scholarly journals Registry-Based Mortality Analysis Reveals a High Proportion of Patient Decrees and Presumed Limitation of Therapy in Severe Geriatric Trauma

2020 ◽  
Vol 9 (9) ◽  
pp. 2686 ◽  
Author(s):  
Cora Rebecca Schindler ◽  
Mathias Woschek ◽  
René Danilo Verboket ◽  
Ramona Sturm ◽  
Nicolas Söhling ◽  
...  
Keyword(s):  
Brain Injuries ◽  
Injury Severity ◽  
Geriatric Trauma ◽  
Hospital Treatment ◽  
Trauma Patients ◽  
Severely Injured ◽  
Severely Injured Patients ◽  
Initial Care ◽  
Limitation Of Therapy ◽  
Injured Patients

Background: The treatment of severely injured patients, especially in older age, is complex, and based on strict guidelines. Methods: We conducted a retrospective study by analyzing our internal registry for mortality risk factors in deceased trauma patients. All patients that were admitted to the trauma bay of our level-1-trauma center from 2014 to 2018, and that died during the in-hospital treatment, were included. The aim of this study was to carry out a quality assurance concerning the initial care of severely injured patients. Results: In the 5-year period, 135 trauma patients died. The median (IQR) age was 69 (38–83) years, 71% were male, and the median (IQR) Injury Severity Score (ISS) was 25 (17–34) points. Overall, 41% of the patients suffered from severe traumatic brain injuries (TBI) (AIShead ≥ 4 points). For 12.7%, therapy was finally limited owing to an existing patient’s decree; in 64.9% with an uncertain prognosis, a ‘therapia minima’ was established in consensus with the relatives. Conclusion: Although the mortality rate was primarily related to the severity of the injury, a significant number of deaths were not exclusively due to medical reasons, but also to a self-determined limitation of therapy for severely injured geriatric patients. The conscientious documentation concerning the will of the patient is increasingly important in supporting medical decisions.

Delays in Transfer of Elderly Less-injured Trauma Patients Can Have Deadly Consequences

2014 ◽  
Vol 80 (11) ◽  
pp. 1132-1135 ◽  
Author(s):  
Peter E. Fischer ◽  
Paul D. Colavita ◽  
Gregory P. Fleming ◽  
Toan T. Huynh ◽  
A. Britton Christmas ◽  
...  
Keyword(s):  
Trauma Center ◽  
Injury Severity ◽  
Trauma Patients ◽  
Severely Injured ◽  
Severely Injured Patients ◽  
Local Trauma ◽  
Level 1 ◽  
Poor Outcomes ◽  
Injured Patients ◽  
Level 1 Trauma Center

Transfer of severely injured patients to regional trauma centers is often expedited; however, transfer of less-injured, older patients may not evoke the same urgency. We examined referring hospitals’ length of stay (LOS) and compared the subsequent outcomes in less-injured transfer patients (TP) with patients presenting directly (DP) to the trauma center. We reviewed the medical records of less-injured (Injury Severity Score [ISS] 9 or less), older (age older than 60 years) patients transferred to a regional Level 1 trauma center to determine the referring facility LOS, demographics, and injury information. Outcomes of the TP were then compared with similarly injured DP using local trauma registry data. In 2011, there were 1657 transfers; the referring facility LOS averaged greater than 3 hours. In the less-injured patients (ISS 9 or less), the average referring facility LOS was 3 hours 20 minutes compared with 2 hours 24 minutes in more severely injured patients (ISS 25 or greater, P < 0.05). The mortality was significantly lower in the DP patients (5.8% TP vs 2.6% DP, P = 0.035). Delays in transfer of less-injured, older trauma patients can result in poor outcomes including increased mortality. Geographic challenges do not allow for every patient to be transported directly to a trauma center. As a result, we propose further outreach efforts to identify potential causes for delay and to promote compliance with regional referral guidelines.

scholarly journals Malnutrition and its effects in severely injured trauma patients

2020 ◽  
Vol 46 (5) ◽  
pp. 993-1004 ◽  
Author(s):  
Suzan Dijkink ◽  
Karien Meier ◽  
Pieta Krijnen ◽  
D. Dante Yeh ◽  
George C. Velmahos ◽  
...  
Keyword(s):  
Nutritional Status ◽  
Adverse Outcomes ◽  
Hospital Length Of Stay ◽  
Geriatric Trauma ◽  
Trauma Patients ◽  
Severely Injured ◽  
Severely Injured Patients ◽  
Trauma Population ◽  
Injured Patients

