Not all comorbidities are the same: the impact of specific comorbidities on mortality in critically ill geriatric trauma patients

AbstractIntroduction:In January of 2010, North Carolina (NC) USA implemented state-wide Trauma Triage Destination Plans (TTDPs) to provide standardized guidelines for Emergency Medical Services (EMS) decision making. No study exists to evaluate whether triage behavior has changed for geriatric trauma patients.Hypothesis/Problem:The impact of the NC TTDPs was investigated on EMS triage of geriatric trauma patients meeting physiologic criteria of serious injury, primarily based on whether these patients were transported to a trauma center.Methods:This is a retrospective cohort study of geriatric trauma patients transported by EMS from March 1, 2009 through September 30, 2009 (pre-TTDP) and March 1, 2010 through September 30, 2010 (post-TTDP) meeting the following inclusion criteria: (1) age 50 years or older; (2) transported to a hospital by NC EMS; (3) experienced an injury; and (4) meeting one or more of the NC TTDP’s physiologic criteria for trauma (n = 5,345). Data were obtained from the Prehospital Medical Information System (PreMIS). Data collected included proportions of patients transported to a trauma center categorized by specific physiologic criteria, age category, and distance from a trauma center.Results:The proportion of patients transported to a trauma center pre-TTDP (24.4% [95% CI 22.7%-26.1%]; n = 604) was similar to the proportion post-TTDP (24.4% [95% CI 22.9%-26.0%]; n = 700). For patients meeting specific physiologic triage criteria, the proportions of patients transported to a trauma center were also similar pre- and post-TTDP: systolic blood pressure <90 mmHg (22.5% versus 23.5%); respiratory rate <10 or >29 (23.2% versus 22.6%); and Glascow Coma Scale (GCS) score <13 (26.0% versus 26.4%). Patients aged 80 years or older were less likely to be transported to a trauma center than younger patients in both the pre- and post-TTDP periods.Conclusions:State-wide implementation of a TTDP had no discernible effect on the proportion of patients 50 years and older transported to a trauma center. Under-triage remained common and became increasingly prevalent among the oldest adults. Research to understand the uptake of guidelines and protocols into EMS practice is critical to improving care for older adults in the prehospital environment.

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Adrenal Insufficiency in the Critically Ill Trauma Population

The American Surgeon ◽

10.1177/000313480607200501 ◽

2006 ◽

Vol 72 (5) ◽

pp. 373-376 ◽

Cited By ~ 6

Author(s):

T.A. Gannon ◽

R.C. Britt ◽

L.J. Weireter ◽

F.J. Cole ◽

J.N. Collins ◽

...

Keyword(s):

Adrenal Insufficiency ◽

Critically Ill ◽

Serum Cortisol ◽

Total Serum ◽

Trauma Patients ◽

Total N ◽

Trauma Population ◽

Number Of Patients ◽

Low Cortisol ◽

The Impact

Acute adrenal insufficiency has been demonstrated in a number of patients with shock. This study was designed to evaluate the rate of occult adrenal insufficiency in the critically ill trauma population and to determine the impact of hypoproteinemia on the use of random cortisol levels as a marker for adrenal insufficiency. Forty-four patients were prospectively enrolled on admission to the trauma intensive care unit, with three excluded, for a total n of 41. Random total serum cortisol and albumin levels were drawn on hospital Days 1, 4, 8, and 14. Occult adrenal insufficiency was defined as a cortisol less than 25 mcg/dL in the setting of an albumin greater than 2.5 g/dL. The prevalence of cortisol less than 25 mcg/dL ranged from 51 to 81 per cent during the study period, and peaked on Days 4 and 8. Albumin 2.5 g/dL or less ranged from 37 to 60 per cent, and this prevalence also peaked on Days 4 and 8. The patients with a low albumin had a high prevalence of low cortisol, ranging from 67 to 100 per cent. The prevalence of adrenal insufficiency, with low cortisol and normal albumin, ranged from 41 to 82 per cent during the study period. None of our patients with occult adrenal insufficiency were treated with steroids, which was a decision made by the treating physicians. Among the patients with occult adrenal insufficiency, survival was 100 per cent. Occult adrenal insufficiency is common in critically ill trauma patients, and is a dynamic entity that can be acquired and even resolved during critical illness. Random cortisol of 25 mcg/dL may actually not be an adequate marker of occult adrenal insufficiency. Low albumin predicts a low cortisol. Hemodynamically stable occult adrenal insufficiency should not be treated with steroid replacement in the critically ill trauma patient, as survival in our series was 100 per cent without replacement.

