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Flores-Sandoval C, MacKenzie HM, McIntyre A, Sait M, Teasell R, Bateman EA. Mortality and discharge disposition among older adults with moderate to severe traumatic brain injury. Arch Gerontol Geriatr 2024; 125:105488. [PMID: 38776698 DOI: 10.1016/j.archger.2024.105488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 05/13/2024] [Accepted: 05/16/2024] [Indexed: 05/25/2024]
Abstract
PURPOSE This study examined the research on older adults with a moderate to severe traumatic brain injury (TBI), with a focus on mortality and discharge disposition. METHOD Systematic searches were conducted in MEDLINE, CINAHL, EMBASE and PsycINFO for studies up to April 2022 in accordance with PRISMA guidelines. RESULTS 64 studies, published from 1992 to 2022, met the inclusion criteria. Mortality was higher for older adults ≥60 years old than for their younger counterparts; with a dramatic increase for those ≥80 yr, with rates as high as 93 %. Similar findings were reported regarding mortality in intensive care, surgical mortality, and mortality post-hospital discharge; with an 80 % rate at 1-year post-discharge. Up to 68.4 % of older adults were discharged home; when compared to younger adults, those ≥65 years were less likely to be discharged home (50-51 %), compared to those <64 years (77 %). Older adults were also more likely to be discharged to long-term care (up to 31.6 %), skilled nursing facilities (up to 46.1 %), inpatient rehabilitation (up to 26.9 %), and palliative or hospice care (up to 58 %). CONCLUSION Given their vulnerability, optimizing outcomes for older adults with moderate-severe TBI across the healthcare continuum is critical.
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Affiliation(s)
| | - Heather M MacKenzie
- Parkwood Institute Research, Lawson Research Institute, London, Ontario, Canada; Department of Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Parkwood Institute, St. Joseph's Health Care London, London, Ontario, Canada
| | - Amanda McIntyre
- Arthur Labatt Family School of Nursing, Faculty of Health Sciences, Western University, London, Ontario, Canada
| | - Muskan Sait
- Parkwood Institute Research, Lawson Research Institute, London, Ontario, Canada; University College Cork, Ireland
| | - Robert Teasell
- Parkwood Institute Research, Lawson Research Institute, London, Ontario, Canada; Department of Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Parkwood Institute, St. Joseph's Health Care London, London, Ontario, Canada.
| | - Emma A Bateman
- Parkwood Institute Research, Lawson Research Institute, London, Ontario, Canada; Department of Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Parkwood Institute, St. Joseph's Health Care London, London, Ontario, Canada
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Harthi N, Goodacre S, Sampson F, Alharbi R. Research priorities for prehospital care of older patients with injuries: scoping review. Age Ageing 2022; 51:6590512. [PMID: 35604804 PMCID: PMC9126200 DOI: 10.1093/ageing/afac108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 01/11/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVE There is increasing recognition of the importance of prehospital trauma care for older patients, but little systematic research to guide practice. We aimed to review the published evidence on prehospital trauma care for older patients, determine the scope of existing research and identify research gaps in the literature. METHODS We undertook a systematic scoping review guided by the Arksey and O'Malley framework and reported in line with the PRISMA-ScR checklist. A systematic search was conducted of Scopus, CINAHL, MEDLINE, PubMed and Cochrane library databases to identify articles published between 2001 and 2021. Study selection criteria were applied independently by two reviewers. Data were extracted, charted and summarised from eligible articles. A data-charting form was then developed to facilitate thematic analysis. Narrative synthesis then involved identifying major themes and subthemes from the data. RESULTS We identified and reviewed 65 studies, and included 25. We identified five categories: 'field triage', 'ageing impacts', 'decision-making', 'paramedic' awareness' and 'paramedic's behaviour'. Undertriage and overtriage (sensitivity and specificity) were commonly cited as poorly investigated field-triage subthemes. Ageing-related physiologic changes, comorbidities and polypharmacy were the most widely researched. Inaccurate decision-making and poor early identification of major injuries were identified as potentially influencing patient outcomes. CONCLUSION This is the first study reviewing the published evidence on prehospital trauma care for older patients and identifying research priorities for future research. Field-triage tools, paramedics' knowledge about injuries in the older population, and understanding of paramedics' negative behaviours towards older patients were identified as key research priorities.