Abstract Purpose In hospitalized patients, malnutrition is associated with adverse outcomes. However, the consequences of malnutrition in trauma patients are still poorly understood. This study aims to review the current knowledge about the pathophysiology, prevalence, and effects of malnutrition in severely injured patients. Methods A systematic literature review in PubMed and Embase was conducted according to PRISMA-guidelines. Results Nine review articles discussed the hypermetabolic state in severely injured patients in relation to malnutrition. In these patients, malnutrition negatively influenced the metabolic response, and vice versa, thereby rendering them susceptible to adverse outcomes and further deterioration of nutritional status. Thirteen cohort studies reported on prevalences of malnutrition in severely injured patients; ten reported clinical outcomes. In severely injured patients, the prevalence of malnutrition ranged from 7 to 76%, depending upon setting, population, and nutritional assessment tool used. In the geriatric trauma population, 7–62.5% were malnourished at admission and 35.6–60% were at risk for malnutrition. Malnutrition was an independent risk factor for complications, mortality, prolonged hospital length of stay, and declined quality of life. Conclusions Despite widespread belief about the importance of nutrition in severely injured patients, the quantity and quality of available evidence is surprisingly sparse, frequently of low-quality, and outdated. Based on the malnutrition-associated adverse outcomes, the nutritional status of trauma patients should be routinely and carefully monitored. Trials are required to better define the optimal nutritional treatment of trauma patients, but a standardized data dictionary and reasonable outcome measures are required for meaningful interpretation and application of results.

scholarly journals Impact of Trauma Center Care on Mortality in Gangwon Province in Korea 

2020 ◽  
Author(s):  
GYOJIN AN ◽  
Yoon-Seop Kim ◽  
Hye Sim Kim ◽  
Chan Young Kang ◽  
Sung Oh Hwang ◽  
...  
Keyword(s):  
Propensity Score ◽  
Propensity Score Matching ◽  
Trauma Center ◽  
Injury Severity ◽  
Trauma Patients ◽  
Severely Injured ◽  
Trauma Centers ◽  
Severely Injured Patients ◽  
Risk Of Mortality ◽  
Injured Patients

Abstract Background: Al though controversial, there has been a consensus that compared with non-regional trauma centers, regional trauma centers have survival benefits. In a predominantly rural province with a single regional trauma center, we compared the in-hospital mortality of all trauma patients and severely injured patients between regional and non-regional trauma centers.Methods: Using data extracted from the National Emergency Department Information System in Korea, we examined all trauma patients who visited emergency departments in Gangwon province between January 2015 and December 2017. The International Classification of Disease-Based Injury Severity Score (ICISS) was used to categorize the severity of the patients. Propensity score matching was used for balancing the severity between the two groups.Results: Of 23,510 trauma patients, 2,857 and 20,653 were treated in regional and non-regional trauma centers, respectively. After propensity score matching, all patients in the non-regional trauma center group had a 6.27-fold higher risk of mortality than those in the regional trauma center group; severely injured patients—defined as those with ICISS < 0.9—in the non-regional trauma center group had a 4.90-fold higher risk of mortality than those in the regional trauma center group. ICISS cutoff values for mortality were 0.9015 and 0.8737 for the non-regional and regional trauma center groups, respectively.Conclusion: Conventional paradigms of trauma systems can be used in predominantly rural Korean provinces, because trauma care in regional trauma centers conferred better survival benefits than that in non-regional trauma centers. Additionally, severely injured patients should be transported to regional trauma centers from the trauma scene.

Trauma in pregnancy: A review of the Pennsylvania Trauma Systems Foundation database

Trauma ◽  
2017 ◽  
Vol 20 (1) ◽  
pp. 30-37 ◽  
Author(s):  
Meike Schuster ◽  
Natasha Becker ◽  
Amanda Young ◽  
Michael J Paglia ◽  
A Dhanya Mackeen
Keyword(s):  
Blunt Trauma ◽  
Motor Vehicle ◽  
Penetrating Trauma ◽  
Blunt Injury ◽  
Trauma Patients ◽  
Severely Injured ◽  
Trauma Systems ◽  
Severely Injured Patients ◽  
Vaginal Deliveries ◽  
Injured Patients

Objective The goal of this study is to determine if injury severity score (ISS) of ≥9 and systolic blood pressure (SBP) predict poor maternal/pregnancy outcomes in blunt and penetrating trauma, respectively. Methods The Pennsylvania Trauma Systems Foundation database was used to identify pregnant trauma patients. Blunt trauma patients were analyzed with regard to ISS, while penetrating trauma patients were analyzed to determine whether SBP < 90 mmHg was predictive of poor maternal outcome. Results Patients with severe blunt injury (ISS ≥ 9) due to motor vehicle accident were less likely to wear seatbelts (51% vs. 63%, p = 0.005), and delivery was required in 17% of these patients as compared to 6% of the less severely injured, and only 6% of those were vaginal deliveries. Severely injured patients were discharged home 68% of the time and 6% died compared to less severely injured patients of which 83% were discharged home and <1% died; all other patients required discharge to a rehabilitation facility. Patients with penetrating trauma and SBP < 90 mmHg on arrival were more likely to require delivery (35% vs. 5%, p < 0.001) and were 14 times more likely to die (58% vs. 4%, p < 0.001) when compared to the normotensive group. Conclusion ISS ≥ 9 and SBP < 90 mmHg are predictors for poor outcomes after trauma during pregnancy. Severely injured blunt trauma patients often require surgery and delivery. Patients who present with SBP < 90 after penetrating trauma are more likely to deliver and are 14 times more likely to die.

