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.     

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.     

An appraisal of trauma in the elderly

To review the trends of trauma in the elderly experienced at our trauma center compared with other Level I trauma centers. This was a retrospective trauma registry analysis (1996-2003) of 2783 blunt trauma in elderly (BTE) and 4568 adult (BTA) patients in a Level 1 trauma center. Falls and motor vehicular crashes were the most common mechanisms noted in 47 per cent and 31 per cent (84% and 13% in BTE, 25% and 42% in BTA). BTE were sicker, with higher Injury Severity Scores (ISS), lengths of stay, and mortality (5% vs 2%, P value < 0.05). ISS was 5.2-fold higher in nonsurvivors to survivors in BTA and 2.4-fold in BTE. Elevation in ISS resulted in higher linear increase in mortality in BTE (vs BTA) at any ISS level. Mortality in patients with ISS > or = 25 was 43.5 per cent vs 23.8 per cent. ISS > or = 50 had 31 per cent adult survivors but no elderly survivors. Among isolated injuries, head trauma in the elderly carried the highest mortality, at 12 per cent (19% in patients with an Abbreviated Injury Score > or = 3). Abdominal injuries were the most lethal (18.3% and 41.2% in patients with an Abbreviated Injury Score > or = 3) in multiple trauma victims (41% vs 18% in isolated trauma). There was 4.4-fold increased mortality in the presence of thoracic trauma. Combined head, chest, and abdominal trauma carried the worst prognosis. Thirty-four per cent of BTE and 88 per cent of BTA patients were discharged home. Elderly patients need more aggressive therapy, as they are sicker with higher mortality.     

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.     

The effect of anemia and blood transfusions on mortality in closed head injury patients

BACKGROUND: The purpose of this study was to determine if anemia in isolated head trauma patients results in a higher mortality rate that would justify a more liberal use of blood transfusions. METHODS: A retrospective review of isolated blunt head trauma patients was performed between January 2001 and December 2006. Comparisons were made between survivors and nonsurvivors regarding demographics, laboratory values, transfusions received, and lengths of stay. RESULTS: There were 788 patients with 735 survivors who were significantly younger (46.3 y +/- 21.5 survivors versus 68.9 y +/- 18.8 nonsurvivors, P < 0.0001) and less injured [(ISS: 14.7 +/- 5.2 survivors versus 23.2 +/- 4.7 nonsurvivors, P < 0.0001), (head abbreviated injury severity: 3.7 +/- 0.7 survivors versus 4.7 +/- 0.5 nonsurvivors, P < 0.0001)] than those who died (n = 53). The survivors also had shorter lengths of stay (days) [(ICU: 2.4 +/- 4.2 versus 5.6 +/- 11.7, P = 0.03), (hospital: 6.3 +/- 9.8 versus 7.8 +/- 14.8, P = 0.02)]. Multivariate logistic regression showed age (OR 1.063, CI 1.042-1.084), ISS (OR 1.376, CI 1.270-1.491), minimum hemoglobin (OR 0.855, CI 0.732-1.000), and total blood products transfused (OR 1.073, CI 1.008-1.142) to be independent predictors of mortality with an ROC of 0.942. Outcome was independent of the operative procedures, hematocrit and packed red blood cells transfused at 24, 48, and 72 h. Hemoglobin levels of <8 mg/dL were more predictive of death than >8 mg/dL (P = 0.01). CONCLUSIONS: This study supports the need to balance mild anemia with judicious blood product use in the head trauma patient. Given the risk with blood product use, each transfusion should be carefully considered and the patient re-evaluated regularly to determine the need for further intervention.     

Blood transfusion is associated with infection and increased resource utilization in combat casualties

