The Impact of Age on Mortality in Patients in Extremis Undergoing Urgent Intervention

2013 ◽  
Vol 79 (12) ◽  
pp. 1248-1252 ◽  
Author(s):  
Eric B. McClellan ◽  
Scott Bricker ◽  
Angela Neville ◽  
Frederic Bongard ◽  
Brant Putnam ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Glasgow Coma Scale ◽  
Glasgow Coma Scale Score ◽  
Older Patients ◽  
Vital Signs ◽  
Blunt Injury ◽  
Trauma Patients ◽  
National Trauma ◽  
The Impact ◽  
Effect Of Age

Trauma patients admitted without vital signs have little hope of survival even with extreme interventions. We performed this study to determine the effect of age on survival in patients in extremis undergoing urgent thoracotomy. The National Trauma Database was searched for patients presenting without a systolic blood pressure (0), a Glasgow Coma Scale score less than 8, and underwent an urgent thoracotomy. Mortality was determined for pediatric (younger than 16 years) and older patients (older than 60 years) and compared. Of 708 patients, 32 (4.5%) were pediatric and 57 (8.1%) were elderly. Pediatric mortality was 93.8 per cent (30) versus 95.6 per cent (646) for patients older than 16 years ( P = 0.981). Mortality in the older patients was 94.7 per cent (54) versus 95.5 per cent (622) in patients younger than 60 years ( P = 0.778). Race and blunt injury were independently associated with death. However, neither pediatric ( P = 0.418) nor older status ( P = 0.184) was predictive. Age does not significantly impact mortality in patients in extremis who undergo urgent thoracotomy. Age should not be a contributing factor in determining who should undergo more extreme maneuvers if they present as a reasonable candidate using other criteria.

Permissive Hypotension: Potentially Harmful in the Elderly? A National Trauma Data Bank Analysis

2015 ◽  
Vol 81 (8) ◽  
pp. 770-777 ◽  
Author(s):  
Lindsay C. Bridges ◽  
Brett H. Waibel ◽  
Mark A. Newell
Keyword(s):  
Blood Pressure ◽  
Systolic Blood Pressure ◽  
Injury Severity ◽  
Damage Control ◽  
Data Bank ◽  
Trauma Patients ◽  
Permissive Hypotension ◽  
National Trauma ◽  
National Trauma Data Bank ◽  
Effect Of Age

Permissive hypotension is a component of damage control resuscitation that aims to provide a directed, controlled resuscitation, while countering the “lethal triad.” This principle has not been specifically studied in elderly (ELD) trauma patients (≥55 years). Given the ELD population's lack of physiologic reserve and risk of inadequate perfusion with “normal” blood pressures, we hypothesized that utilized a permissive hypotension strategy in ELD trauma patients would result in worse outcomes compared with younger patients (18–54 years). A retrospective review of National Trauma Data Bank reports from 2009 and 2010, identifying critically ill patients undergoing a “damage control laparotomy,” was performed to determine the effect of age and systolic blood pressure on outcome. Logistic regression analysis, including evaluation of an interaction between age and admission blood pressure, was performed on mortality using admission demographics, physiology, injury severity, mechanism of injury, and in-hospital complications. Although there was a higher likelihood of death with greater age, lower admission systolic blood pressure, lower Glasgow Coma Score, increased injury severity score, and acute renal failure, a synergistic effect of age and blood pressure on mortality was not identified. Permissive hypotension appears to be a possible management strategy in ELD trauma patients.

scholarly journals The association between vital signs and clinical outcomes in emergency department patients of different age categories

2022 ◽  
pp. emermed-2020-210628
Author(s):  
Bart GJ Candel ◽  
Renée Duijzer ◽  
Menno I Gaakeer ◽  
Ewoud ter Avest ◽  
Özcan Sir ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Emergency Department ◽  
Risk Stratification ◽  
Hospital Mortality ◽  
Older Patients ◽  
Vital Signs ◽  
Risk Scores ◽  
Case Mix ◽  
Peripheral Oxygen Saturation ◽  
The Impact

