Functional Status after Injury: A Longitudinal Study of Geriatric Trauma

We evaluated self-rated functional status measured longitudinally in the year after injury in a geriatric trauma population. The longitudinal (L) group included 37 of 60 eligible trauma patients aged 65 years or older admitted December 2006 to November 2007 for greater than 24 hours who completed a Short Functional Status questionnaire (SFS) at 3, 6, and 12 months after injury. The SFS yields scores of 0 to 5 (5 = independent in all five activities of daily living [ADLs]) and has been validated among community-dwelling elders. The control (C) group included 63 trauma patients aged 65 years or older admitted December 2007 to July 2009 for greater than 24 hours who reported their preinjury functional status using the SFS at hospital admission. We used characteristics and scores of the C group to impute preinjury ADL scores for the L group. The groups were similar in baseline characteristics (age, ethnicity, Injury Severity Score, Charlson Comorbidity Index, and living arrangement; P > 0.05). For the C group, the preinjury ADL score was 4.6 (SD = 0.9). For the L group, ADL scores declined at all intervals reaching statistical significance at 12 months. We conclude that in the year after traumatic injury, geriatric patients lost the equivalent of approximately one ADL, increasing their risk of further functional decline, loss of independence, and death.

Download Full-text

Anion Gap as a Predictor of Trauma Outcomes in the Older Trauma Population: Correlations with Injury Severity and Mortality

The American Surgeon ◽

10.1177/000313481307901126 ◽

2013 ◽

Vol 79 (11) ◽

pp. 1203-1206 ◽

Cited By ~ 5

Author(s):

John J. Leskovan ◽

Carla F. Justiniano ◽

John A. Bach ◽

Charles H. Cook ◽

David E. Lindsey ◽

...

Keyword(s):

Injury Severity ◽

Traumatic Injury ◽

Serum Lactate ◽

Anion Gap ◽

Morbidity And Mortality ◽

Trauma Patients ◽

Metabolic Derangement ◽

Trauma Outcomes ◽

Tissue Hypoperfusion ◽

Trauma Population

The relationship among traumatic injury, the associated metabolic/physiologic responses, and mortality is well established. Tissue hypoperfusion and metabolic derangement may not universally correlate with initial clinical presentation. We hypothesized that anion gap (AG) could be a useful gauge of trauma-related physiologic response and mortality in older patients with relatively lower injury acuity. We retrospectively analyzed data from 711 trauma patients older than 45 years. Parameters examined included demographics, injury characteristics, laboratories, morbidity, and mortality. Univariate and survival analyses were performed using PASW 18. A step-wise correlation exists between increasing Injury Severity Score and AG. Although AG less than 8 to 15 was not associated with a significant increase in mortality, greater mortality was seen for AG greater than 16 with further stepwise increases for AGs greater than 22. Anion gap correlated moderately with serum lactate and poorly with base excess. Increasing AG also correlated with morbidity and greater incidence of intensive care admissions. The presence of any complication increased from 28.6 per cent for patients with AG 12 or less to 45.5 per cent for patients with AG 22 or greater ( P < 0.04). These findings support the contention that “low acuity” trauma patients with high AGs may not appear acutely ill but may harbor significant underlying metabolic and physiologic disturbances that could contribute to morbidity and mortality. Higher AG values (i.e., greater than 16) may be associated with worse clinical outcomes.

Download Full-text

Evaluation of Microvascular Perfusion and Resuscitation after Severe Injury

The American Surgeon ◽

10.1177/000313481508101231 ◽

2015 ◽

Vol 81 (12) ◽

pp. 1272-1278 ◽

Cited By ~ 1

Author(s):

Yann-Leei L. Lee ◽

Jon D. Simmons ◽

Mark N. Gillespie ◽

Diego F. Alvarez ◽

Richard P. Gonzalez ◽

...