Combat casualty care has made significant advances in recent years, including administration of blood products in far-forward locations. However, recent studies have shown blood transfusion to be a significant risk factor for infection and increased resource utilization in critically injured patients. We therefore sought to investigate the incidence of blood transfusion and its association with infection and resource utilization in combat casualties. Prospective data were collected and retrospectively reviewed on 210 critically injured patients admitted to the USNS Comfort over a 7-week period during the 2003 assault phase of Operation Iraqi Freedom. Patients were stratified by age, gender, and injury severity score (ISS). Multivariate regression analyses were used to assess blood transfusion and hematocrit (HCT) as independent risk factors for infection and intensive care unit (ICU) admission controlling for age, gender, and ISS. The study cohort had a mean age of 30 +/- 2 years, a mean ISS of 14 +/- 3, 84 per cent were male, and 88 per cent sustained penetrating trauma. Blood transfusion was required in 44 per cent (n = 93) of the study cohort. Transfused patients had a higher ISS (18 +/- 4 vs. 10 +/- 3, P < 0.01), a higher pulse rate (105 +/- 4 vs. 93 +/- 3, P < 0.0001), and a lower admission HCT (27 +/- 1 vs. 33 +/- 2, P < 0.0001) compared with patients not transfused. Patients receiving blood transfusion had an increased infection rate (69% vs. 18%, P < 0.0001), ICU admission rate (52% vs. 21%, P < 0.0001), and ICU length of stay (6.7 +/- 2.1 days vs. 1.4 +/- 0.5 days, P < 0.0001) compared with nontransfused patients. However, there was no significant difference in mortality between transfused and nontransfused patients. Multivariate binomial regression analysis identified blood transfusion and HCT as independent risk factors for infection (P < 0.01) and blood transfusion as an independent risk factor for ICU admission (P < 0.05). Combat casualties have a high incidence of blood transfusion. Blood transfusion is an independent risk factor for infection and increased resource utilization. Therefore, consideration should be given to the use of alternative blood substitutes and recombinant human erythropoietin in the treatment and management of combat casualties.     

Poor glycemic control is associated with increased mortality in critically ill trauma patients

Glycemic control improves outcome in cardiac surgical patients and after myocardial infarction or stroke. Hyperglycemic predicts poor outcome in trauma, but currently no data exist on the effect of glycemic control in critically ill trauma patients. In our intensive care unit (ICU), we use a subcutaneous sliding scale insulin protocol to achieve glucose levels <140 mg/dL. We hypothesized that aggressive glycemic control would be associated with improved outcome in critically ill trauma patients. At our urban Level 1 trauma center, a retrospective study was conducted of all injured patients admitted to the surgical ICU >48 hours during a 6-month period. Data were collected for mechanism of injury, age, diabetic history, Injury Severity Score (ISS), and APACHE II score. All blood glucose levels, by laboratory serum measurement or by point-of-care finger stick, were collected for the entire ICU stay. Outcome data (mortality, ICU and hospital length of stay, ventilator days, and complications) were collected and analyzed. Patients were stratified by their preinjury diabetic history and their level of glucose control (controlled <140 mg/dL vs non-controlled > or =141 mg/dL) and these groups were compared. During the study period, 103 trauma patients were admitted to the surgical ICU >48 hours. Ninety (87.4%) were nondiabetic. Most (83.5%) sustained blunt trauma. The average age was 50 +/- 21 years, the average ISS was 22 +/- 12, and the average APACHE II was 16 +/- 9. The average glucose for the population was 128 +/-25 mg/dL. Glycemic control was not attained in 27 (26.2%) patients; 19 (70.4%) of these were nondiabetic. There were no differences in ISS or APACHE II for controlled versus non-controlled patients. However, non-controlled patients were older. Mortality was 9.09 per cent for the controlled group and was 22.22 per cent for the non-controlled group. Diabetic patients were older and less severely injured than nondiabetics. For nondiabetic patients, mortality was 9.86 per cent in controlled patients and 31.58 per cent in non-controlled patients (P < 0.05). Also, urinary tract infections were more prevalent and complication rates overall were higher in nondiabetic patients with noncontrolled glucose levels. Nonsurvivors had higher average glucose than survivors (P < 0.03). Poor glycemic control is associated with increased morbidity and mortality in critically ill trauma patients; this is more pronounced in nondiabetic patients. Age may be a factor in these findings. Subcutaneous sliding scale insulin alone may be inadequate to maintain glycemic control in older critically ill injured patients and in patients with greater physiologic insult. Prospective assessment is needed to further clarify the benefits of aggressive glycemic control, to assess the optimal mode of insulin delivery, and to better define therapeutic goals in critically ill, injured patients.     

Survival after trauma in geriatric patients.

