Pediatric blunt trauma: a retrospective analysis in a Level I trauma center

This study consisted of an 8-year retrospective trauma registry analysis of blunt trauma and comprised of 2458 children (<18 years of age) and 4568 adults (18-64 years of age). Falls and motor vehicular crashes were seen in 30.4 per cent (749) and 23 per cent (566) of children, and 25.4 per cent (1158) and 41.9 per cent (1914) of adults. Children had a higher mean revised trauma score (7.69 vs 7.66) and Glasgow Coma Score (14.5 vs 14.3), and a lower Injury Severity Score (ISS; 6.68 vs 7.83 and hospital length of stay (2.8 vs 3.8 days) with P < 0.05. Overall mortality was 1.3 per cent in children and 1.9 per cent in adults (P = 0.05). Pedestrian accidents resulted in a 3.8 per cent (6/161) mortality rate. Pediatric nonsurvivors had a 6.4-fold higher ISS than survivors compared with a 5.2-fold increase in adults. Mortality progressively increased with higher ISS; 0.09 per cent in <15, 1.3 per cent, in 15 to 24, and 17 per cent in children with > or = 25 ISS. Mortality in multiple chest injuries was 19 per cent. The presence of chest trauma resulted in a 46-fold higher mortality in children. Most lethal injuries were combined head, chest, and abdomen trauma with a 25 per cent mortality in children and 28 per cent in adults. Admission Glasgow Coma Score <9 and systolic blood pressure below 100 mm Hg carried high mortality: 39 and 6 per cent in children vs 31 and 24 per cent in adults. Ninety-seven per cent of children and 89 per cent of adults were discharged home.     

Trauma in cirrhotics: survival and hospital sequelae in patients requiring abdominal exploration

Hepatic cirrhosis significantly increases the mortality and morbidity of elective surgery; therefore we hypothesized that cirrhosis would adversely impact outcome after abdominal trauma. We used the trauma registry to identify 17 patients with cirrhosis who sustained trauma injuries requiring emergent exploratory laparotomy. Patients were characterized with respect to age, sex, hospital days, intensive care unit days, and trauma scores. A control group (n = 73) was constructed from the registry by matching age, sex, Injury Severity Score (ISS) and Abbreviated Injury score. Mortality rates were compared by Fisher's exact test and age, ISS, Revised Trauma Score 2, and hospital and intensive care unit days were compared by Student's t test. Despite similar ISS between cirrhotic patients and controls, patients with cirrhosis had a fourfold increase in mortality (mortality odds ratio = 7.2; 95% confidence interval = 2.2-24.0). Cirrhotic trauma patients had a complication rate of 71 per cent and a mortality of 44 per cent. We conclude that cirrhosis is a major independent risk factor for mortality in trauma patients with injuries that require emergent abdominal surgery.     

Effect on outcome of early intensive management of geriatric trauma patients

BACKGROUND: Despite significant injuries elderly patients (aged 70 years or more) often do not exhibit any of the standard physiological criteria for trauma team activation (TTA), i.e. hypotension, tachycardia or unresponsiveness to pain. As a result of these findings the authors' TTA criteria were modified to include age 70 years or more, and a protocol of early aggressive monitoring and resuscitation was introduced. The aim of the present study was to assess the effect of the new policy on outcome. METHODS: This trauma registry study included patients aged 70 years or more with an Injury Severity Score (ISS) greater than 15 who were admitted over a period of 8 years and 8 months. The patients were divided into two groups: group 1 included patients admitted before age 70 years and above became a TTA criterion and group 2 included patients admitted during the period when age 70 years or more was a TTA criterion and the new management protocol was in place. The two groups were compared with regard to survival, functional status on discharge and hospital charges. RESULTS: There were 336 trauma patients who met the criteria, 260 in group 1 and 76 in group 2. The two groups were similar with respect to mechanism of injury, age, gender, ISS and body area Abbreviated Injury Score. The mortality rate in group 1 was 53.8 per cent and that in group 2 was 34.2 per cent (P = 0.003) (relative risk (RR) 1.57 (95 per cent confidence interval 1.13 to 2.19)). The incidence of permanent disability in the two groups was 16.7 and 12.0 per cent respectively (P = 0.49) (RR 1.39 (0.59 to 3.25)). In subgroups of patients with an ISS of more than 20 the mortality rate was 68.4 and 46.9 per cent in groups 1 and 2 respectively (P = 0.01) (RR 1.46 (1.06 to 2.00)); 12 of 49 survivors in group 1 and two of 26 in group 2 suffered permanent disability (P = 0.12) (RR 3.18 (0.77 to 13.20)). CONCLUSION: Activation of the trauma team and early intensive monitoring, evaluation and resuscitation of geriatric trauma patients improves survival.     