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Application of a Geriatric Injury Protocol Demonstrates High Survival Rates for Geriatric Trauma Patients with High Injury Acuity

The American Surgeon ◽

10.1177/000313481708301022 ◽

2017 ◽

Vol 83 (10) ◽

pp. 1122-1126

Author(s):

Tigran Karamanukyan ◽

Andrea Pakula ◽

Maureen Martin ◽

Ashwitha Francis ◽

Ruby Skinner

Keyword(s):

Injury Severity ◽

Survival Rates ◽

Geriatric Trauma ◽

Study Cohort ◽

High Survival ◽

Trauma Patients ◽

Advanced Directives ◽

Severity Scores ◽

The Mean ◽

The Impact

Geriatric trauma has historically been associated with poor outcomes, particularly in the setting of severe polytrauma. Although geriatric trauma protocols are common, there are limited data on their impact in patients with high injury severity. In this study, we sought to investigate the impact of a geriatric injury protocol on outcomes in patients with severe trauma acuity. Ninety-eight geriatric patients (age ≥65) admitted to our trauma center with injury severity scores (ISS) ≥15 comprised the study cohort. The mean age was 75 ± 7.7 yrs. The mean ISS was 25 ± 9.2, and the mean geriatric trauma outcome score was 150 ± 3. Mortality was 17 per cent and 70 per cent were due to central nervous system injury. When patients with nonsurvivable injuries or advanced directives resulting in early care withdrawal were excluded, the mortality was 6 per cent. Extremes of age did not impact mortality [(>80 years, 21%) vs (65–79, 16%, P = 0.5)]. Most patients (53%) were discharged home. The application of our geriatric trauma protocol led to favorable results despite high injury acuity. These data suggest that even at the extremes of age, a large percentage of patients can be expected to survive. A prospective validation of these findings is warranted.

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The impact of associated diseases on the etiology, course and mortality in geriatric trauma patients

European Journal of Emergency Medicine ◽

10.1097/00063110-200610000-00010 ◽

2006 ◽

Vol 13 (5) ◽

pp. 295-298 ◽

Cited By ~ 7

Author(s):

Serkan Yilmaz ◽

Ozgur Karcioglu ◽

Serkan Sener

Keyword(s):

Geriatric Trauma ◽

Trauma Patients ◽

Associated Diseases ◽

The Impact

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Failure to Rescue in Geriatric Trauma: The Impact of Any Complication Increases with Age and Injury Severity in Elderly Trauma Patients

The American Surgeon ◽

10.1177/00031348211054072 ◽

2021 ◽

pp. 000313482110540

Author(s):

David P. Stonko ◽

Eric W. Etchill ◽

Katherine A. Giuliano ◽

Sandra R. DiBrito ◽

Daniel Eisenson ◽

...

