Trauma in elderly patients evaluated in a hospital emergency department in Konya, Turkey: a retrospective study

Five Key Papers About Emergency Department Fall Evaluation: A Curated Collection for Emergency Physicians

The evaluation of patients who have experienced a fall has been an integral part of geriatric emergency care. All physicians who engage in the care of the geriatric population in acute settings need to familiarize themselves with the current literature on this topic. However, it can be challenging to navigate the large body of literature on this topic. The purpose of this article is to identify and summarize the key studies that can be helpful for faculty interested in an evidence-based fall evaluation.

The authors compiled a list of key papers on emergency department (ED) based upon a structured literature search supplemented with suggestions by key informants and an open call on social media; 32 studies on ED evaluation were identified. Our authorship group then engaged in a modified Delphi technique to develop consensus on the most important studies about fall evaluation for emergency physicians. This process eventually resulted in the selection of the top five articles on fall evaluation. Additionally, we summarize these studies with regard to their relevance to emergency medicine (EM) trainees and junior faculty.

Evaluation of older patients with a history of falls is a challenging but crucial component of EM training. We believe our review will be educational for junior and senior EM faculty to better understand these patients' care and to design an evidence-based practice.

Females fall more from heights but males survive less among a geriatric population: insights from an American level 1 trauma center

Background

Approximately one third of subjects ≥65 year old and half of subjects ≥80 years old sustain a fall injury each year. We aimed to study the outcomes of fall from a height (FFH) among older adults. We hypothesized that in an elderly population, fall-related injury and mortality are the same in both genders.

Methods

A retrospective analysis was conducted between January 2012 and December 2016 in patients who sustained fall injury at age of at least 60 years and were admitted into a Level 1 Trauma center. Patients were divided into 3 groups: Gp-I: 60–69, Gp-II: 70–79 and Gp-III: ≥80 years old. Data were analyzed and compared using Chi-square, one-way analysis of variance (ANOVA) and logistic regression analysis tests.

Results

Forty-three percent (3665/8528) of adult trauma patients had FFH and 59.5% (2181) were ≥ 60 years old and 52% were women. The risk of fall increased with age with an Odd ratio (OR) 1.52 for age 70–79 and an OR 3.40 for ≥80.

Females fell 1.2 times more (age-adjusted OR 1.24; 95% CI 1.05–1.45) and 47% of ≥80 years old suffered FFH. Two-thirds of FFH occurred at a height ≤ 1 m. Injury severity (ISS, NISS and GCS) were worse in Gp-II, lower extremities max Abbreviated Injury score (max AIS) was higher in Gp-III. Overall mortality was 8.7% (Gp-I 3.6% vs. 11.3% in Gp-II and 14% in Gp- III). Males showed higher mortality than females in the entire age groups (Gp-I: 4.6% vs 1%, Gp-II: 12.9% vs 4.2% and Gp-III: 17.3% vs 6.9% respectively). On multivariate analysis, shock index (OR 3.80; 95% CI 1.27–11.33) and male gender (OR 2.70; 95% CI 1.69–4.16) were independent predictors of mortality.

Conclusions

Fall from a height is more common in older adult female patients, but male patients have worse outcomes. Preventive measures for falls at home still are needed for the older adults of both genders.

Electronic supplementary material

The online version of this article (10.1186/s12877-019-1252-6) contains supplementary material, which is available to authorized users.

Hand injuries in an older population - a retrospective cohort study from a single hand surgery centre

Background

Hand injuries occur at all ages. With an aging population globally an increasing number of hand injuries among the elderly is to be expected. The aim of the present study is to describe the health characteristics and detailed injury patterns for elderly with hand injuries, with incidence, as a background for further studies on the topic. Specific knowledge is currently lacking about hand injuries among this group. The study is a retrospective cohort study from a single hand surgery centre.

Methods

Data were collected for 286 patients, aged > 65 years, treated for traumatic hand injury between July 1, 2013 and June 30, 2014 at the Department of Hand Surgery in Malmö.