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Affiliation(s)
- Naif Harthi
- School of Health and Related-Research, University of Sheffield, Sheffield City, UK
- Faculty of Applied Medical Sciences, Jazan University, Jazan City, Saudi Arabia
| | - Steve Goodacre
- School of Health and Related-Research, University of Sheffield, Sheffield City, UK
| | - Fiona Sampson
- School of Health and Related-Research, University of Sheffield, Sheffield City, UK
| | - Rayan Alharbi
- Faculty of Applied Medical Sciences, Jazan University, Jazan City, Saudi Arabia
- School of Nursing and Midwifery, La Trobe University, Melbourne City, Australia
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Salamati P, Saberian L, Baigi V, Zafarghandi M, Naghdi K, Ozlaty M, Bahrami S, Madadi N, Rahimi-Movaghar V, Sadeghi-Bazargani H, Fakharian E, Pahlavanhosseini H, Piri S, Khormali M, Mirzamohamadi S. Gender-based trauma outcomes and predictors of postinjury in-hospital mortalities: A multicenter analysis from the national trauma registry of Iran. ARCHIVES OF TRAUMA RESEARCH 2021. [DOI: 10.4103/atr.atr_64_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Jensen KO, Lempert M, Sprengel K, Simmen HP, Pothmann C, Schlögl M, Bischoff-Ferrari HA, Hierholzer C, Pape HC, Neuhaus V. Is There Any Difference in the Outcome of Geriatric and Non-Geriatric Severely Injured Patients?-A Seven-Year, Retrospective, Observational Cohort Study with Matched-Pair Analysis. J Clin Med 2020; 9:jcm9113544. [PMID: 33153102 PMCID: PMC7692238 DOI: 10.3390/jcm9113544] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 10/28/2020] [Accepted: 10/30/2020] [Indexed: 11/16/2022] Open
Abstract
Geriatric trauma is expected to increase due to the lifestyle and activity of the aging population and will be among the major future challenges in health care. Therefore, the aim of this study was to investigate differences between polytraumatized geriatric and non-geriatric patients regarding mortality, length-of-stay and complications with a matched pair analysis. We included patients older than 17 years with an Injury Severity Score (ISS) of 16 or more admitted to our level 1 trauma center between January 2008 and December 2015. The cohort was stratified into two groups (age < 70 and ≥ 70 years). One-to-one matching was performed based on gender, ISS, mechanism of injury (penetrating/blunt), Glasgow coma scale (GCS), base excess, and the presence of coagulopathy (international normalized ratio (INR) ≥ 1.4). Outcome was compared using the paired t-test and McNemar-test. A total of 1457 patients were identified. There were 1022 male (70%) and 435 female patients. Three hundred and sixty-four patients (24%) were older than 70 years. Matching resulted in 57 pairs. Mortality as well as length-of-stay were comparable between geriatric and non-geriatric polytraumatized patients. Complication rate (34% vs. 56%, p = 0.031) was significantly higher in geriatric patients. This indicates the possibility of similar outcomes in geriatric polytraumatized patients receiving optimal care.
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Affiliation(s)
- Kai O. Jensen
- Department of Trauma, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland; (M.L.); (K.S.); (H.P.S.); (C.P.); (C.H.); (H.C.P.); (V.N.)
- Correspondence: ; Tel.: +41-442551111; Fax: +41-442554466
| | - Maximilian Lempert
- Department of Trauma, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland; (M.L.); (K.S.); (H.P.S.); (C.P.); (C.H.); (H.C.P.); (V.N.)
| | - Kai Sprengel
- Department of Trauma, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland; (M.L.); (K.S.); (H.P.S.); (C.P.); (C.H.); (H.C.P.); (V.N.)
| | - Hans P. Simmen
- Department of Trauma, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland; (M.L.); (K.S.); (H.P.S.); (C.P.); (C.H.); (H.C.P.); (V.N.)
| | - Carina Pothmann
- Department of Trauma, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland; (M.L.); (K.S.); (H.P.S.); (C.P.); (C.H.); (H.C.P.); (V.N.)