Is helicopter evacuation effective in rural trauma transport?

Helicopter transport for trauma remains controversial because its appropriate utilization and efficacy with regard to improved survival is unproven. The purpose of this study was to assess rural trauma helicopter transport utilization and effect on patient survival. A retrospective chart review over a 2-year period (2007-2008) was performed of all rural helicopter and ground ambulance trauma patient transports to an urban Level I trauma center. Data was collected with regard to patient mortality and Injury Severity Score (ISS). Miles to the Level I trauma center were calculated from the point where helicopter or ground ambulance transport services initiated contact with the patient to the Level I trauma center. During the 2-year period, 1443 rural trauma patients were transported by ground ambulance and 1028 rural trauma patients were transported by helicopter. Of the patients with ISS of 0 to 10, 471 patients were transported by helicopter and 1039 transported by ground. There were 465 (99%) survivors with ISS 0 to 10 transported by helicopter with an average transport distance of 34.6 miles versus 1034 (99.5%) survivors with ISS 0 to 10 who were transported by ground an average of 41.0 miles. Four hundred and twenty-one patients with ISS 11 to 30 were transported by helicopter an average of 33.3 miles with 367 (87%) survivors versus a 95 per cent survival in 352 patients with ISS 11 to 30 who were transported by ground an average of 39.9 miles. One hundred and thirty-six patients with ISS > 30 were transported by helicopter an average of 32.8 miles with 78 (57%) survivors versus a 69 per cent survival in 52 patients with ISS > 30 who were transported by ground an average of 33.0 miles. Helicopter transport does not seem to improve survival in severely injured (ISS > 30) patients. Helicopter transport does not improve survival and is associated with shorter travel distances in less severely injured (ISS < 10) patients in rural areas. This data questions effective helicopter utilization for trauma patients in rural areas. Further study with regard to helicopter transport effect on patient survival and cost-effective utilization is warranted.     

Age, blood transfusion, and survival after trauma

Blood transfusion affects outcomes after trauma, but whether elderly patients are disproportionately affected remains unknown. To determine the possible interaction between age, packed cell transfusion volume (PCTV), and mortality after injury, we designed a 6-year retrospective review (January 1995 through December 2000) of patients > or = 16 years of age who received blood transfusion within the first 24 hours after injury. One thousand three hundred twelve patients > or = 16 years of age admitted to our trauma center received packed red blood cells in the initial 24 hours after admission. Of the 1312 patients, 1028 (78%) were < or = 55 years and 284 (22%) were > 55 years of age, and overall mortality was 21.2 per cent. Age, Injury Severity Score (ISS) Glasbow Coma Scale (GCS), and PCTV emerged as independent predictors of mortality. PCTV for elderly survivors (4.6 units) was significantly less than that of younger survivors (6.7 units). Furthermore, mean PCTV for all survivors decreased progressively with advancing age. No patient >75 years with a PCTV > 12 units survived. Age and PCTV act independently, yet synergistically to increase mortality following injury.     