Vasopressor Use during Emergency Trauma Surgery

2014 ◽  
Vol 80 (5) ◽  
pp. 472-478 ◽  
Author(s):  
Robert M. Van Haren ◽  
Chad M. Thorson ◽  
Evan J. Valle ◽  
Gerardo A. Guarch ◽  
Jassin M. Jouria ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Mortality Rate ◽  
Odds Ratio ◽  
Injury Severity ◽  
Trauma Surgery ◽  
Vital Signs ◽  
Severely Injured ◽  
Severely Injured Patients ◽  
Vasopressor Use ◽  
Injured Patients

Most evidence suggests early vasopressor use is associated with death after trauma, but no previous study has focused on patients requiring emergency operative intervention (OR). We test the hypothesis that vasopressors are harmful in this population. Records from 746 patients requiring OR from July 2009 to March 2013 were retrospectively reviewed and stratified based on vasopressor use (epinephrine [EPI], phenylephrine, ephedrine, norepinephrine, dobutamine, vasopressin) or no vasopressor use. Vasopressors were administered to 225 patients (30%) during OR; 59 patients (8%) received multiple vasopressors. Patients who received vasopressors were older, more severely injured, had worse vital signs, and increased mortality rate (all P < 0.001). EPI was independently associated with mortality (odds ratio, 6.88; P = 0.001). If patients who received EPI were excluded, there was no difference in mortality between those who received vasopressors alone or in combination and those that did not (5 vs 6%, P = 0.523), although multiple markers of injury severity were worse. We conclude that vasopressor use is relatively common in the most severely injured patients requiring OR and is associated with mortality. EPI is most often used for cardiac arrest, whereas other vasopressors are used for their vasoconstrictive properties. This suggests that, except for EPI, vasopressors during OR are not independently associated with mortality.

scholarly journals Evidence of Prolonged Monitoring of Trauma Patients Admitted via Trauma Resuscitation Unit without Primary Proof of Severe Injuries

2020 ◽  
Vol 9 (8) ◽  
pp. 2516 ◽  
Author(s):  
Martin Heinrich ◽  
Matthias Lany ◽  
Lydia Anastasopoulou ◽  
Christoph Biehl ◽  
Gabor Szalay ◽  
...  
Keyword(s):  
Injury Severity ◽  
Treatment Completion ◽  
Trauma Patients ◽  
Trauma Resuscitation ◽  
Abbreviated Injury Scale ◽  
Severely Injured Patients ◽  
Severe Injuries ◽  
Level I ◽  
Evidence Based Guidelines ◽  
Injured Patients

Introductio: Although management of severely injured patients in the Trauma Resuscitation Unit (TRU) follows evidence-based guidelines, algorithms for treatment of the slightly injured are limited. Methods: All trauma patients in a period of eight months in a Level I trauma center were followed. Retrospective analysis was performed only in patients ≥18 years with primary TRU admission, Abbreviated Injury Scale (AIS) ≤ 1, Maximum Abbreviated Injury Scale (MAIS) ≤ 1 and Injury Severity Score (ISS) ≤3 after treatment completion and ≥24 h monitoring in the units. Cochran’s Q-test was used for the statistical evaluation of AIS and ISS changes in units. Results: One hundred and twelve patients were enrolled in the study. Twenty-one patients (18.75%) reported new complaints after treatment completion in the TRU. AIS rose from the Intermediate Care Unit (IMC) to Normal Care Unit (NCU) 6.2% and ISS 6.9%. MAIS did not increase >2, and no intervention was necessary for any patient. No correlation was found between computed tomography (CT) diagnostics in TRU and AIS change. Conclusions: The data suggest that AIS, MAIS and ISS did not increase significantly in patients without a severe injury during inpatient treatment, regardless of the type of CT diagnostics performed in the TRU, suggesting that monitoring of these patients may be unnecessary.

scholarly journals Loss of GPVI and GPIbα contributes to trauma-induced platelet dysfunction in severely injured patients