Results

Incidence was 21.3/10000 inhabitants/year. The 286 patients included comprised 145 women and 141 men. The men had more severe injuries, often involving a wound, while women most commonly sustained a fracture after a fall. The men were younger than the women and required more surgery/admissions. Among all patients, 13% were healthy, while 27% patients took ≥5 drugs, mainly for cardiovascular disease.

Conclusions

The incidence of hand injuries among the elderly is lower than among a younger population. Men sustained more wounds from using hazardous equipment, while women sustained post-fall fractures. A minority of the elderly is healthy. Prevention of fall injuries is crucial and emphasising safety awareness might reduce injuries in both sexes.

Injury Patterns and Outcomes of Trauma in the Geriatric Population Presenting to the Emergency Department in a Tertiary Care Hospital of South India

Background:

The geriatric population is more prone for injuries with complications due to their associated comorbidities. This study was done to understand the mode, severity, and outcome of injuries among geriatric patients presenting to the emergency department (ED).

Materials and Methods:

This retrospective study included all patients >60 years who presented with trauma between October 2014 and March 2015. Details of the incident, injuries, and hospital outcome were noted.

Results:

Among 8563 geriatric patients, who presented to the ED during the study, 427 (4.9%) patients were trauma related. The mean age was 69 (standard deviation: 6.76) years with 87.6% being young-old (60–79 years) and 12.4% being old-old (>80 years). Majority (63.2%) were Priority 2 patients. The median time between the incident and ED arrival among Priority 1 patients was 3 h (interquartile range: 2–5). Common modes of injuries were slip and fall (37.4%), two-wheeler accidents (25.8%), fall from height (9.1%), and pedestrian (8.9%). The ED team alone managed 25.8% of patients. Specialty departments referred to included orthopedics (48%), neurosurgery (18.3%), plastic surgery (4.2%), HLRS (4%), and others. Injuries due to slip and fall were significantly more among the old-old (P = 0.001), and two-wheeler accidents were more among the young-old (P = 0.001), respectively. Superficial head injuries (28.8%), extremity (24.8%), facial (18.7%), and traumatic brain injuries (17.8%) were common presentations. Thoracic injuries were significantly more among the old-old (P < 0.001). Half (46.3%) of the young-old were discharged stable (P = 0.017). In-hospital mortality rate was 0.7% (3/427), while 12.9% (55/427) left against medical advice due to poor prognosis.

Conclusion:

Our study demonstrates the pattern of injury seen in the elderly in an urban setting in India. From this, we perceive the need for a prospective study evaluating the causes for geriatric trauma, which would help work on ways to prevent and minimize injuries in the elderly.

Activities of Daily Living and Determinant Factors among Older Adult Subjects with Lower Body Fracture after Discharge from Hospital: A Prospective Study

Fracture is a type of musculoskeletal injury that contributes to an inability to perform daily activities. The objective of this study was to evaluate activities of daily living (ADL) of older adult patients with lower body fracture and to determine factors influencing ADL. Patient's ADL was assessed at pre-fracture, ward admission and post-discharge phases using the Katz ADL questionnaire. There were 129 subjects at pre-fracture and ward phases and 89 subjects at discharge phase. There were four independent variables; age, gender, type of fracture and ability to walk before fracture. Logistic regression models showed that 'age' and 'ability to walk before fracture' were the determinant factors of dependent for 'bathing', 'dressing' and 'toileting'. The 'ability to walk before fracture' was the determinant factor of dependent for 'transferring'. 'Age' and 'gender' were the determinant factors of dependent for 'continence', while 'age' was the determinant factor of dependent for 'feeding'. The ADL score changes were significant across the phases with a reduction in ADL score in the ward admission phase and partial increment during the post-discharge phase. There were improvements in the health outcomes of subjects aged more than 50 years old after 3 months of being discharged from the hospital. In conclusion, age, being female, having a hip fracture and using a walking aid before fracture were the determinants identified in this study.

Preventing emergency department (ED) visits and hospitalisations of older adults with cognitive impairment compared with the general senior population: what do we know about avoidable incidents? Results from a scoping review

OBJECTIVES

Older cognitively impaired adults present a higher risk of hospitalisation and mortality following a visit to the emergency department (ED). Better understanding of avoidable incidents is needed to prevent them and the associated ED presentations in community-dwelling adults. This study aimed to synthetise the actual knowledge concerning these incidents leading this population to ED presentation, as well as possible preventive measures to reduce them.