A successful multimodality strategy for management of liver injuries

The treatment of liver injuries involves many strategies ranging from observation to operative intervention and includes numerous options such as angiography, packing, and damage-control procedures. In July 1994 we instituted a protocol for the management of traumatic liver injuries. The main objective of this study was to evaluate the management of liver injuries occurring since the institution of the protocol. Two hundred three consecutive adult patients with liver injuries were evaluated at our Level I trauma center between July 1994 and May 1999. Eighty-eight per cent of the injuries were blunt with a mean Injury Severity Score (ISS) of 24.3 +/- 0.8 and a survival probability (Ps) of 90.0 +/- 1.5 per cent. The overall mortality was 6.4 per cent. A comparison between patients with minor liver injuries and patients with more severe injuries [Abbreviated Injury Score (AIS) <3 vs >3] demonstrated no difference in mortality between the two groups despite a Ps of 93.8 +/- 1.3 per cent in patients with an AIS <3 versus 84.1 +/- 3.3 per cent in patients with an AIS >3. The most common complication in our patient population was posthemorrhagic anemia, which was seen in 10.8 per cent of cases. Severity of injury did not result in a significant difference in the complication rate. Patients who underwent laparotomy had a statistically higher ISS, a lower Ps, and a mortality rate of 11.5 per cent compared with 3.7 per cent (P = 0.03) in patients managed nonoperatively. However, a comparison of patients undergoing laparotomy with those who did not and who had equivalent ISS demonstrated no difference in mortality. Our results demonstrated that a preplanned management strategy was a successful way in which to treat patients with traumatic liver injuries. Although nonoperative management of liver injuries has been common practice a management plan that involves a multimodal surgical strategy is essential.     

Trauma in nonagenarians and centenarians: review of 137 consecutive patients

The purpose of this study was to examine the hospital course and outcomes of elderly trauma patients. We accomplished a retrospective review of all consecutive trauma patients admitted to a level II trauma center from January 2000 to April 2002. Gender, Injury Severity Score (ISS), length of stay (LOS), operative procedure, morbidity, and mortality of patients > or = 90 years of age were compared with younger patients. Of 2645 trauma admissions, 137 patients (5%) were > or = 90 years (range, 90 to 108 years; mean, 93.1 years); 5 patients were > or = 100 years. One hundred eleven (81%) patients were female; 26 (19%) male. Average ISS for patients > or = 90 was 8.75 and was 7.78 for younger patients. One hundred sixteen elderly patients (85%) had ISS < 15. Falls were the most common mechanism of injury (93%), usually ground-level falls (64%). Two hundred ninety-two injuries included 133 fractures and 102 soft tissue injuries. Thirty-four elderly patients (25%) and 733 younger patients (29%) required surgery. Complications developed in 8 per cent of older and 6 per cent of younger patients. Hospital LOS averaged 4.36 days for older and 3.51 days for younger patients. Six older (4.4%) and 63 younger (2.5%) patients died. ISS scores and LOS were slightly higher in elderly patients, but morbidity and mortality were comparable in both groups.     

How we die: the impact of nonneurologic organ dysfunction after severe traumatic brain injury

Although nonneurologic organ dysfunction (NNOD) has been shown to significantly affect mortality in subarachnoid hemorrhage, the contribution of NNOD to mortality after severe traumatic brain injury (TBI) has yet to be defined. We hypothesized that NNOD has a significant impact on mortality after severe TBI. The trauma registry was queried for all patients admitted between January 2004 and December 2004 who died during their initial hospitalization after severe TBI (head Abbreviated Injury Score 3 or greater). Cause of death and contributing factors to mortality were determined by an attending trauma surgeon from the medical record. The data were analyzed using both Fisher's exact and Wilcoxon rank sum. One hundred thirty-five patients met inclusion criteria. Sixty-seven per cent were males, 83 per cent were white, and the mean age was 38.5 years. Mean length of stay was 2.9 days. Fifty-four patients (40%) had isolated TBI (chest Abbreviated Injury Score = 0, abdominal Abbreviated Injury Score = 0). Of the 81 deaths attributed to a single cause, 48 (60%) patients died from nonsurvivable TBI or brain death, whereas 33 (40%) died of a nonneurologic cause. Cardiovascular and respiratory dysfunction (excluding pneumonia) contributed to mortality in 51.1 per cent and 34.1 per cent of patients, respectively. NNOD contributes to approximately two-thirds of all deaths after severe TBI. These complications occur early and are seen even among those with isolated head injuries. These findings demonstrate the impact of the extracranial manifestations of severe TBI on overall mortality and highlight potential areas for future intervention and research.     