In contrast to other studies, a recent report from the authors' institution has shown a good prognosis for functional recovery in geriatric patients that survive trauma. Because most survivors regained their pre-injury function, the authors examined factors related to nonsurvival in this population of 82 consecutive blunt trauma victims older than the age of 65. Seventeen patients died (21%). Compared with survivors, nonsurvivors were older, had more severe overall injury, and had more severe head and neck trauma but did not differ in severity of trauma that did not involve the head and neck, number of body regions injured, mechanism of injury, or incidence of surgery after injury. Nonsurvivors experienced more frequent complications (82% vs. 33%, p less than 0.05), including a higher incidence of cardiac complications (53% vs. 15%, p less than 0.05) and ventilator dependence for 5 or more days (41% vs. 14%, p less than 0.05). Mortality rates were increased in patients who were 80 years of age or older compared with those ages 65-79 (46% vs. 10%, p less than 0.01), despite injury of similar severity. More frequent complications may contribute to an increased mortality rate in the older group, including an increased incidence of prolonged mechanical ventilation (36% vs. 12%, p less than 0.025), cardiac complications (54% vs. 10%, p less than 0.01), and pneumonia (36% vs. 16%, p less than 0.06). Severely injured patients (Injury Severity Score [ISS] greater than or equal to 25) older than 80 years old had a mortality rate of 80%, and the survivors required permanent nursing home care. Discriminant analysis yielded a reliable method of differentiating survivors from nonsurvivors based on age, ISS, and the presence of cardiac and septic complications. To assess the accuracy of the discriminant function, 61 consecutive patients admitted during 1985 were reviewed prospectively. Discriminant scoring predicted outcome correctly in 92% of these patients. A Geriatric Trauma Survival Score (GTSS) based on the discriminant function was calculated for each of the 143 patients studied and was highly correlated with mortality rate (r = 0.99, p less than 0.001). Thus, the GTSS may serve as a valuable tool for evaluating death in geriatric trauma victims. Furthermore, because complications are potentially avoidable and contribute to increased mortality rates, routine aggressive care for geriatric patients with moderate overall injury is indicated.     

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.     

Gender-related outcomes in trauma

BACKGROUND: Recent data suggest that sex hormones may play a role in regulating posttraumatic immunosuppression, leading to gender-based differences in outcome after injuries. This study examined gender-related outcomes in trauma patients. METHODS: We conducted a retrospective review of trauma registry data from our Level I trauma center over a 4-year period. Patients > 15 years of age, with Injury Severity Scores > 15, who survived and received mechanical ventilation for > 48 hours were included. Patients were divided into two groups on the basis of age (15-45 years and > 45 years) and the groups were further stratified by gender. Groups were matched by Injury Severity Scores, Glasgow Coma Scale score, Abbreviated Injury Score for the head, and transfusion requirement. Gender-based outcomes consisted of ventilator days, intensive care unit length of stay (LOS), hospital LOS, pneumonia, and death. RESULTS: Data were reported as mean +/- SD. There were 612 patients. In the younger age group, male patients had a higher incidence of multiple organ failure (10.5% vs. 1.5%), longer intensive care unit (13.5 +/- 9.2 days vs. 9.2 +/- 7.2 days) and hospital LOS (30.2 +/- 37.7 days vs. 18.9 +/- 13.0 days), and higher mortality (13.4% vs. 6.8%) compared with female patients (p < 0.05 for all). These differences did not exist in the older age group. The incidence of pneumonia did not differ by gender. Age > 45 years was associated with higher mortality (odds ratio, 2.0; 95% confidence interval, 1.1-3.5). CONCLUSION: Although the incidence of pneumonia was not influenced by gender, female trauma patients had better outcomes than male patients in the younger age group. Outcome in the older age group was not gender-related. Our data support a gender-based difference in outcome after traumatic injuries in younger patients.     

Pulmonary tractotomy versus lung resection: viable options in penetrating lung injury.