DESIGN

A scoping review was performed according to the Arksey and O'Malley framework.

METHODS

Scientific and grey literature published between 1996 and 2017 were examined in databases (Medline, Cumulative Index of Nursing and Allied Health, Ageline, Scopus, ProQuest Dissertations/theses, Evidence-based medecine (EBM) Reviews, Healthstar), online library catalogues, governmental websites and published statistics. Sources discussing avoidable incidents leading to ED presentations were included and then extended to those discussing hospitalisation and mortality due to a lack of sources. Data (type, frequency, severity and circumstances of incidents, preventive measures) was extracted using a thematic chart, then analysed with content analysis.

RESULTS

67 sources were included in this scoping review. Five types of avoidable incidents (falls, burns, transport accidents, harm due to self-negligence and due to wandering) emerged, and all but transport accidents were more frequent in cognitively impaired seniors. Differences regarding circumstances were only reported for burns, as scalding was the most prevalent mechanism of injury for this population compared with flames for the general senior population. Multifactorial interventions and implications of other professionals (eg, pharmacist, firefighters) were reported as potential interventions to reduce avoidable incidents. However, few preventive measures were specifically tested in this population.

CONCLUSIONS

Primary research that screens for cognitive impairment and involves actors (eg, paramedics) to improve our understanding of avoidable incidents leading to ED visits is greatly needed. This knowledge is essential to develop preventive measures tailored to the needs of older cognitively impaired adults.

An increasing number of hand injuries in an elderly population - a retrospective study over a 30-year period

Background

Both the number and the proportion of elderly people in the society increase. The number of elderly subjects with a disability due to a disease has decreased resulting in more active elderly. Therefore, an increase in numbers of injury in the elderly population can be expected; a hypothesis that was investigated in the present study.

Methods

Two-hundred sixteen patients with an age of > 65 years, and admitted to a hand surgery ward with a hand injury, were retrospectively collected at four different 2-years periods over a 30 years time (1980–81 to 2010–11). Information about patient gender, age at injury, injury place and mechanism (s), injured structures, duration of hospital stay, number of out patient visits and rehabilitation visits as well as social status was collected. The injuries were classified with the Modified Hand Injury Severity Score (MHISS).

Results

Most injured patients were men (72%) and the number of patients who reported to be healthy significantly decreased (67% to 18%) during the study period. The number of injuries increased over the study period (n = 24 to n = 83/2-year period). Outside home was the most common injury place and a saw or a fall was the most frequent injury mechanism. Several fingers were most often injured. The majority of the injuries were classified to be Minor or Moderate (MHISS) and a fracture was the most common injured structure.

Conclusions

We found an increased number of hand injuries over a 30-year period in combination with a decrease in patients reported health treated at a hand surgery ward. Further studies regarding hand trauma in the elderly population will be valuable for future prevention and rehabilitation of this patient group.

Epidemiological Profile of Extremity Fractures and Dislocations in Road Traffic Accidents in Kashan, Iran: a Glance at the Related Disabilities

BACKGROUND

Apart from the mortality, road traffic injuries are associated with significant morbidities. This study has aimed to examine the pattern of traffic accident-related extremity fractures/dislocations and their related disabilities.

METHODS

A retrospective hospital-based study was conducted to assess the characteristics of limb fractures/dislocations among road traffic accident victims registered in Trauma Research Center registry of Kashan University of Medical Sciences, Kashan, Iran, during 2012-2013. Age and sex distribution, cause of injury, and site of fractures/dislocations were recorded. Years lived with disability (YLD) was calculated as a scale to measure the disability. One-way ANOVA and chi-square tests were used for data analysis.

RESULTS

From a total of 962 subjects, 812 (84.4%) were males (the male/female sex ratio: 5.4:1). The mean age of victims was 32.7±17.9. Leg (37%) and forearm (19%) fractures were the most frequent fractures. Shoulder dislocations were among the most affected joints accounting for 36.6% of the cases. The total calculated YLD was 135.6 (34.4 for temporal and 101.2 for lifelong disabilities, and totally 117.3 and 18.3 for males and females, respectively). The highest YLD was for motorcyclists (104) and while the most YLD was for 15-29 years (68.2).