BackgroundAppropriate interpretation of vital signs is essential for risk stratification in the emergency department (ED) but may change with advancing age. In several guidelines, risk scores such as the Systemic Inflammatory Response Syndrome (SIRS) and Quick Sequential Organ Failure Assessment (qSOFA) scores, commonly used in emergency medicine practice (as well as critical care) specify a single cut-off or threshold for each of the commonly measured vital signs. Although a single cut-off may be convenient, it is unknown whether a single cut-off for vital signs truly exists and if the association between vital signs and in-hospital mortality differs per age-category.AimsTo assess the association between initial vital signs and case-mix adjusted in-hospital mortality in different age categories.MethodsObservational multicentre cohort study using the Netherlands Emergency Department Evaluation Database (NEED) in which consecutive ED patients ≥18 years were included between 1 January 2017 and 12 January 2020. The association between vital signs and case-mix adjusted mortality were assessed in three age categories (18-65; 66-80; >80 years) using multivariable logistic regression. Vital signs were each divided into five to six categories, for example, systolic blood pressure (SBP) categories (≤80, 81–100, 101–120, 121–140, >140 mm Hg).ResultsWe included 101 416 patients of whom 2374 (2.3%) died. Adjusted ORs for mortality increased gradually with decreasing SBP and decreasing peripheral oxygen saturation (SpO2). Diastolic blood pressure (DBP), mean arterial pressure (MAP) and heart rate (HR) had quasi-U-shaped associations with mortality. Mortality did not increase for temperatures anywhere in the range between 35.5°C and 42.0°C, with a single cut-off around 35.5°C below which mortality increased. Single cut-offs were also found for MAP <70 mm Hg and respiratory rate >22/min. For all vital signs, older patients had larger increases in absolute mortality compared with younger patients.ConclusionFor SBP, DBP, SpO2 and HR, no single cut-off existed. The impact of changing vital sign categories on prognosis was larger in older patients. Our results have implications for the interpretation of vital signs in existing risk stratification tools and acute care guidelines.

Age affects the efficacy of immune checkpoint inhibitors in patients with advanced cancer.

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. 2638-2638
Author(s):  
Yongjie Wang ◽  
Ronghua Yang ◽  
Dong Wang ◽  
Donghua Zhao ◽  
Peng Li ◽  
...  
Keyword(s):  
Lung Cancer ◽  
Advanced Cancer ◽  
Immune Checkpoint ◽  
Older Patients ◽  
Immune Checkpoint Inhibitors ◽  
Checkpoint Inhibitors ◽  
Sign Test ◽  
Patients With Cancer ◽  
The Impact ◽  
Effect Of Age

2638 Background: Immune checkpoint inhibitors (ICIs), such as programmed death(ligand)1 (PD-(L)1) and cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) inhibitors, have dramatic effects on treatment in patients with various malignancies. High tumor mutation burden (TMB) is predictive of clinical response to ICI in multiple cancer types. Although age-related immune dysfunction might induce difference on the efficacy of ICIs between younger and older patients, the potential effect of age on the efficacy of ICIs remains little known and controversial. Herein, we aimed to analysis the association between age and the efficacy of ICIs based on MSKCC cohort. Methods: We screened out 1661 patients having complete information with advanced cancer, whose tumors underwent next-generation sequencing (NGS) detection and who were treated with at least one dose of ICI in MSKCC cohort. All patients were divided into two groups according to age, the younger group (age ≤50-year old) and the older group (age > 50-year old). We further analyzed the differences in overall survival (OS) and TMB between the two groups. The pooled hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated via Cox regression model for OS and P-values were calculated via the Wilcoxon sign test for TMB. We analyzed the effect of age on ICI in lung cancer using the same way. Results: In 1661 patients with cancer in our study, 312 (19%) younger and 1349 (81%) older patients were found. The pooled HRs for OS was 1.28 (95% CI: 1.09-1.52) in younger group compared with older group. In 1661 patients with cancer, there was 350 (21%) patients with lung cancer, including 30 (9%) younger and 320 (91%) older patients. The pooled HRs for OS was 1.45 (95% CI: 0.95-2.23) in younger group compared with older group in lung cancer. In addition, TMB in older group was higher than in younger group and significant difference of TMB was found via the Wilcoxon sign test (p = 2.6e-10) between the two groups, especially in lung cancer (p = 1e-4). Conclusions: Our study assessed the impact of age on the efficacy of ICIs using the threshold of 50 years old for the first time and we founded that patients in older group had higher TMB and longer OS than younger group.