Trauma in the elderly: intensive care unit resource use and outcome

BACKGROUND: As the population ages, the elderly will constitute a prominent proportion of trauma patients. The elderly suffer more severe consequences from traumatic injuries compared with the young, presumably resulting in increased resource use. In this study, we sought to examine ICU resource use in trauma on the basis of age and injury severity. METHODS: This study was a retrospective review of trauma registry data prospectively collected on 26,237 blunt trauma patients admitted to all trauma centers (n = 26) in one state over 24 months (January 1996-December 1997). Age-dependent and injury severity-dependent differences in mortality, ICU length of stay (LOS), and hospital LOS were evaluated by logistic regression analysis. RESULTS: Elderly (age > or = 65 years, n = 7,117) patients had significantly higher mortality rates than younger (age < 65 years) trauma patients after stratification by Injury Severity Score (ISS), Revised Trauma Score, and other preexisting comorbidities. Age > 65 years was associated with a two- to threefold increased mortality risk in mild (ISS < 15, 3.2% vs. 0.4%; < 0.001), moderate (ISS 15-29, 19.7% vs. 5.4%; < 0.001), and severe traumatic injury (ISS > or = 30, 47.8% vs. 21.7%; < 0.001) compared with patients aged < 65 years. Logistic regression analysis confirmed that elderly patients had a nearly twofold increased mortality risk (odds ratio, 1.87; confidence interval, 1.60-2.18; < 0.001). Elderly patients also had significantly longer hospital LOS after stratifying for severity of injury by ISS (1.9 fewer days in the age 18-45 group, 0.89 fewer days in the age 46-64 group compared with the age > or = 65 group). Mortality rates were higher for men than for women only in the ISS < 15 (4.4% vs. 2.6%, < 0.001) and ISS 15 to 29 (21.7% vs. 17.6%, = 0.031) groups. ICU LOS was significantly decreased in elderly patients with ISS > or = 30. CONCLUSION: Age is confirmed as an independent predictor of outcome (mortality) in trauma after stratification for injury severity in this largest study of elderly trauma patients to date. Elderly patients with severe injury (ISS > 30) have decreased ICU resource use secondary to associated increased mortality rates.     

Geriatric falls: injury severity is high and disproportionate to mechanism

OBJECTIVE: Falls are a well-known source of morbidity and mortality in the elderly. Fall-related injury severity in this group, however, is less clear, particularly as it relates to type of fall. Our purpose is to explore the relationship between mechanism of fall and both pattern and severity of injury in geriatric patients as compared with a younger cohort. METHODS: Our trauma registry was queried for all patients evaluated by the trauma service over a 412-year period (1994-1998). Two cohorts were formed on the basis of age greater than 65 or less than or equal to 65 years and compared as to mechanism, Injury Severity Score (ISS), Abbreviated Injury Scale score, and mortality. RESULTS: Over the study period, 1,512 patients were evaluated, 333 greater than 65 years and 1,179 less than or equal to 65 years of age. Falls were the injury mechanism in 48% of the older group and 7% of the younger group (p < 0.05). Falls in the older group constituted 65% of patients with ISS >15, with 32% of all falls resulting in serious injury (ISS >15). In contrast, falls in the younger group constituted only 11% of ISS >15 patients, with falls causing serious injury only 15% of the time (both p < 0.05). Notably, same-level falls resulted in serious injury 30% of the time in the older group versus 4% in the younger group (p < 0.05), and were responsible for an ISS >15 30-fold more in the older group (31% vs. <1%; p < 0.05). Abbreviated Injury Scale evaluation revealed more frequent head/neck (47% vs. 22%), chest (23% vs. 9%), and pelvic/extremity (27% vs. 15%) injuries in the older group for all falls (all p < 0.05). The mean ISS for same-level falls in the older group was twice that for the younger group (9.28 vs. 4.64, p < 0.05), whereas there was no difference in mean ISS between multilevel and same-level falls within the older group itself (10.12 vs. 9.28, p > 0.05). The fall-related death rate was higher in the older group (7% vs. 4%), with falls seven times more likely to be the cause of death compared with the younger group (55% vs. 7.5%) (both p < 0.05). Same-level falls as a cause of death was 10 times more common in the elderly (25% vs. 2.5%, p < 0.05). CONCLUSION: Falls among the elderly, including same-level falls, are a common source of both high injury severity and mortality, much more so than in younger patients. A different pattern of injury between older and younger fall patients also exists.     