Keyword(s):

Injury Severity ◽

Capillary Flow ◽

Severe Trauma ◽

Dark Field ◽

Serum Lactate ◽

Microvascular Perfusion ◽

Trauma Patients ◽

Sidestream Dark Field ◽

Trauma Population ◽

Severity Scores

Achieving adequate perfusion is a key goal of treatment in severe trauma; however, tissue perfusion has classically been measured by indirect means. Direct visualization of capillary flow has been applied in sepsis, but application of this technology to the trauma population has been limited. The purpose of this investigation was to compare the efficacy of standard indirect measures of perfusion to direct imaging of the sublingual microcirculatory flow during trauma resuscitation. Patients with injury severity scores >15 were serially examined using a handheld sidestream dark-field video microscope. In addition, measurements were also made from healthy volunteers. The De Backer score, a morphometric capillary density score, and total vessel density (TVD) as cumulative vessel area within the image, were calculated using Automated Vascular Analysis (AVA3.0) software. These indices were compared against clinical and laboratory parameters of organ function and systemic metabolic status as well as mortality. Twenty severely injured patients had lower TVD (X = 14.6 ± 0.22 vs 17.66 ± 0.51) and De Backer scores (X = 9.62 ± 0.16 vs 11.55 ± 0.37) compared with healthy controls. These scores best correlated with serum lactate (TVD R2 = 0.525, De Backer R2 = 0.576, P < 0.05). Mean arterial pressure, heart rate, oxygen saturation, pH, bicarbonate, base deficit, hematocrit, and coagulation parameters correlated poorly with both TVD and De Backer score. Direct measurement of sublingual microvascular perfusion is technically feasible in trauma patients, and seems to provide real-time assessment of micro-circulatory perfusion. This study suggests that in severe trauma, many indirect measurements of perfusion do not correlate with microvascular perfusion. However, visualized perfusion deficiencies do reflect a shift toward anaerobic metabolism.

Download Full-text

Geriatric Trauma

DeckerMed Surgery ◽

10.2310/surg.2254 ◽

2019 ◽

Author(s):

Sigrid Burruss ◽

Lillian Min ◽

Areti Tillou

Keyword(s):

Risk Factors ◽

Care Coordination ◽

Unintentional Injury ◽

The Elderly ◽

Geriatric Trauma ◽

Trauma Patients ◽

Age Related ◽

Trauma Population ◽

Downward Spiral ◽

Risk Factors For Falls

The geriatric trauma population continues to grow as life expectancy and unintentional injury increase. Age-related physiologic changes and complex comorbidities may not only lead to injury but also may precipitate a downward spiral. The injury patterns, presentation of life-threatening injury, and response to injury are unique in the elderly trauma population, and dedicated evaluation of elderly trauma patients at a trauma center may be beneficial. Aggressive, early intervention with a focus on geriatric-specific needs and care coordination are an integral part of the management to reduce morbidity and mortality. Much of the unintentional injuries may be preventable with identification of risk factors for falls and fall prevention programs. Frailty measurements may be used to predict morbidity and functional status. Surgeons must become familiar with geriatric-specific issues and how best to treat the geriatric trauma population. This review contains 3 figures, 2 tables, and 133 references. Key Words: care coordination, elderly, frailty, geriatric, injury, prevention, risk factors, trauma, triage

Download Full-text

Suburban geriatric trauma: the experiences of a level I trauma center

American Journal of Critical Care ◽

10.4037/ajcc1995.4.5.379 ◽

1995 ◽

Vol 4 (5) ◽

pp. 379-382 ◽

Cited By ~ 9

Author(s):

F DeKeyser ◽

D Carolan ◽

A Trask

Keyword(s):