| | - Mathias Schlögl
- University Clinic for Acute Geriatric Care, City Hospital Waid, 8037 Zurich, Switzerland;
| | - Heike A. Bischoff-Ferrari
- Department of Geriatrics and Ageing Research, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland;
| | - Christian Hierholzer
- Department of Trauma, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland; (M.L.); (K.S.); (H.P.S.); (C.P.); (C.H.); (H.C.P.); (V.N.)
| | - Hans C. Pape
- Department of Trauma, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland; (M.L.); (K.S.); (H.P.S.); (C.P.); (C.H.); (H.C.P.); (V.N.)
| | - Valentin Neuhaus
- Department of Trauma, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland; (M.L.); (K.S.); (H.P.S.); (C.P.); (C.H.); (H.C.P.); (V.N.)
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Independent Predictors of Mortality in Torso Trauma Injuries. J Clin Med 2020; 9:jcm9103202. [PMID: 33023012 PMCID: PMC7600101 DOI: 10.3390/jcm9103202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 09/23/2020] [Accepted: 10/01/2020] [Indexed: 11/17/2022] Open
Abstract
Noncompressible torso injuries (NCTIs) represent a trauma-related condition with high lethality. This study’s aim was to identify potential prediction factors of mortality in this group of trauma patients at a Level 1 trauma center in Italy. Materials and Methods: A total of 777 patients who had sustained a noncompressible torso injury (NCTI) and were admitted to the Niguarda Trauma Center in Milan from 2010 to 2019 were included. Of these, 166 patients with a systolic blood pressure (SBP) <90 mmHg were considered to have a noncompressible torso hemorrhage (NCTH). Demographic data, mechanism of trauma, pre-hospital and in-hospital clinical conditions, diagnostic/therapeutic procedures, and survival outcome were retrospectively recorded. Results: Among the 777 patients, 69% were male and 90.2% sustained a blunt trauma with a median age of 43 years. The comparison between survivors and non-survivors pointed out a significantly lower pre-hospital Glasgow coma scale (GCS) and SBP (p < 0.001) in the latter group. The multivariate backward regression model identified age, pre-hospital GCS and injury severity score (ISS) (p < 0.001), pre-hospital SBP (p = 0.03), emergency department SBP (p = 0.039), performance of torso contrast enhanced computed tomography (CeCT) (p = 0.029), and base excess (BE) (p = 0.008) as independent predictors of mortality. Conclusions: Torso trauma patients who were hemodynamically unstable in both pre- and in-hospital phases with impaired GCS and BE had a greater risk of death. The detection of independent predictors of mortality allows for the timely identification of a subgroup of patients whose chances of survival are reduced.
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Freigang V, Müller K, Ernstberger A, Kaltenstadler M, Bode L, Pfeifer C, Alt V, Baumann F. Reduced Recovery Capacity After Major Trauma in the Elderly: Results of a Prospective Multicenter Registry-Based Cohort Study. J Clin Med 2020; 9:jcm9082356. [PMID: 32717963 PMCID: PMC7464491 DOI: 10.3390/jcm9082356] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/09/2020] [Accepted: 07/21/2020] [Indexed: 01/07/2023] Open
Abstract
AIMS Considering the worldwide trend of an increased lifetime, geriatric trauma is moving into focus. Trauma is a leading cause of hospitalization, leading to disability and mortality. The purpose of this study was to compare the global health-related quality of life (HRQoL) of geriatric patients with adult patients after major trauma. METHODS This multicenter prospective registry-based observational study compares HRQoL of patients aged ≥65 years who sustained major trauma (Injury Severity Score (ISS) ≥ 16) with patients <65 years of age within the trauma registry of the German Trauma Society (DGU). The global HRQoL was measured at 6, 12, and 24 months post trauma using the EQ-5D-3L score. RESULTS We identified 405 patients meeting the inclusion criteria with a mean ISS of 25.6. Even though the geriatric patients group (≥65 years, n = 77) had a lower ISS (m = 24, SD = 8) than patients aged <65 years (n = 328), they reported more difficulties in each EQ dimension compared to patients <65 years. Contrary to patients < 65, the EQ-5D Index of the geriatric patients did not improve at 12 and 24 months after trauma. CONCLUSIONS We found a limited HRQoL in both groups after major trauma. The group of patients ≥65 showed no improvement in HRQoL from 6 to 24 months after trauma.