CONCLUSION

Young men motorcyclist accidents are a major problem in Kashan region. Generally, they have been accounted for the highest YLD due to fractures/dislocations, especially in lower extremity. Although the calculated YLD will be decreased with increasing age, the elder people also had the high rate of traffic-related limb injuries.

The effects of magnesium sulfate therapy after severe diffuse axonal injury

Purpose

To evaluate the clinical effects of magnesium sulfate in the treatment of diffuse axonal injury (DAI).

Patients and methods

This study was a randomized, double-blind, placebo-controlled trial conducted in the First Affiliated Hospital of Sun Yat-sen University, Guangzhou and Zhuhai People’s Hospital, Zhuhai, two trauma center hospitals. A total of 128 patients suffered from DAI, with initial Glasgow coma scale (GCS) scores of 3–8. They were randomly divided into two groups: magnesium sulfate treatment (MST) group (n=64) and control group (n=64). The MST group received 250 μmol/kg magnesium sulfate intravenously 20 minutes after admission, followed by 750 μmol/kg magnesium sulfate intravenously daily for 5 days. The control group received standard management without MST. GCS scores and serum neuron-specific enolase values were measured and recorded at admission, and on days 3 and 7 after injury. Outcomes were determined by Glasgow outcome scale scores at discharge and at 3 months’ follow-up, respectively.

Results

After the 7-day treatment, patients in the MST group, compared with those in the control group, had a lower serum neuron-specific enolase level (25.40±6.66 vs 29.58±7.32, respectively, P=0.001) and higher GCS score (8.23±2.72 vs 7.05±2.64, respectively, P=0.016). Although the length of stay and mortality did not differ between the groups in the intensive care unit, Glasgow outcome scale score was significantly lower in the MST group at discharge (3.30±1.35 vs 3.90±1.10, P=0.004) and 3 months after discharge (2.95±1.48 vs 3.66±1.44, P=0.009).

Conclusion

Early treatment with magnesium sulfate resulted in a significant improvement in DAI outcome. Further studies are needed to confirm the clinical significance of treatment of DAI patients with magnesium sulfate.

Geriatric fall-related injuries

BACKGROUND

Falls are the leading cause of geriatric injury.

OBJECTIVES

We aimed to study the anatomical distribution, severity, and outcome of geriatric fall-related injuries in order to give recommendations regarding their prevention.

METHODS

All injured patients with an age ≥ 60 years who were admitted to Al-Ain Hospital or died in the Emergency Department due to falls were prospectively studied over a four year period.

RESULTS

We studied 92 patients. Fifty six of them (60.9%) were females. The mean (standard deviation) of age was 72.2 (9.6) years. Seventy three (89%) of all incidents occurred at home. Eighty three patients (90.2%) fell on the same level. The median (range) ISS was 4 (1-16) and the median GCS (range) was 15 (12-15). The lower limb was the most common injured body region (63%). There were no statistical significant differences between males and females regarding age, ISS, and hospital stay (p = 0.85, p = 0.57, and p = 0.35 respectively).

CONCLUSION

The majority of geriatric fall-related injuries were due to fall from the same level at home. Assessment of risk factors for falls including home hazards is essential for prevention of geriatric fall-related injuries.

Predictive Factors of Dependency in Activities of Daily Living Following Limb Trauma in the Elderly

Background

Traumatic injuries in the elderly often lead to permanent disabilities and long-term treatments that can adversely influence their activities of daily of living (ADL). The effect on ADL is an important outcome in elderly trauma.

Objectives

The present study was designed to evaluate the predictive factors of dependency in ADL following limb trauma in elderly referred to Shahid Beheshti Hospital, Kashan, Iran, in 2013.

Patients and Methods

This descriptive study was conducted on 200 traumatic patients admitted to the trauma emergency ward of Shahid Beheshti hospital in 2013. The questionnaire used in this study had three parts: demographic data, information related to trauma, and an independence scale of ADL (ISADL). The ISADL was completed in the emergency ward to declare pre-traumatic status; it was also completed one and three months after trauma. Statistical analysis was conducted by the t-test and analysis of variance (ANOVA). The repeated measure was used to study the trend of the ISADL and other demographic variables. The multiple regression analysis was also used to declare the predictive variables related to the ISADL.

