater proportion of soft tissue injuries. Results of logistic regression analyses subsequent to group comparisons revealed that higher injury severity was associated with TC admission. The likelihood of TC admission of severely injured patients decreased in the presence of spinal, internal, and head injuries. Internal injuries, liver, renal, and cardiovascular diseases were associated with non-survival while hypertension was associated with survival. Special attention is needed when triaging older trauma patients because their injuries may be covert, thus putting them at risk for admission to a level of care that may be inappropriate given the extent of their injuries.

Geriatric All-Terrain Vehicle Trauma

More than 300 all-terrain vehicle (ATV) trauma deaths occur annually. Most experience to date focuses on the pediatric trauma. However, senior citizens constitute the fastest growing segment of ATV enthusiasts. We queried our trauma registry from January 1988 to December 2002 and found 200 total ATV accidents. There were 8 patients over age 60. We compared geriatric and nongeriatric riders for presentation and outcome data. The anatomic distribution of injury was similar. Younger patients were more likely to have used ethanol or drugs. Tachypnea and hypotension were generally absent at presentation. The geriatric patients had worse predictive physiologic scores. Clinical outcomes for the geriatric group trended toward longer hospital stays, and they had significantly worse functional outcomes. The geriatric group nonsignificantly trended toward a higher mortality (12.5% vs 3.45%). Our study reflects the recent national trend toward a dramatic rise in geriatric ATV-related trauma. We recommend that geriatric ATV safety programs be instituted.

Special considerations in geriatric injury

PURPOSE OF REVIEW

As the elderly population expands and adopts increasingly more active lifestyles, trauma and critical care practitioners will be faced with providing care for greater numbers of severely injured patients. However, because of their associated preexisting medical conditions and poor relative physiologic reserve, geriatric patients have higher mortality rates and poorer long-term functional outcomes than their younger counterparts. A thorough understanding of the causes for these disparate outcomes is critical if successful strategies and treatments for this unique patient population are to be developed.

RECENT FINDINGS

The currently available geriatric trauma literature is largely descriptive and retrospective, and does not provide ready explanations or solutions for the substantially worse outcomes experienced by this patient population. It does appear that outcomes are improved by providing early and aggressive care in designated trauma centers, yet undertriage remains a significant problem. Early admission to an ICU has been recommended, but its benefits remain unproved. Significant differences exist between older and younger patients in injury patterns, and in the frequency and type of complications These differences in turn demand prompt diagnostic approaches, aggressive treatment, and unique prevention strategies.

SUMMARY

Ironically, the field of geriatric trauma is still in its infancy. Given the relation between advanced age, associated preexisting medical conditions, and poor physiologic reserve, a poor outcome may be inevitable by the time the geriatric patient presents for medical attention. Greater emphasis should therefore be placed on injury prevention efforts in this patient population. There is a dire need for well-designed prospective studies in geriatric trauma.