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Affiliation(s)
- Viola Freigang
- Department of Trauma, Regensburg University Medical Center, 93053 Regensburg, Germany; (A.E.); (C.P.); (V.A.); (F.B.)
- Correspondence: ; Tel.: +49-094-1944-6805
| | - Karolina Müller
- Center for Clinical Studies, Regensburg University Medical Center, 93053 Regensburg, Germany;
| | - Antonio Ernstberger
- Department of Trauma, Regensburg University Medical Center, 93053 Regensburg, Germany; (A.E.); (C.P.); (V.A.); (F.B.)
| | - Marlene Kaltenstadler
- Department of Surgery, Regensburg University Medical Center, 93053 Regensburg, Germany;
| | - Lisa Bode
- Department of Orthopaedics and Trauma Surgery, Faculty of Medicine, Medical Center—Albert-Ludwigs-University of Freiburg, 79085 Freiburg im Breisgau, Germany;
| | - Christian Pfeifer
- Department of Trauma, Regensburg University Medical Center, 93053 Regensburg, Germany; (A.E.); (C.P.); (V.A.); (F.B.)
| | - Volker Alt
- Department of Trauma, Regensburg University Medical Center, 93053 Regensburg, Germany; (A.E.); (C.P.); (V.A.); (F.B.)
| | - Florian Baumann
- Department of Trauma, Regensburg University Medical Center, 93053 Regensburg, Germany; (A.E.); (C.P.); (V.A.); (F.B.)
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Gioffrè-Florio M, Murabito LM, Visalli C, Pergolizzi FP, Famà F. Trauma in elderly patients: a study of prevalence, comorbidities and gender differences. G Chir 2019; 39:35-40. [PMID: 29549679 DOI: 10.11138/gchir/2018.39.1.035] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Horst K, Höfler J, Martin L, Greven J, Schürholz T, Simon TP, Marx G, Hildebrand F. Geriatric Polytrauma-Cardiovascular and Immunologic Response in a Murine Two-Hit Model of Trauma. J Surg Res 2019; 241:87-94. [PMID: 31018170 DOI: 10.1016/j.jss.2019.03.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 03/07/2019] [Accepted: 03/22/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND The aims of the present study were to establish a clinically relevant two-hit model with trauma/hemorrhage followed by sepsis in older mice and investigate age-dependent cardiovascular and immunologic specificities under these conditions. MATERIALS AND METHODS In aged mice (12, 18, and 24 mo old), a femur fracture followed by hemorrhage was induced. After resuscitation, animals were monitored for 72 h before sepsis was induced. Vital signs were monitored during shock. Systemic interleukin (IL)-6 levels were measured daily. Expression of sarcoplasmic or endoplasmic reticulum calcium ATPase (SERCA) and IL-6 receptor were analyzed in heart, lung, and liver tissues. RESULTS After induction of shock, mean arterial pressure decreased significantly in all groups (12 mo, P < 0.001; 18 mo, P < 0.001; 24 mo, P = 0.013). Compared with younger animals, 24-mo old mice were not able to adequately compensate for hypovolemia by an increase of heart rate (P = 0.711). Expression of SERCA2 (P = 0.002) and IL-6 receptor on myocytes (P = 0.037), lung (P = 0.005), and liver (P = 0.009) tissues were also lowest in this group. Systemic IL-6 values showed the most distinct posttraumatic response in 24-mo-old mice (P = 0.016). Survival rate decreased significantly with increased age (P = 0.005). CONCLUSIONS The increased mortality rate in older animals was associated with a limited compensatory physiological response and a more distinct immunologic reaction after trauma and sepsis. A decreased SERCA2 expression and missing feedback loops due to a reduced density of organ bound immune receptors might represent possible explanations for the observed age-dependent differences.