Ten years of mechanical complications of central venous catheterization in trauma patients

The study purpose was to determine the incidence of mechanical complications (MC) associated with central venous catheterization (CVC) and to evaluate their impact on outcomes. This was a retrospective review of trauma morbidity and mortality records at a Level I trauma center (1999 to 2009). Demographics and outcomes were extracted for all trauma patients with CVC. Patients developing MC were compared with those who did not. Four thousand eight hundred eighteen lines were placed in 2935 patients. Of these, 1.5 per cent (n = 73) had MC. A total of 64.4 per cent (n = 47) were pneumothoraces followed by arterial cannulation at 8.2 per cent (n = 6) and thrombosis at 6.8 per cent (n = 5). The rate of MC by access site was: subclavian 1.8 per cent (n = 52), internal jugular 1.2 per cent (n = 10), and femoral 0.3 per cent (n = 3) (P value for trend = 0.001). Change in management was required in 31.5 per cent (n = 23). Number of lines (P < 0.001), Injury Severity Score (P < 0.001), body mass index less than 20 kg/m(2) (P = 0.036), and chest Abbreviated Injury Score greater than 3 (P = 0.034) were significant predictors of MC. Patients with MC had a longer intensive care unit length of stay (18.8 ± 25.7 vs 11.4 ± 13.3; adjusted odds ratio, 5.75; 95% confidence interval, 2.24-9.25; P = 0.001). Incidence of MC was 1.5 per cent. Complications were clinically significant in 31.5 per cent and resulted in longer intensive care unit stays.     

Emergency medical services (EMS) vs non-EMS transport of critically injured patients: a prospective evaluation

BACKGROUND: A previous report of 5,782 trauma patients demonstrated higher mortality among those transported by emergency medical services (EMS) than among their non-EMS-transported counterparts. HYPOTHESIS: Trauma patients who are transported by EMS and those who are not differ in the injury-to-hospital arrival time interval. DESIGN: Prospective cohort-matched observation study. SETTING: Level I trauma center, multidisciplinary study group. PATIENTS: All non-EMS patients were matched with the next appropriate EMS patient by an investigator who was unaware of the outcome and mode of transport. Every 10th EMS patient with an Injury Severity Score (ISS) of 13 or greater was also randomly enrolled. Matching characteristics included age, ISS, mechanism of injury, head Abbreviated Injury Score, and presence of hypotension. An interview protocol was developed to determine the time of injury. Interview responses from patients, witnesses, and friends were combined with data obtained from police, sheriff, and medical examiner reports. MAIN OUTCOME MEASURES: Time to the hospital, mortality, morbidity, and length of stay. RESULTS: A total of 103 patients were enrolled (38 non-EMS, 38 EMS matched, 27 random EMS). Injury time was estimated using all available data made on 100 patients (97%). Independent raters agreed in 81% of cases. Deaths, complications, and length of hospital stay were similar between the EMS- and non-EMS-transported groups. Although time intervals were similar among the groups overall, more critically injured non-EMS patients (ISS > or = 13) got themselves to the trauma center in less time than their EMS counterparts (15 minutes vs 28 minutes; P<.05). CONCLUSIONS: A multidisciplinary approach can be utilized, and an interview protocol created to determine actual time of injury. Critically injured non-EMS-transported patients (ISS > or =13) arrived at the hospital earlier after their injuries.     