Keyword(s):

Geriatric Patients ◽

Injury Severity ◽

Data Bank ◽

Geriatric Trauma ◽

Trauma Patients ◽

Failure To Rescue ◽

Elderly Trauma Patients ◽

Injured Patients ◽

The Impact ◽

Overall Mortality

Introduction The interaction of increasing age, Injury Severity Score (ISS), and complications is not well described in geriatric trauma patients. We hypothesized that failure to rescue rate from any complication worsens with age and injury severity. Methods The National Trauma Data Bank (NTDB) was queried for injured patients aged 65 years or older from January 1, 2013 through December 31, 2016. Demographics and injury characteristics were used to compare groups. Mortality rates were calculated across subgroups of age and ISS, and captured with heatmaps. Multivariable logistic regression was performed to identify independent predictors of mortality. Results 614,496 geriatric trauma patients were included; 151,880 (24.7%) experienced a complication. Those with complications tended to be older, female, non-white, have non-blunt mechanism, higher ISS, and hypotension on arrival. Overall mortality was highest (19%) in the oldest (≥86 years old) and most severely injured (ISS ≥ 25) patients, with constant age increasing across each ISS group was associated with a 157% increase in overall mortality ( P < .001, 95% CI: 148-167%). Holding ISS stable, increasing age group was associated with a 48% increase in overall mortality ( P < .001, 95% CI: 44-52%). After controlling for standard demographic variables at presentation, the existence of any complication was an independent predictor of overall mortality in geriatric patients (OR: 2.3; 95% CI: 2.2-2.4). Conclusions Any complication was an independent risk factor for mortality, and scaled with increasing age and ISS in geriatric patients. Differences in failure to rescue between populations may reflect critical differences in physiologic vulnerability that could represent targets for interventions.

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1551: THE IMPACT OF AUGMENTED RENAL CLEARANCE ON VANCOMYCIN THERAPY IN CRITICALLY ILL TRAUMA PATIENTS

Critical Care Medicine ◽

10.1097/01.ccm.0000812528.71914.cf ◽

2021 ◽

Vol 50 (1) ◽

pp. 779-779

Author(s):

Timothy Rice ◽

Christopher Droege ◽

Molly Droege ◽

Eric Mueller ◽

Neil Ernst ◽

...

Keyword(s):

Renal Clearance ◽

Critically Ill ◽

Trauma Patients ◽

Vancomycin Therapy ◽

Augmented Renal Clearance ◽

The Impact

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Risk Factors for Delirium and Association of Antipsychotic Use with Delirium Progression in Critically Ill Trauma Patients

The American Surgeon ◽

10.1177/00031348211069792 ◽

2022 ◽

pp. 000313482110697

Author(s):

Bethany R. Shoulders ◽

Sarah Elsabagh ◽

Douglas J. Tam ◽

Amanda M. Frantz ◽

Kaitlin M. Alexander ◽

...

Keyword(s):

Risk Factors ◽

Critically Ill ◽

Negative Impact ◽

Linear Regression Analysis ◽

Multiple Linear Regression Analysis ◽

Trauma Patients ◽

Icu Patients ◽

Tertiary Referral Center ◽

Surgical Icu ◽

The Impact

Background Delirium occurs frequently in critically ill and injured patients and is associated with significant morbidity and mortality. Limited data exists on the risk factors for developing delirium in critically ill trauma patients and the effect of antipsychotic (AP) medications on delirium progression. Objective The objective of this study is to determine the incidence of delirium in critically ill trauma versus non-trauma surgical patients and determine if the presence of trauma was associated with intensive care unit (ICU) delirium. Secondary outcomes included identifying risk factors for delirium and determining the impact of AP medication use on delirium progression in critically ill trauma patients. Methods This retrospective review studies adult trauma/surgical ICU patients admitted between May 2017-July 2018 to a level I trauma and tertiary referral center. Regression modeling was used to determine the impact of AP use on delirium-free days. Results Delirium was more common in critically ill trauma patients versus non-trauma surgical ICU patients [54/157 (34.4%) vs 42/270 (15.6%), P < .001]. Of the 54 trauma patients with delirium, 28 (52%) received an AP medication for delirium treatment and in the multiple linear regression analysis, AP use was significantly associated with fewer delirium-free days ( P = .02). Discussion Higher admission sequential organ failure assessment scores and increased length of stay were significantly associated with delirium onset in critically ill trauma patients. Use of AP medications for delirium treatment in this population had a negative impact on delirium-free days.

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