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Affiliation(s)
- Klemens Horst
- Department of Orthopaedic Trauma, RWTH Aachen University, Aachen, Germany.
| | - Johannes Höfler
- Department of Orthopaedic Trauma, RWTH Aachen University, Aachen, Germany
| | - Lukas Martin
- Department of Intensive Care and Intermediate Care, RWTH Aachen University, Aachen, Germany
| | - Johannes Greven
- Department of Orthopaedic Trauma, RWTH Aachen University, Aachen, Germany
| | - Tobias Schürholz
- Department of Anaesthesia and Intensive Care, University of Rostock, Rostock, Germany
| | - Tim P Simon
- Department of Intensive Care and Intermediate Care, RWTH Aachen University, Aachen, Germany
| | - Gernot Marx
- Department of Intensive Care and Intermediate Care, RWTH Aachen University, Aachen, Germany
| | - Frank Hildebrand
- Department of Orthopaedic Trauma, RWTH Aachen University, Aachen, Germany
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Elkbuli A, Yaras R, Elghoroury A, Boneva D, Hai S, McKenney M. Comorbidities in Trauma Injury Severity Scoring System: Refining Current Trauma Scoring System. Am Surg 2019. [DOI: 10.1177/000313481908500130] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The revised trauma score combined with the Injury Severity Score (ISS) remains the mostly commonly used system for predicting trauma mortality, but these scoring systems do not account for the patient's comorbidities. This study aims to evaluate the effect of comorbidities on ISS-related mortality and length of stay. A review of our trauma center's data registry from 2014 to 2016 was carried out. Patients were divided according to ISS into two groups: ISS ≤ 15 and ISS > 15. Each ISS group was then subdivided by number of comorbidities into two groups: 1 to 2 or ≥3 comorbidities. Demographic characteristics and outcome measures were compared. ANOVA, chi-squared, and t tests were used with significance defined as P < 0.05. A total 9845 adult trauma patients were admitted to our trauma center during the three-year study period. In the ISS ≤ 15 group, patients with <3 comorbidities had significantly higher mortality rate compared with patients with 1 to 2 comorbidities (1.50% vs 0.12%, P << 0.000007). Comparing the ISS ≤ 15 group with ≥3 comorbidities with the ISS > 15 group with 1 to 2 comorbidities, the mortality rate was significantly higher (23.40% vs 4.50%, P << 0.000002). The ICU length of stay was significantly higher in the ISS ≤ 15 groups (17 vs 10 days, P < 0.05) but similar in the ISS > 15 groups (31 vs 29 days) (P > 0.05). It was concluded that when controlling for injury severity, increased comorbidities are associated with a significantly higher mortality, indicating that they may serve as a marker of lower physiologic reserve and be an independent variable. Adding comorbidity parameters to the current trauma scoring systems can assist in predicting more accurate/reliable outcomes.
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Affiliation(s)
- Adel Elkbuli
- Department of Surgery, Kendall Regional Medical Center, Miami, Florida and
| | - Reed Yaras
- Department of Surgery, Kendall Regional Medical Center, Miami, Florida and
| | - Ahmad Elghoroury
- Department of Surgery, Kendall Regional Medical Center, Miami, Florida and
| | - Dessy Boneva
- Department of Surgery, Kendall Regional Medical Center, Miami, Florida and
- Department of Surgery, University of Florida, Gainesville, Florida
| | - Shaikh Hai
- Department of Surgery, Kendall Regional Medical Center, Miami, Florida and
| | - Mark McKenney
- Department of Surgery, Kendall Regional Medical Center, Miami, Florida and
- Department of Surgery, University of Florida, Gainesville, Florida
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Kirshenbom D, Ben-Zaken Z, Albilya N, Niyibizi E, Bala M. Older Age, Comorbid Illnesses, and Injury Severity Affect Immediate Outcome in Elderly Trauma Patients. J Emerg Trauma Shock 2017; 10:146-150. [PMID: 28855778 PMCID: PMC5566026 DOI: 10.4103/jets.jets_62_16] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
| | - Zila Ben-Zaken
- Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Nehama Albilya
- Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Eva Niyibizi
- Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Miklosh Bala
- Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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Kocuvan S, Brilej D, Stropnik D, Lefering R, Komadina R. Evaluation of major trauma in elderly patients - a single trauma center analysis. Wien Klin Wochenschr 2016; 128:535-542. [PMID: 27896468 DOI: 10.1007/s00508-016-1140-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 11/10/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND The objective of the study was to gather information about elderly major trauma patients admitted to one particular Slovenian trauma centre in Celje and examine this group of polytrauma patients, specifically with respect to mechanisms of injury, injury severity and distribution of injuries. Further on, to identify morbidity and mortality rates and compare these to the younger population and, finally, to determine the factors that have the most impact on treatment results. METHODS The study gathered and evaluated data of 532 patients included in the Trauma Register DGU® of the German Trauma Society (TR-DGU) during a 10-year period and two distinct groups of patients were established, separated on account of age as older or younger than 65 years. The differences between these two groups were analyzed with respect to demographics, comorbidities, preclinical management, injury patterns, relevant clinical and laboratory findings. Furthermore, differences between deceased and surviving elderly patients were also analyzed. RESULTS The majority of elderly patients suffered from a blunt mechanism of trauma (96.6%) and of these simple falls represented 47.9% within this injury mechanism. There were two body regions, which were most frequently represented, namely head and thorax injuries, accounting for 54.7% each. Complications were more frequent among the elderly, with sepsis being present in 29.9% and multiple organ failure (MOF) in 19.7% of cases. Cardiovascular failure was also high in both the elderly and young, accounting for 45.3% of the elderly and 31.3% of the younger population. The in-hospital mortality rate for the elderly group was 25.6% and was significantly higher compared to the younger counterparts (14.7%). Low fall mechanism of injury, coma and the new injury severity score (NISS) were statistically important factors for the mortality of seriously injured elderly patients during the acute phase of treatment. CONCLUSIONS Despite advances in care, morbidity and mortality in elderly patients after major trauma remains considerably higher than in younger populations with head injuries accounting for the majority of fatalities. The elderly patient population in this study mostly suffered from blunt mechanisms of injury, with simple falls representing a high proportion of injury mechanisms. Generally, the injury severity scale (ISS) in the elderly is not statistically higher than with the younger population. Likewise, the distribution of injuries according to body regions is also similar; however, the elderly are more prone to complications (e. g. sepsis and MOF), which is likely due to a lower physiological reserves.
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Affiliation(s)
- Samo Kocuvan
- Trauma Department, General and Teaching Hospital Celje, Oblakova 5, 3000, Celje, Slovakia
| | - Drago Brilej
- Trauma Department, General and Teaching Hospital Celje, Oblakova 5, 3000, Celje, Slovakia.
| | - Domen Stropnik
- Trauma Department, General and Teaching Hospital Celje, Oblakova 5, 3000, Celje, Slovakia
| | - Rolf Lefering
- Institut für Forschung in der operativen Medizin, Fakultät für Gesundheit, Universität Witten/Herdecke, Ostmerheimer Str 200, 51109, Cologne, Germany
| | - Radko Komadina
- Trauma Department, General and Teaching Hospital Celje, Oblakova 5, 3000, Celje, Slovakia
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Reich MS, Dolenc AJ, Moore TA, Vallier HA. Is Early Appropriate Care of axial and femoral fractures appropriate in multiply-injured elderly trauma patients? J Orthop Surg Res 2016; 11:106. [PMID: 27671737 PMCID: PMC5037639 DOI: 10.1186/s13018-016-0441-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Accepted: 09/15/2016] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Previous work established resuscitation parameters that minimize complications with early fracture management. This Early Appropriate Care (EAC) protocol was applied to patients with advanced age to determine if they require unique parameters to mitigate complications. METHODS Between October 2010 and March 2013, 376 consecutive skeletally mature patients with unstable fractures of the pelvis, acetabulum, thoracolumbar spine, and/or proximal or diaphyseal femur fractures were treated at a level I trauma center and were prospectively studied. Patients aged ≤30 years (n = 114), 30 to 60 years (n = 184), and ≥60 years (n = 37) with Injury Severity Scores (ISS) ≥16 and unstable fractures of the pelvis, acetabulum, spine, and/or diaphyseal femur were treated