Results

The study population consisted of 81 males (40.5%) and 119 females (59.5%). The participants’ average age was 70.57 ± 9.05 years. In total, 80.5% of the elderly were completely independent in ADL before trauma; this decreased to 13.5% one month after trauma. The repeated measure analysis showed a significant improvement in the ISADL three months after trauma. Gender, age, and education had significant interaction with the ISADL. The multiple regression analysis showed that type of trauma and location of injured organ had predictive values related to the ISADL, one and three months after trauma. The place and cause of trauma, and having surgery showed a significant relationship with the ISADL three months after trauma.

Conclusions

Many factors, such as gender, age, education, type of trauma, and location of injured organ, may predict ADL following limb trauma.

Evaluation of preventable trauma death in emergency department of Imam Reza hospital

BACKGROUND

Trauma is considered as a worldwide problem despite socio-economic development. Motor vehicle accidents (MVAs) are the most important cause of trauma. Trauma related deaths are mostly preventable. This study aimed to investigate the causes and prevention of death in trauma patients.

METHODS

This retrospective, descriptive-analytic study assessed 100 trauma patients referred to our emergency department (ED) from January 2013 to Januanry 2015. The included patients were those with trauma died after arrival at our ED. Age, sex, cause of trauma, clinical causes of death, causes of death defined by autopsy, way of transfer to the ED, time of ambulance arrival at the scene of trauma, and time elapsed to enter the ED from the scene of trauma were studied.

RESULTS

In the 100 patients, 21 (21%) patients were female and 79 (79%) male. Forty-three patients were older than 60 years. Trauma was largely due to pedestrian accidents in 31% of the patients, and 33% had a hypo-volemic shock. About 80% of deaths were due to intra-cranial hemorrhage (ICH) or intra-ventricular hemorrhage (IVH), and spinal injuries were not preventable. Autopsy revealed that 28% of the patients suffered from internal injuries. Autopsy revealed that 19% of the deaths were not preventable and 81% were considered preventable. In our patients, 76 were transferred to the hospital by emergency medicine services (EMS). Analysis of time for ambulance arrival to the scene and frequency of death revealed that 52.2% of the deaths occurred between 11 and 15 minutes. Analysis of time for admission to the ED from the scene of trauma showed that 74.6% deaths occurred between 6 and 10 minutes.

CONCLUSIONS

The rate of hospital preventable deaths is about 80%, a high mortality rate, which denotes a lack of proper diagnosis and treatment. The time for arrival of EMS at the scene of trauma is longer than that in other countries.

Prevalence of Oral and Maxillofacial Trauma in Elders Admitted to a Reference Hospital in Northeastern Brazil

OBJECTIVE

To know the prevalence and etiology of oral and maxillofacial trauma in elders.

METHODS

Analytical quantitative cross-sectional study conducted at a public trauma hospital located in Fortaleza-Ceará, Brazil. The study population comprised patients with trauma who were hospitalized from April to August 2014. Of these patients, patients with oral and maxillofacial trauma were chosen to be included in the research. A questionnaire was administered in order to obtain information on socio-demographics, systemic comorbidities, use of medication, deleterious habits (smoking and alcohol consumption), etiology of oral and maxillofacial trauma and type of pre-hospital care.

RESULTS

Of the 280 elderly hospitalized with trauma, 47 had oral and maxillofacial trauma, with a prevalence of 16.8%. In this group, the age ranged from 60 to 88 years, with a mean age of 72.4 years (SD± 8.38). The elderly were mostly women (55.3%), self-declared pardos (53.2%), who presented with cardiovascular disorders (48.9%), and who received formal pre-hospital care (70.2%). Elderly who were in the 60-69 years age group, spent 6-9 years at school and drank alcohol were 2.64, 3.75, and 1.97, respectively, more likely to suffer oral and maxillofacial trauma. The main causes of trauma were physical aggression, traffic accidents, falls and domestic accidents. All of the physical aggressions resulted in oral and maxillofacial traumas, and the elderly who suffered traffic accidents were four times more likely to have oral and maxillofacial trauma.