Devastating Consequences of Subway Accidents: Traumatic Amputations

2006 ◽  
Vol 72 (1) ◽  
pp. 74-76 ◽  
Author(s):  
Alexandra A. Maclean ◽  
Andrea M. O'Neill ◽  
H. Leon Pachter ◽  
Maurizio A. Miglietta
Keyword(s):  
New York ◽  
Glasgow Coma Scale ◽  
Limb Salvage ◽  
Scale Score ◽  
Glasgow Coma Scale Score ◽  
Injury Severity ◽  
Vital Signs ◽  
Wound Infection Rate ◽  
Operative Procedures ◽  
Coma Scale

The efficiencies of the subway system are tempered by the occurrence of accidents, some with devastating injuries. The purpose of this study is to examine our experience with traumatic amputations after subway accidents. A retrospective trauma registry review (1989–2003) of 41 patients who presented to Bellevue Hospital, New York City, with amputations from subway accidents was undertaken to examine the following end points: age, sex, Injury Severity Score, time and mechanism of accident, history of psychiatric disorders and alcohol use, admission vital signs, Glasgow Coma Scale score, amputation type, associated injuries, limb salvage rate, operative procedures, mortality, and disposition. Elevated alcohol levels and prior psychiatric diagnoses were present in 39 per cent and 17 per cent of the patients, respectively. Patients were stable on admission with a mean systolic blood pressure of 114 mmHg, hematocrit of 32, and Glasgow Coma Scale score range of 13 to 15. The most common amputation was below knee, and patients underwent an average of three operative procedures. Limb salvage was attempted in eight patients with no successes. Amputation wound infection rate was 32 per cent and mortality rate was 5 per cent. Victims of subway trauma who arrive at the hospital with devastating amputations have an excellent chance of surviving to discharge.

Early versus Late Tracheostomy: Is There an Outcome Difference?

2019 ◽  
Vol 85 (4) ◽  
pp. 370-375 ◽  
Author(s):  
Adel Elkbuli ◽  
Raed Ismail Narvel ◽  
Paul J. Spano ◽  
Valerie Polcz ◽  
Astrid Casin ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Glasgow Coma Scale ◽  
Primary Outcome ◽  
Injury Severity ◽  
Future Research ◽  
Trauma Patients ◽  
Early Tracheostomy ◽  
Outcome Difference ◽  
The Impact

The effect of timing in patients requiring tracheostomy varies in the literature. The purpose of this study was to evaluate the impact of early tracheostomy on outcomes in trauma patients with and without traumatic brain injury (TBI). This study is a four-year review of trauma patients undergoing tracheostomy. Patients were divided into two groups based on TBI/non-TBI. Each group was divided into three subgroups based on tracheostomy timing: zero to three days, four to seven days, and greater than seven days postadmission. TBI patients were stratified by the Glasgow Coma Scale (GCS), and non-TBI patients were stratified by the Injury Severity Score (ISS). The primary outcome was ventilator-free days (VFDs). Significance was defined as P < 0.05. Two hundred eighty-nine trauma patients met the study criteria: 151 had TBI (55.2%) versus 138 (47.8%) non-TBI. There were no significant differences in demographics within and between groups. In TBI patients, statistically significant increases in VFDs were observed with GCS 13 to 15 for tracheostomies performed in four to seven versus greater than seven days ( P = 0.005). For GCS <8 and 8 to 12, there were significant increases in VFDs for tracheostomies performed at days 1 to 3 and 4 to 7 versus greater than seven days (P << 0.05 for both). For non-TBI tracheostomies, only ISS ≥ 25 with tracheostomies performed at zero to three days versus greater than seven days was associated with improved VFDs. Early tracheostomies in TBI patients were associated with improved VFDs. In trauma patients with no TBI, early tracheostomy was associated with improved VFDs only in patients with ISS ≥ 25. Future research studies should investigate reasons TBI and non-TBI patients may differ.