Trauma Center ◽

Functional Outcomes ◽

Injury Severity ◽

The Elderly ◽

Mortality Rates ◽

Geriatric Trauma ◽

Trauma Patients ◽

Younger Patients ◽

Severity Scores ◽

Trauma Scores

BACKGROUND: As the mean age of the US population increases, so does the incidence of geriatric trauma. Investigators have shown that the elderly have high morbidity and mortality rates associated with traumatic injuries. OBJECTIVE: To compare the severity of injury, mortality, and functional outcomes of geriatric patients with younger patients admitted to a suburban trauma center. METHOD: A convenience sample of trauma patients who were 65 years old or older was compared with trauma patients who were 35 to 45 and 55 to 64 years old. Demographic data, injury data, Injury Severity Scores, Revised Trauma Scores, length of stay, and functional ability outcomes were abstracted from a trauma registry in aggregate form and then analyzed. RESULTS: The sample consisted of 766 subjects (age 35-45, n = 223; age 55-64, n = 135; age 65 and older, n = 408) with a mean age of 64.6 years. A larger percentage of the elderly were victims of falls; younger trauma patients were more likely to be victims of motor vehicle crashes. Significant differences were found between age groups on Glasgow Coma Scale scores. Revised Trauma Scores, and length of stay. Significant differences were not found on Injury Severity Scores, mortality rates, or functional outcomes. CONCLUSIONS: Although anatomic injury severity of elderly patients was similar to that of younger patients, the elderly demonstrated greater physiologic compromise and longer hospital stays. Mortality rates were lower for the elderly group, but this result might be because a larger proportion of elderly patients were hospitalized with minor or moderate injuries.

Download Full-text

Geriatric Trauma Screening Tool: Preinjury Functional Status Dictates Intensive Care Unit Discharge Disposition

The American Surgeon ◽

10.1177/000313481908500828 ◽

2019 ◽

Vol 85 (8) ◽

pp. 800-805

Author(s):

Lindsey C. Bridges ◽

Amy B. Christie ◽

Hamza H. Awad ◽

Erika J. Sigman ◽

D. Benjamin Christie ◽

...

Keyword(s):

Older Adults ◽

Functional Status ◽

Screening Tool ◽

Intensive Care Unit Discharge ◽

Hospital Length ◽

Transitions Of Care ◽

Geriatric Trauma ◽

Trauma Patients ◽

Discharge Disposition ◽

Hospital Resources

Older adults account for an increasing percentage of trauma patients and have worse outcomes when compared with younger populations. Simple prediction tools are needed to designate risk categories among these patients. The Geriatric Trauma Screening Tool (GTST) was developed to risk stratify older adults admitted to the ICU at a Level 1 trauma center. One hundred fifty patients aged ≥ 65 years were prospectively screened for high-risk (HR) injuries, comorbidities, and pre-hospital function using the GTST. Patients who screened for HR were more likely to have an unfavorable disposition than non-HR patients. HR patients had significantly longer ICU and hospital length of stays when compared with non-HR patients. In addition, patients with prior functional impairment were at higher risk for an unfavorable discharge disposition than their counterparts. Implementation of the GTST predicted discharge disposition in geriatric trauma patients admitted to the ICU. Pre-injury functional status was a better predictor of discharge disposition than either the types of HR injuries or the presence of comorbidities. Risk stratification of geriatric trauma patients allows for early engagement of patients and caregivers regarding transitions of care as well as more efficient utilization of hospital resources.

Download Full-text

Clinical Characteristics of Trauma Patients Requiring Hydrocortisone Treatment for Refractory Hypotension

The American Surgeon ◽

10.1177/000313481708300829 ◽

2017 ◽

Vol 83 (8) ◽

pp. 821-824

Author(s):

Gina Kim ◽

Jeffrey Young

Keyword(s):

Hospital Mortality ◽

Injury Severity ◽

Traumatic Injury ◽

Patient Characteristics ◽

Data Repository ◽

Trauma Patients ◽

Lower Blood ◽

Refractory Hypotension ◽

The University ◽

Stress Dose

Corticosteroids play an important role in responding to physiologic stress in the human body. However, its application in critical care remains heavily debated. The purpose of this study was to identify patient characteristics associated with receiving stress-dose steroids during the intensive care unit stay after traumatic injury and its effect on in-hospital mortality. Patients admitted to the University of Virginia trauma center between January 1, 2011, and December 31, 2015, were identified using our Trauma Registry. Stress dose steroids were defined as 100 mg IV hydrocortisone every eight hours. Patients who received stress-dose steroids were identified using the Clinical Data Repository. Patient characteristics associated with increased likelihood of receiving stress-dose steroids during admission were age >65, diabetes mellitus, congestive heart failure, burn injuries, Injury Severity Score >15, lower blood pressure (141/80 vs 125/76 mm Hg), and higher heart rate (87 vs 94/min). Patients who received stress-dose steroids were found to have increased mortality but not after controlling for the aforementioned patient factors associated with increased likelihood of receiving stress-dose steroids. The use of stress-dose steroids in critically ill patients with refractory hypotension does not appear to affect in-hospital mortality.