Elderly trauma patients with rib fractures are at greater risk of death and pneumonia

BACKGROUND: The purpose of this study was to show that elderly patients admitted with rib fractures after blunt trauma have increased mortality. METHODS: Demographic, injury severity, and outcome data on a cohort of consecutive adult trauma admissions with rib fractures to a tertiary care trauma center from April 1, 1993, to March 31, 2000, were extracted from our trauma registry. RESULTS: Among 4,325 blunt trauma admissions, there were 405 (9.4%) patients with rib fractures; 113 were aged > or = 65. Injuries were severe, with Injury Severity Score (ISS) > or = 16 in 54.8% of cases, a mean hospital stay of 26.8 +/- 43.7 days, and 28.6% of patients requiring mechanical ventilation. Mortality (19.5% vs. 9.3%; p < 0.05), presence of comorbidity (61.1% vs. 8.6%; p < 0.0001), and falls (14.6% vs. 0.7%; p < 0.0001) were significantly higher in patients aged > or = 65 despite significantly lower ISS (p = 0.031), higher Glasgow Coma Scale score (p = 0.0003), and higher Revised Trauma Score (p < 0.0001). After adjusting for severity (i.e., ISS and Revised Trauma Score), comorbidity, and multiple rib fractures, patients aged > or = 65 had five times the odds of dying when compared with those < 65 years old. CONCLUSION: Despite lower indices of injury severity, even after taking account of comorbidities, mortality was significantly increased in elderly patients admitted to a trauma center with rib fractures.     

Mortality in Severely Injured Elderly Trauma Patients—When Does Age Become a Risk Factor?

Age is a well-known risk factor in trauma patients. The aim of the present study was to define the age-dependent cut-off for increasing mortality in multiple injured patients. Pre-existing medical conditions in older age and impaired age-dependent physiologic reserve contributing to a worse outcome in multiple injured elderly patients are discussed as reasons for increased mortality. A retrospective clinical study of a statewide trauma data set from 1993 through 2000 included 5375 patients with an Injury Severity Score (ISS) > or = 16 who were stratified by age. The ISS and Abbreviated Injury Score (AIS) quantified the injury severity. Outcome measures were mortality, shock, multiple organ failure, and severe head injury. Mortality in this series increased beginning at age 56 years, and that increase was independent of the ISS. The mortality rate increased from 7.3% (patients 46-55 years of age) to 13.0% (patients ages 56-65 years) in patients with ISS 16-24; from 23.8% to 32.1% in those with ISS 25-50; and from 62.2% to 82.1% in those with ISS 51-75 (P < or = 0.05). Severe traumatic brain injury (sTBI) was the most frequent cause of death, with a significant peak in patients older than 75 years. The incidence of lethal multiple organ failure increased significantly beginning at age 56 years (P < or = 0.05), but it showed no further increase in patients aged 76 years or older. In contrast, the incidence of lethal shock showed a significant increase from age 76 years (P < or = 0.05), but not at age 56 years. However, from age 56 years, mortality increased significantly in patients who sustained multiple trauma-an increase that was independent of trauma severity.     

Prevalence of delayed hemothorax in blunt thoracic trauma

Delayed hemothorax (DHTX) is rarely seen. On an 8-year retrospective analysis of blunt thoracic trauma (BTT), hemothorax (HTX) was diagnosed in 167 patients: 18 children, 113 adults, and 36 elderly. No statistical differences were seen in any age groups regarding Injury Severity Score (mean ISS, 30.54), critical care length of stay (CLOS, 9.0), and hospital LOS (HLOS, 11.21). Mortality rate was 18 per cent in adults and 28 per cent in elderly (P value < 0.0001). HTX was acute in 160 and delayed in 7 patients. Two-thirds of HTX patients were males and 75 per cent had rib fractures. All of our DHTX patients were males (5 adults and 2 elderly) and had rib fractures. Acute HTX was seen in younger patients (43.3 vs 56.1 years, P value 0.46), with higher ISS (31.44 vs 14.43, P value < 0.001), CLOS (7.19 vs 3.0 days, P value 0.511) and HLOS (11.9 vs 11.6, P value 0.468). Mortality was 22.5 per cent in AHTX and none in DHTX. Eighty-six per cent of DHTX and 49 per cent of AHTX patients went home on discharge. DHTX was rare (5%) in the current report with lower ISS, HLOS, and no mortality. Patients with rib fractures should be watched for development of DHTX as timely diagnosis and treatment is essential for favorable outcome.     