Effects of subcutaneous esketamine on blood pressure and heart rate in treatment-resistant depression

2020 ◽  
Vol 34 (10) ◽  
pp. 1155-1162
Author(s):  
Lorena Catarina Del Sant ◽  
Luciana Maria Sarin ◽  
Eduardo Jorge Muniz Magalhães ◽  
Ana Cecília Lucchese ◽  
Marco Aurélio Tuena ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Heart Rate ◽  
Vital Signs ◽  
Response To Treatment ◽  
Treatment Resistant Depression ◽  
Treatment Resistant ◽  
Post Dose ◽  
Before And After ◽  
Resistant Depression ◽  
The Impact

Introduction and objectives: The impact of multiple subcutaneous (s.c.) esketamine injections on the blood pressure (BP) and heart rate (HR) of patients with unipolar and bipolar treatment-resistant depression (TRD) is poorly understood. This study aimed to assess the cardiovascular safety of multiple s.c. doses of esketamine in patients with TRD. Methods: Seventy TRD patients received 394 weekly s.c. esketamine injections in conjunction with oral antidepressant therapy for up to six weeks. Weekly esketamine doses were 0.5, 0.75 or 1.0 mg/kg according to each patient’s response to treatment. Participants were monitored before each treatment and every 15 minutes thereafter for 120 minutes. We assessed systolic blood pressure (SBP), diastolic blood pressure (DBP), and HR measurements for the entire treatment course. Results: BP increased after the first s.c. esketamine injection, reaching maximum mean SBP/DBP levels of 4.87/5.54 mmHg within 30–45 minutes. At the end of monitoring, 120 minutes post dose, vital signs returned to pretreatment levels. We did not detect significant differences in BP between doses of 0.5, 0.75, and 1 mg/kg esketamine. Mean HR did not differ significantly between doses or before and after s.c. esketamine injection. Conclusions: The BP changes observed with repeated s.c. esketamine injections were mild and well tolerated for doses up to 1 mg/kg. The s.c. route is a simple and safe method of esketamine administration, even for patients with clinical comorbidities, including obesity, hypertension, diabetes, and dyslipidemia. However, 14/70 patients experienced treatment-emergent transient hypertension (SBP >180 mmHg and/or a DBP >110 mmHg). Therefore, we strongly recommend monitoring BP for 90 minutes after esketamine dosing. Since s.c. esketamine is cheap, requires less frequent dosing (once a week), and is a simpler procedure compared to intravenous infusions, it might have an impact on public health.

scholarly journals P136: What happens to bypassed trauma patients meeting Field Trauma Triage standards?

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S113-S113
Author(s):  
M. Austin ◽  
J. Sinclair ◽  
S. Leduc ◽  
S. Duncan ◽  
J. Rouleau ◽  
...  
Keyword(s):  
Orthopedic Surgery ◽  
Motor Vehicle ◽  
Vital Signs ◽  
Trauma Patients ◽  
Level Of Consciousness ◽  
Control And Prevention ◽  
Ct Head ◽  
Trauma Triage ◽  
Record Review ◽  
The Impact