Download Full-text

P142: The anticoagulated trauma patient: a Canadian experience in the era of direct oral anticoagulants

CJEM ◽

10.1017/cem.2016.316 ◽

2016 ◽

Vol 18 (S1) ◽

pp. S125-S125 ◽

Cited By ~ 1

Author(s):

B. Wood ◽

A. Ackery ◽

S. Rizoli ◽

B. Nascimento ◽

M. Sholzberg ◽

...

Keyword(s):

Trauma Patient ◽

Injury Severity ◽

Hematological Parameters ◽

Oral Anticoagulants ◽

Demographic Data ◽

Direct Oral Anticoagulants ◽

Significant Proportion ◽

Common Mechanism ◽

Trauma Patients ◽

Trauma Population

Introduction: The anticoagulated trauma patient is a particularly vulnerable population. Our current practice is guided by experience with patients taking vitamin K dependent antagonists (VKA, like warfarin). It is currently unknown how the increasing use of direct oral anticoagulants (DOACs) will change our trauma population. We collected data about this new subset of patients to compare their clinical characteristics to patients on pre-injury VKA therapy. Methods: Retrospective review of anticoagulated trauma patients presenting to Toronto’s two adult trauma centres, Saint Michael’s Hospital and Sunnybrook Health Sciences Centre, from June 2014-June 2015 was undertaken. Patients were recruited through the institutions’ trauma registries and were eligible if they suffered a traumatic injury and taking an oral anticoagulant pre-injury. Clinical and demographic data were extracted by a trained reviewer and analysed with descriptive statistics. Results: Our study recruited 85 patients, 33% were taking DOACs and 67% VKAs. Trauma patients on DOACs & VKAs respectively had similar baseline characteristics such as age (75.9 vs 77.4), initial injury severity score (ISS (16.9 vs 20.6)) and concomitant antiplatelet use (7.1% vs 5.4%). Both groups’ most common mechanism for injury was falls and the most common indication for anticoagulation was atrial fibrillation. Patients on DOACs tended to have lower average INR (1.25 vs 2.3) and serum creatinine (94.9 vs 127.4). Conclusion: Patients on DOACs pre-injury now account for a significant proportion of orally anticoagulated trauma patients. Patients on DOACs tended to have less derangement of basic hematological parameters complicating diagnosis and management of coagulopathy.

Download Full-text

An Objective Study of the Impact of the Electronic Medical Record on Outcomes in Trauma Patients

The American Surgeon ◽

10.1177/000313481207801134 ◽

2012 ◽

Vol 78 (11) ◽

pp. 1249-1254 ◽

Cited By ~ 4

Author(s):

Paul J. Schenarts ◽

Claudia E. Goettler ◽

Michael A. White ◽

Brett H. Waibel

Keyword(s):

Length Of Stay ◽

Medical Record ◽

Electronic Medical Record ◽

Injury Severity ◽

Unit Length ◽

Traumatic Injury ◽

Hospital Length Of Stay ◽

Trauma Patients ◽

Delay In Diagnosis ◽

The Impact

It is commonly believed that the electronic medical record (EMR) will improve patient outcomes. However, there is scant published literature to support this claim and no studies in any surgical population. Our hypothesis was that the EMR would not improve objective outcome measures in patients with traumatic injury. Prospectively collected data from our university-based Level I trauma center was retrospectively reviewed. Demographic, injury severity as well as outcomes and complications data were compared for all patients admitted over a 20-month period before introduction of the EMR and a 20-month period after full, hospital-wide use of the EMR. Implementation of the EMR was associated with a decreased hospital length of stay, P = 0.02; intensive care unit length of stay, P = 0.001; ventilator days, P = 0.002; acute respiratory distress syndrome, P = 0.006, pneumonia, P = 0.008; myocardial infarction, P = 0.001; line infection, P = 0.03; septicemia, P = 0.000; renal failure, P = 0.000; drug complication, P = 0.001; and delay in diagnosis, P = 0.04. There was no difference in mortality, unexpected cardiac arrest, missed injury, pulmonary embolism/deep vein thrombosis, or late urinary tract infection. This is the first study to investigate the impact of the EMR in surgical patients. Although there was an improvement in some complications, the overall impact was inconsistent.