Pedestrians injured by automobiles: relationship of age to injury type and severity

BACKGROUND: There is little research on the effect of age on the nature and severity of injuries to pedestrians struck by automobiles. STUDY DESIGN: Trauma registry study included all auto versus pedestrian trauma admissions of pedestrians injured by automobiles at an academic Level I trauma center over 10 years and 4 months. Injury Severity Score, severe body area (head, chest, abdomen, extremities) trauma with Abbreviated Injury Score >3, specific organ injuries, and mortality were calculated according to age groups (< or =14 years, 15 to 55 years, 56 to 65 years, >65 years). RESULTS: During the study period 5,838 admissions were reviewed. There were 1,136 patients (19.4%) 14 years old or less, 3,741 (64.1%) who were 15 to 55 years, 420 (7.2%) 56 to 65 years, and 541 (9.3%) older than 65 years. Overall mortality was 7.7% and ranged from 3.2% in the age group 14 years or less to 25.1% in patients over 65 years. The incidences of severe trauma (Injury Severity Score >15) in the four age groups were 11.2%, 18.7%, 23.6%, and 36.8%, respectively. The incidences of critical trauma (Injury Severity Score >30) were 2.3%, 3.9%, 5.7%, and 13.9%, respectively. The incidence of severe head and chest trauma (Abbreviated Injury Score >3) increased with age. The incidence of solid organ and hollow viscus injuries was similar in all age groups. Spinal injuries increased significantly with age and ranged from 0.4% in the pediatric group to 8.5% in the elderly group. Pelvic and tibial fractures were significantly more common in adults; femur fractures were significantly more common in the pediatric group. CONCLUSIONS: Age plays an important role in the anatomic distribution and severity of injuries and survival outcomes after pedestrian injuries.     

The New Injury Severity Score: a more accurate predictor of in-hospital mortality than the Injury Severity Score

OBJECTIVE: The purpose of this study was to determine whether the New Injury Severity Score (NISS) is a better predictor of mortality than the Injury Severity Score (ISS) in general and in subgroups according to age, penetrating trauma, and body region injured. METHODS: The study population consisted of 24,263 patients from three urban Level I trauma centers in the province of Quebec, Canada. Discrimination and calibration of NISS and ISS models were compared using receiver operator characteristic (ROC) curves and Hosmer-Lemeshow statistics. RESULTS: NISS showed better discrimination than ISS (area under the ROC curve = 0.827 vs. 0.819; p = 0.0006) and improved calibration (Hosmer-Leme-show = 62 vs. 112). The advantage of the NISS over the ISS was particularly evident among patients with head/neck injuries (area under the ROC curve = 0.819 vs. 0.784; p < 0.0001; Hosmer-Lemeshow = 59 vs. 350). CONCLUSION: The NISS is a more accurate predictor of in-hospital death than the ISS and should be chosen over the ISS for case-mix control in trauma research, especially in certain subpopulations such as head/neck-injured patients.     

Epidural versus intravenous pain control in elderly patients with rib fractures

BACKGROUND: Epidural catheters are used in older patients with rib fractures to improve outcome. We reviewed the efficacy of epidural analgesia (EA) compared with intravenous narcotics (IVN) in this population. METHODS: Rib fracture patients >55 years old admitted to our level I trauma center from 1999 through 2002 were reviewed for demographics, Injury Severity Score (ISS), Abbreviated Injury Score for chest, length of stay, cardiopulmonary comorbidities, complications, and type of analgesia. RESULTS: There were 187 patients: 72 men and 115 women. The mean age was 77 years. For ISS <9, length of stay for EA patients was 12 +/- 5 days versus 5 +/- 4 days for IVN patients (P < 0.001). Complications occurred in 9 of 10 EA patients versus 21 of 52 IVN patients (P < 0.001). No difference was noted in length of stay for patients with ISS > or =9. Complications in the high ISS group occurred in 29 of 43 EA patients versus 37 of 82 IVN patients (P <0.05). Stratification of patients based on low versus high Abbreviated Injury Score for chest yielded similar results. CONCLUSIONS: EA is associated with prolonged length of stay and increased complications in elderly patients, particularly those with less significant injuries, regardless of cardiopulmonary comorbidities. EA for elderly patients with rib fractures should be prospectively re-evaluated.     