CONCLUSION

The prevalence of 16.8% and the lack of research on oral and maxillofacial traumas in the elderly is worrisome and should be included in the oral health indicators for the elderly population to support the importance of oral health.

Geriatric hospitalizations in fall-related injuries

BACKGROUND

To investigate the injury pattern, severity, and mortality of elderly patients hospitalized for treatment of trauma following fall accidents.

METHODS

Data obtained from the Trauma Registry System were retrospectively reviewed for trauma admissions between January 1, 2009 and December 31, 2013 in a Level I trauma center. Of 16,548 registered patients, detailed information was retrieved from the 2,403 elderly patients (aged 65 years and above) with fall accidents and was compared with information from 1,909 adult patients (aged 20-64) with fall accidents.

RESULTS

Falls presented the major mechanism for admission (59.9%) in the elderly patients. The number of elderly patients who fell from a height <1 m was greater than that of the adult patients (91.9% vs. 62.5%, respectively, p <0.001). The Injury Severity Score (ISS) (9.3 ± 4.4 vs. 8.3 ± 6.1, respectively, p =0.007) and New Injury Severity Score (NISS) (10.3 ± 6.8 vs. 9.5 ± 8.2, respectively, p <0.001) were significantly higher in the elderly than the adult patients. A significantly larger proportion of the elderly patients were admitted to the ICU (16.2% vs. 13.4%, respectively, p =0.009), and the elderly were found to have longer stays in the intensive care unit (ICU) (8.6 days vs. 7.6 days, respectively, p =0.034) but not in the hospital in general (9.6 days vs. 8.5 days, respectively, p =0.183). Additionally, a significantly higher percentage of the elderly patients sustained subdural hematoma (10.1% vs. 8.2%, respectively, p =0.032) and femoral fracture (50.6% vs. 14.1%, respectively, p <0.001). There were significant differences in in-hospital mortality (18.2% vs. 10.3%, respectively, p =0.031) and length of stay in the hospital (11.6 days vs. 14.9 days, respectively, p =0.037) between the elderly and adult patients with subdural hematoma, but not between those with femoral fracture.

CONCLUSIONS

Analysis of the data indicates that elderly patients hospitalized for treatment of trauma following fall accidents present with a bodily injury pattern that differs from that of adult patients and have a higher severe injury score, worse outcome, and higher mortality than those of adult patients.

Dependency in activities of daily living following limb trauma in elderly referred to shahid beheshti hospital, kashan-iran in 2013

Background:

Activities of daily living (ADL) are an important indicator of health and independence in elderly. It provides useful information for proper planning in the field of elderly care. Trauma in elderly population is frequent and can negatively affect the independence in ADL.

Objectives:

The purpose of the present study was to evaluate elderly independence in activities of daily living (ADL) following limb trauma and its related factors in patients referred to trauma emergency ward of Shahid Beheshti Hospital, Kashan, Iran, in 2013.

Patients and Methods:

This descriptive study was conducted on 200 traumatic patients admitted to trauma emergency ward of Shahid Beheshti Hospital in 2013. The questionnaire used in this study had three parts as demographic data, information related to trauma and ISADL (independency scale of activities of daily living). ISADL was completed in emergency ward to declare pretraumatic status; it was also completed 1 and 3 months after trauma. Statistical analysis was conducted by Chi-square test, One-way and two-factor ANOVA, and Multiple regression analysis. Data analysis was conducted using SPSS software, version 16.

Results:

The average age of participants was 70.57 ± 9.05 years. In total, 80.5% of the elderly were completely independent in ISADL before trauma; this decreased to 13.5% one month after trauma. Besides, 32% of the elderly were completely or relatively dependent three months after trauma. Two-factor ANOVA showed a significant association between the scores of ISADL, the time interval and the type and location of an injured organ, and having the surgery as a treatment.

Conclusions:

More than three-quarters of the elderly were independent in ISADL before the trauma, but trauma in elderly patients had a substantial negative effect on patients' ability and ADL function.