within 36 h, provided they showed evidence of adequate resuscitation. ISS, Glasgow Coma Scale (GCS), and American Society of Anesthesiologists (ASA) classification were determined. Lactate, pH, and base excess (BE) were measured at 8-h intervals. Complications included pneumonia, pulmonary embolism (PE), acute renal failure, acute respiratory distress syndrome (ARDS), multiple organ failure (MOF), deep vein thrombosis, infection, sepsis, and death. RESULTS Patients ≤30 years old (y/o) were more likely to sustain gunshot wounds (p = 0.039), while those ≥60 y/o were more likely to fall from a height (p = 0.002). Complications occurred at similar rates for patients ≤30 y/o, 30 to 60 y/o, and ≥60 y/o. There were no differences in lactate, pH, or BE at the time of surgery. For patients ≤30 y/o, there were increased overall complications if pH was <7.30 (p = 0.042) or BE <-6.0 (p = 0.049); patients ≥60 y/o demonstrated more sepsis if BE was <-6.0 (p = 0.046). CONCLUSIONS EAC aims to definitively manage axial and femoral shaft fractures once patients have been adequately resuscitated to minimize complications. EAC is associated with comparable complication rates in young and elderly patients. Further study is warranted with a larger sample to further validate EAC in elderly patients. LEVEL OF EVIDENCE level II prospective, comparative study.
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Affiliation(s)
- M S Reich
- Department of Orthopaedic Surgery, Case Western Reserve University, The MetroHealth System, 2500 MetroHealth Drive, Cleveland, OH, 44109, USA
| | - A J Dolenc
- Department of Orthopaedic Surgery, Case Western Reserve University, The MetroHealth System, 2500 MetroHealth Drive, Cleveland, OH, 44109, USA
| | - T A Moore
- Department of Orthopaedic Surgery, Case Western Reserve University, The MetroHealth System, 2500 MetroHealth Drive, Cleveland, OH, 44109, USA
| | - H A Vallier
- Department of Orthopaedic Surgery, Case Western Reserve University, The MetroHealth System, 2500 MetroHealth Drive, Cleveland, OH, 44109, USA.
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Andruszkow H, Schweigkofler U, Lefering R, Frey M, Horst K, Pfeifer R, Beckers SK, Pape HC, Hildebrand F. Impact of Helicopter Emergency Medical Service in Traumatized Patients: Which Patient Benefits Most? PLoS One 2016; 11:e0146897. [PMID: 26771462 PMCID: PMC4714808 DOI: 10.1371/journal.pone.0146897] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Accepted: 12/24/2015] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION The Helicopter Emergency Medical Service (HEMS) was established for the prehospital trauma care of patients. Improved rescue times and increased coverage areas are discussed as specific advantages of HEMS. We recently found evidence that HEMS exerts beneficial effects on outcomes for severely injured patients. However, it still remains unknown which group of trauma patients might benefit most from HEMS rescue. Consequently, the unique aim of this study was to reveal which patients might benefit most from HEMS rescue. METHODS Trauma patients (ISS ≥9) primarily treated by HEMS or ground emergency medical services (GEMS) between 2002 and 2012 were analysed using the TraumaRegister DGU. A multivariate regression analysis was used to reveal the survival benefit between different trauma populations. RESULTS The study included 52 281 trauma patients. Of these, 68.8% (35 974) were rescued by GEMS and 31.2% (16 307) by HEMS. HEMS patients were more severely injured compared to GEMS patients (ISS: HEMS 24.8±13.5 vs. GEMS 21.7±18.0) and more frequently suffered traumatic shock (SBP sys <90mmHg: HEMS 18.3% vs. GEMS 14.8%). However, logistic regression analysis revealed that HEMS rescues resulted in an overall survival benefit compared to GEMS (OR 0.81, 95% CI [0.75-0.87], p<0.001, Nagelkerke's R squared 0.526, area under the ROC curve 0.922, 95% CI [0.919-0.925]). Analysis of specific subgroups demonstrated that patients aged older than 55 years (OR 0.62, 95% CI [0.50-0.77]) had the highest survival benefit after HEMS treatment. Furthermore, HEMS rescue had the most significant impact after 'low falls' (OR 0.68, 95% CI [0.55-0.84]) and in the case of minor severity injuries (ISS 9-15) (OR 0.66, 95% CI [0.49-0.88]). CONCLUSIONS In general, trauma patients benefit from HEMS rescue with in-hospital survival as the main outcome parameter. Focusing on special subgroups, middle aged and older patients, low-energy trauma, and minor severity injuries had the highest survival benefit when rescued by HEMS. Further studies are required to determine the potential reasons of this benefit.