Penetrating trauma in patients older than 55 years: a case-control study

BACKGROUND: Multiple studies have compared young and elderly blunt trauma patients, and concluded that, because elderly patients have outcomes similar to young patients, aggressive resuscitation should be offered regardless of age. Similar data on penetrating trauma patients are limited. STUDY DESIGN: In a retrospective review, 79 patients with penetrating injuries and age > or =55 were blindly matched for Injury Severity Score (ISS) and Abbreviated Injury Scores (AIS) with 79 penetrating trauma patients aged 15-35 years, who were admitted to the hospital over the same 4 year period (June 1994-June 1998). Mortality rates and length of stay in the intensive care unit (ICU) and the hospital were compared between the two groups. RESULTS: The average ISS for all patients was 12 (range 1-75) and identical for both groups. Both groups had similar injuries and were evaluated by an equal number and type of diagnostic studies. The mean ISS was not different between severely injured older and younger patients who required ICU admission or died. Among 32 nonsurvivors (18 older and 14 younger), older patients were more likely than younger patients to present with normal vital signs, although the comparison did not reach statistical significance (50% vs. 13%, P=0.25). There was a clinically significant trend for longer ICU (15+/-30 vs. 3+/-2 days, P=0.096) and hospital stay (10+/-18 vs. 6+/-8 days, P=0.08) among older patients, but mortality rates were similar (23% in older vs. 18% in younger, P=NS). Furthermore, these outcome parameters showed no difference when both groups were classified according to severity of injury or physiologic response. CONCLUSIONS: Following penetrating trauma, older patients arriving alive and admitted to the hospital are as likely to survive as younger patients who have injuries of similar severity, but at the expense of longer ICU and hospital stays.     

Young versus old: factors affecting mortality after blunt traumatic injury

Advanced age predicts poor outcome after trauma. We have previously demonstrated that prolonged occult hypoperfusion (POH), defined as serum lactic acid >2.4 mmol/L persisting for >12 hours, is also associated with worse outcomes. We hypothesized that older patients--a group with potentially less physiologic reserve--would be at greater risk from POH. Prospective data from adult blunt trauma patients admitted to a surgical/trauma intensive care unit from January 1, 1998 through December 31, 1999 were analyzed. Mortality, POH, Injury Severity Score (ISS), chronic health designation (CH) from the Acute Physiology and Chronic Health Evaluation, emergency department Glasgow Coma Scale score (EDGCS), emergency department systolic blood pressure (EDSBP), and gender were compared between older (>55 years) and younger (<56 years) patients and then between nonsurvivors and survivors within age cohorts. Two hundred sixty-four patients were analyzed: 195 younger and 69 older. Mortality was 8.3 per cent (22/264). Older patients had higher mortality (20.3% vs 4.1%, P < 0.05), higher CH (42.9% +/- 1.3 vs 8.4% +/- 0.6), lower ISS (22.6 +/- 1.5 vs 25.6 +/- 0.8, P < 0.05), higher EDGCS (12.9 +/- 0.5 vs 10.7 +/- 0.4, P < 0.05), and higher EDSBP (141.5 +/- 4.1 vs 129.3 +/- 2.2). There were no differences in incidence of POH and gender. Within both age cohorts nonsurvivors had higher ISS, lower EDGCS, and higher CH. Older patients with POH had 34.6 per cent mortality as compared with 11.6 per cent for no POH (P < 0.05). Mortality in younger patients was no different in the presence of POH, and all non-survivors were male. Despite lower ISS and higher EDGCS and EDSBP older patients had five times the mortality of younger patients. Age-specific mortality was influenced by POH and gender. POH was associated with higher mortality only in older patients. With less physiologic reserve older patients may not have been able to adequately compensate for POH; this emphasizes the importance of rapidly correcting serum lactic acid as an endpoint in resuscitation in this population.