Introduction: Prehospital field trauma triage (FTT) standards were reviewed and revised in 2014 based on the recommendations of the Centers for Disease Control and Prevention. The FTT standard allows a hospital bypass and direct transport, within 30 min, to a lead trauma hospital (LTH). Our objectives were to assess the impact of the newly introduced prehospital FTT standard and to describe the emergency department (ED) management and outcomes of patients that had bypassed closer hospitals. Methods: We conducted a 12-month multi-centred health record review of paramedic and ED records following the implementation of the 4 step FTT standard (step 1: vital signs and level of consciousness (physiologic), step 2: anatomical injury, step 3: mechanism and step 4: special considerations) in nine paramedic services across Eastern Ontario. We included adult trauma patients transported as urgent that met FTT standard, regardless of transport time. We developed and piloted a data collection tool and obtained consensus on all definitions. The primary outcome was the rate of appropriate triage to a LTH which was defined as: ISS ≥12, admitted to intensive care unit (ICU), non-orthopedic surgery, or death. We have reported descriptive statistics. Results: 570 patients were included: mean age 48.8, male 68.9%, falls 29.6%, motor vehicle collisions 20.2%, stab wounds 10.5%, transported to a LTH 76.5% (n = 436). 72.2% (n = 315) of patients transported to a LTH had bypassed a closer hospital and 126/306 (41.2%) of those were determined to be an appropriate triage to LTH (9 patients had missing outcomes). ED management included: CT head/cervical spine 69.9%, ultrasound 53.6%, xray 51.6%, intubation 15.0%, sedation 11.1%, tranexamic acid 9.8%, blood transfusion 8.2%, fracture reduction 6.9%, tube thoracostomy 5.9%. Outcomes included: ISS ≥ 12 32.7%, admitted to ICU 15.0%, non-orthopedic surgery 11.1%, death 8.8%. Others included: admission to hospital 57.5%, mean LOS 12.8 days, orthopedic surgery 16.3% and discharged from ED 37.3%. Conclusion: Despite a high number of admissions, the majority of trauma patients bypassed to a LTH were considered over-triaged, with a low number of ED procedures and non-orthopedic surgeries. Continued work is needed to appropriately identify patients requiring transport to a LTH.

Mortality Risk Stratification in Elderly Trauma Patients Based on Initial Arterial Lactate and Base Deficit Levels

2011 ◽  
Vol 77 (10) ◽  
pp. 1337-1341 ◽  
Author(s):  
Angela L. Neville ◽  
Denis Nemtsev ◽  
Raed Manasrah ◽  
Scott D. Bricker ◽  
Brant A. Putnam
Keyword(s):  
Blood Pressure ◽  
Risk Stratification ◽  
Systolic Blood Pressure ◽  
Vital Signs ◽  
Base Deficit ◽  
Trauma Patients ◽  
Arterial Lactate ◽  
Urban Level ◽  
Level I ◽  
Elderly Trauma Patients

Elderly trauma patients have worse outcomes than their younger counterparts. Early risk stratification remains difficult, particularly because traditional vital signs are less reliable. We hypothesized that arrival lactate and base deficit (BD) could be used to predict mortality in elderly trauma patients with a normal admission blood pressure. We retrospectively evaluated the prospectively collected trauma registry at our urban Level I trauma center between 2003 and 2009. Patients sustaining blunt trauma, age 55 years or older, with a systolic blood pressure 90 mmHg or higher, and who had arterial lactate and/or BD measured within 4 hours of arrival comprised the study group. Primary outcomes were in-hospital and 24-hour mortality. There were 364 patients with a lactate and 324 with a BD drawn. Patients with a lactate 2.5 mmol or greater were 3.7 times more likely to die than those with a lactate less than 2.5 mmol (95% CI, 1.6 to 8.2; P = 0.0018). The OR for mortality was 5.2 (95% CI, 2.5 to 11.2; P < 0.0001) in patients with a BD -4 or less. Elevated lactate and BD were even stronger predictors of early mortality (within first 24 hours). After increasing the hypotension threshold to a systolic blood pressure 110 mmHg or greater, lactate and BD remained highly predictive of in-hospital and 24-hour mortality.

Sign in / Sign up

Export Citation Format

Share Document