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Affiliation(s)
- Hagen Andruszkow
- Department of Orthopedic Trauma at Aachen University and Harald Tscherne Laboratory, University Hospital Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
- * E-mail:
| | - Uwe Schweigkofler
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstraße 430, 60389 Frankfurt am Main, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Str. 200, 51109 Cologne, Germany
| | - Magnus Frey
- Department of Orthopedic Trauma at Aachen University and Harald Tscherne Laboratory, University Hospital Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Klemens Horst
- Department of Orthopedic Trauma at Aachen University and Harald Tscherne Laboratory, University Hospital Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Roman Pfeifer
- Department of Orthopedic Trauma at Aachen University and Harald Tscherne Laboratory, University Hospital Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Stefan Kurt Beckers
- Emergency Medical Service Aachen, Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstraße 30, Germany
| | - Hans-Christoph Pape
- Department of Orthopedic Trauma at Aachen University and Harald Tscherne Laboratory, University Hospital Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Frank Hildebrand
- Department of Orthopedic Trauma at Aachen University and Harald Tscherne Laboratory, University Hospital Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
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Hildebrand F, Pape HC, Horst K, Andruszkow H, Kobbe P, Simon TP, Marx G, Schürholz T. Impact of age on the clinical outcomes of major trauma. Eur J Trauma Emerg Surg 2015; 42:317-32. [PMID: 26253883 DOI: 10.1007/s00068-015-0557-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 07/31/2015] [Indexed: 12/20/2022]
Abstract
PURPOSE In view of demographic changes over the past few decades, the average age of trauma patients is progressively increasing. We therefore aimed to summarize the specific characteristics of geriatric trauma and to identify potential fields for further research to improve the care of elderly trauma patients. METHODS Review of the literature. RESULTS Due to the diverse risk factors (e.g., pre-existing conditions, limited physiological reserve), geriatric patients are prone to developing severe complications, even after less severe trauma. Yet, age is not considered as the only predictor of worse outcomes, and it should not be considered the only criterion for limiting care in those patients. It is crucial that age-specific treatment guidelines are developed to optimize the outcomes for senior trauma patients. Based on the current literature, these guidelines should emphasize the importance of field triage directly to a trauma center, along with the activation of the trauma team. Furthermore, early intensive monitoring, aggressive resuscitation, and time of surgical intervention are of upmost importance to reduce mortality. CONCLUSION The impact of several factors [age, premedical conditions (PMC), decreased physiological reserves, and impaired immune function] on the post-traumatic course of elderly trauma patients needs to be clarified in future experimental and clinical studies for the early identification of geriatric high-risk patients and for the development of age-adapted therapeutic strategies.
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Affiliation(s)
- F Hildebrand
- Department of Orthopaedic Trauma, Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany. .,Harald Tscherne Research Laboratory for Orthopaedic Trauma, Aachen University, Aachen, Germany.
| | - H-C Pape
- Department of Orthopaedic Trauma, Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - K Horst
- Department of Orthopaedic Trauma, Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany.,Harald Tscherne Research Laboratory for Orthopaedic Trauma, Aachen University, Aachen, Germany
| | - H Andruszkow
- Department of Orthopaedic Trauma, Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany.,Harald Tscherne Research Laboratory for Orthopaedic Trauma, Aachen University, Aachen, Germany
| | - P Kobbe
- Department of Orthopaedic Trauma, Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - T-P Simon
- Department of Intensive Care Medicine, Aachen University, Aachen, Germany
| | - G Marx
- Department of Intensive Care Medicine, Aachen University, Aachen, Germany
| | - T Schürholz
- Department of Intensive Care Medicine, Aachen University, Aachen, Germany
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