Download Full-text

A Contemporary Analysis of Delayed Diagnoses After Traumatic Injury

The American Surgeon ◽

10.1177/0003134820951458 ◽

2020 ◽

pp. 000313482095145

Author(s):

Justin S. Hatchimonji ◽

Catherine E. Sharoky ◽

Elinore J. Kaufman ◽

Lucy W. Ma ◽

Anna E. Garcia Whitlock ◽

...

Keyword(s):

Regression Analysis ◽

Injury Severity ◽

Traumatic Injury ◽

Trauma Team ◽

Trauma Patients ◽

Extremity Injury ◽

Factors Associated ◽

Common Category ◽

Multivariable Regression Model ◽

Multivariable Regression

Background Factors associated with delayed injury diagnosis (DID) have been examined, but incompletely researched. Methods We evaluated demographics, mechanism, and measures of mental status and injury severity among 10 years’ worth of adult trauma patients at our center for association with DID in a multivariable regression model. Descriptions of DID injuries were reviewed to highlight characteristics of these injuries. Results We included 13 509 patients, 89 (0.7%) of whom had a recognized DID. In regression analysis, ISS (OR 1.04 per point, 95% CI 1.02-1.06) and number of injuries (OR 1.08 per injury, 95% CI 1.04-1.11) were associated with DID. Operative patients had twice the odds of DID (OR 2.02, 95% CI 1.18-3.44). The most common category of DID was orthopedic extremity injury (22/89). Conclusion DID is associated with injury severity and operative intervention. This suggests that the presence of an injury requiring operation may distract the trauma team from additional injuries.

Download Full-text

Clinical Outcome and Management for Geriatric Traumatic Injury: Analysis of 2688 Cases in the Emergency Department of a Teaching Hospital in Taiwan

Journal of Clinical Medicine ◽

10.3390/jcm7090255 ◽

2018 ◽

Vol 7 (9) ◽

pp. 255 ◽

Cited By ~ 1

Author(s):

Meng-Yu Wu ◽

Yu-Long Chen ◽

Giou-Teng Yiang ◽

Chia-Jung Li ◽

Amy Lin

Keyword(s):

Clinical Outcome ◽

Injury Severity Score ◽

Clinical Outcomes ◽

Severity Score ◽

Injury Severity ◽

Strong Predictor ◽

Traumatic Injury ◽

Geriatric Trauma ◽

Shock Index ◽

New Injury Severity Score

Geriatric traumatic injuries in emergency departments are frequent and associated with higher mortality rates and catastrophic functional outcomes. Several prediction scores have been established to manage traumatic patients, including the shock index (SI), revised trauma score (RTS), injury severity score (ISS), trauma injury severity score (TRISS), and new injury severity score (NISS). However, it was necessary to investigate the effectiveness and efficiency of care for the geriatric traumatic population. In addition, image studies such as computed tomography and magnetic resonance imaging play an important role in early diagnosis and timely intervention. However, few studies focus on this aspect. The association between the benefit of carrying out more image studies and clinical outcomes remains unclear. In this study, we included a total of 2688 traumatic patients and analyzed the clinical outcomes and predicting factors in terms of geriatric trauma via pre-hospital and in-hospital analysis. Our evaluation revealed that a shock index ≥1 may be not a strong predictor of geriatric trauma due to the poor physical response in the aging population. This should be modified in geriatric patients. Other systems, like RTS, ISS, TRISS, and NISS, were significant in terms of predicting the clinical outcome.

Download Full-text