2020 ◽  
Vol 4 (12) ◽  
pp. 2623-2630 ◽  
Author(s):  
Paul Vulliamy ◽  
Samantha J. Montague ◽  
Scarlett Gillespie ◽  
Melissa V. Chan ◽  
Lucy A. Coupland ◽  
...  
Keyword(s):  
Patient Characteristics ◽  
Surface Expression ◽  
Trauma Patients ◽  
Severely Injured ◽  
Platelet Dysfunction ◽  
Severely Injured Patients ◽  
Severe Injuries ◽  
Glycoprotein Vi ◽  
Active Hemorrhage ◽  
Injured Patients

Abstract Trauma-induced coagulopathy (TIC) is a complex, multifactorial failure of hemostasis that occurs in 25% of severely injured patients and results in a fourfold higher mortality. However, the role of platelets in this state remains poorly understood. We set out to identify molecular changes that may underpin platelet dysfunction after major injury and to determine how they relate to coagulopathy and outcome. We performed a range of hemostatic and platelet-specific studies in blood samples obtained from critically injured patients within 2 hours of injury and collected prospective data on patient characteristics and clinical outcomes. We observed that, although platelet counts were preserved above critical levels, circulating platelets sampled from trauma patients exhibited a profoundly reduced response to both collagen and the selective glycoprotein VI (GPVI) agonist collagen-related peptide, compared with those from healthy volunteers. These responses correlated closely with overall clot strength and mortality. Surface expression of the collagen receptors GPIbα and GPVI was reduced on circulating platelets in trauma patients, with increased levels of the shed ectodomain fragment of GPVI detectable in plasma. Levels of shed GPVI were highest in patients with more severe injuries and TIC. Collectively, these observations demonstrate that platelets experience a loss of GPVI and GPIbα after severe injury and translate into a reduction in the responsiveness of platelets during active hemorrhage. In turn, they are associated with reduced hemostatic competence and increased mortality. Targeting proteolytic shedding of platelet receptors is a potential therapeutic strategy for maintaining hemostatic competence in bleeding and improving the efficacy of platelet transfusions.

Influence of late fluid management on the outcomes of severe trauma patients: A retrospective analysis of 294 severely-injured patients

Injury ◽  
2017 ◽  
Vol 48 (9) ◽  
pp. 1964-1971 ◽  
Author(s):  
Mehdi Mezidi ◽  
Mehdi Ould-Chikh ◽  
Pauline Deras ◽  
Camille Maury ◽  
Orianne Martinez ◽  
...  
Keyword(s):  
Retrospective Analysis ◽  
Fluid Management ◽  
Severe Trauma ◽  
Trauma Patients ◽  
Severely Injured ◽  
Severely Injured Patients ◽  
Injured Patients

Despite Trauma Center Closures, Trauma System Regionalization Reduces Mortality and Time to Definitive Care in Severely Injured Patients

2017 ◽  
Vol 83 (6) ◽  
pp. 591-597 ◽  
Author(s):  
Jack C. He ◽  
David Schechtman ◽  
Debra L. Allen ◽  
Jillian J. Cremona ◽  
Jeffrey A. Claridge
Keyword(s):  
Median Time ◽  
Injury Severity ◽  
Trauma System ◽  
Relative Reduction ◽  
Severely Injured ◽  
Severely Injured Patients ◽  
Trauma Outcomes ◽  
Hospital Systems ◽  
Injured Patients ◽  
Patient Subgroups

The Northern Ohio Trauma System (NOTS), consisting of multiple hospital systems, was established in 2010 to improve trauma outcomes. This study assessed its impact on mortality and time to definitive care, focusing especially on the severely injured patients. NOTS trauma registry was queried for all trauma activations from 2008 to 2013. The years between 2008–2009 and 2011–2013 were designated as pre- and post-NOTS, respectively. Data from 2010 was excluded as a transitional year. Two trauma centers (TCs) closed in 2010. Predetermined patient subgroups were analyzed. A total of 27,843 patients were examined. Mean age was 46 and 64 per cent were male. Median Injury Severity Score (ISS) was five, and 87 per cent sustained blunt injuries. Of these, 10,641 patients were pre-NOTS and 17,202 were post-NOTS. Comparing the two groups, mortality decreased from 5 to 4 per cent post-NOTS (P < 0.001); median time to definitive care increased by 12 minutes post-NOTS. Multivariate logistic regression showed that NOTS implementation was an independent predictor for survival (P = 0.008), whereas time to definitive care was not. Subgroup analyses demonstrated mortality reductions post-NOTS for all subgroups except patients with penetrating injuries, where mortality remained the same despite an increase in ISS. Patients with ISS ≥15 had a 23 per cent relative reduction in mortality, and their median time to definitive care decreased by 12 minutes. Implementation of a collaborative, regional trauma system was associated with mortality reduction and shortened time to definitive care in the severely injured patients. These findings highlight the importance of collaboration in the future development of regional trauma systems.

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