BACKGROUND: Emergency lung resection following penetrating chest trauma has been associated with mortality rates as high as 55-100%. Pulmonary tractotomy is advocated as a rapid alternative method of dealing with deep lobar injuries. We reviewed our experience with resection and tractotomy to determine whether method of management affects mortality or if patient presentation is more critical in determining outcome. METHODS: A retrospective review of all patients with chest injury seen at an urban Level I trauma center from 2/89-1/99 was performed. All patients undergoing parenchymal surgery were included. Records were abstracted for grade of injury, type of resection, presenting systolic blood pressure (SBP), temperature, Injury Severity Score (ISS), operative time, and estimated blood loss (EBL). Mortality and thoracic complications were compared between groups. RESULTS: Two hundred forty-six of 2736 patients with penetrating chest trauma underwent thoracotomy, with 70 (28%) requiring some form of lung resection. There were 11 (15.7%) deaths. Patients who died had lower SBP (53 +/- 32 mm Hg vs 77 +/- 28 mm Hg), lower temperature (32.5 degrees +/- 1.3 degrees C vs 34.3 degrees +/- 1.2 degrees C), higher ISS (33 +/- 13 vs 23 +/- 9), and greater EBL (9.8 +/- 4.3 liters vs 2.8 +/- 2.1 liters) compared with survivors (p < 0.05 for all). Mortality was also increased in the presence of cardiac injury (33% with vs 12% without) and the need for laparotomy (26% with vs 9% without) (p < 0.05 for all). Tractotomy was associated with an increased incidence of chest complications (67% vs 24%, p = 0.05) compared with lobectomy with no difference in presenting physiology, operative time, or mortality. CONCLUSION: Lung resection for penetrating injuries can be done safely with morbidity and mortality rates lower than previously reported. Patient outcome is related to severity of injury rather than type of resection. Tractotomy is associated with a higher incidence of infectious complications and is not associated with shortened operative times or survival.     

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.     

Anticoagulation and the elderly head trauma patient

We sought to determine the effect of anticoagulation therapy on outcomes in elderly patients with closed head injury. We retrospectively reviewed elderly closed head injury patients (> or = 65 years) comparing 52 patients on warfarin (AC) with 439 patients not on warfarin (NAC) with subsequent 1:3 propensity matching used to analyze comparable groups. The overall AC group had a higher head abbreviated injury score (AIS) (4.0 +/- 0.7 vs 3.8 +/- 0.7, P = 0.04) compared with the NAC group. After propensity matching, 49 AC patients were compared with 147 NAC patients who were similar for age, gender, injury severity score, and head AIS. Admission INR was higher in the AC group compared to the NAC group (2.5 +/- 1.3 vs 1.1 +/- 0.3, P < 0.0001) and the AC group had a higher mortality rate (38.8% AC (19/49) vs 23.1% NAC (34/147), P = 0.04). In the AC group, survivors and nonsurvivors had similar repeat International Normalized Ratio (INR) values (1.57 +/- 0.65 survivors vs 1.8 +/- 0.72 nonsurvivors, P = 0.31). The AC group experienced greater morbidity after trauma and had higher mortality rates than their NAC counterparts. Prevention of injury and more selective use of warfarin in this patient population are essential to decrease mortality.     

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.     

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.     

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.     

Mortality in retroperitoneal hematoma

Eighty-one patients sustained retroperitoneal hematoma (RH) from blunt (70%) and penetrating (30%) trauma. Retroperitoneal hematomas were classified into 10 centro-medial Zone I, 25 lateral Zone II, and 46 pelvic Zone III hematomas. The mean injury Severity Score (ISS) for the entire series was 26.4 +/- 14. The mean ISS of nonsurvivors was 37.6 +/- 12. Overall mortality was 20%; if head injury deaths are excluded (six), mortality was 13%. Retroperitoneal hematoma associated with pelvic fracture had a mortality of 19%. Incidence of respiratory failure for entire series, excluding head trauma, was 29%. Respiratory failure occurred in 37% of patients with Zone III injuries. A requirement for ventilatory support greater than 48 hours was associated with a mortality of 35%. PaO2/FIO2 at 48 hours in intubated patients was significantly decreased in nonsurvivors compared to survivors, whereas the mean ISS of this subset of patients did not differentiate between survivors and nonsurvivors.     

Predictors of morbidity and mortality in patients with traumatic duodenal injuries

The aim of our study is to determine factors that predict morbidity and mortality in patients with traumatic duodenal injury (DI). A retrospective review from July 1996 to March 2003 identified 52 patients admitted to our trauma center (age 24.4 +/- 2.1 years, ISS = 18.8 +/- 1.76). The mortality rate for patients with duodenal injury was 15.4 per cent (n = 8). The mechanisms of injury were blunt (62%), gun shot wound (GSW) (27%), and stab wound (SW) (11%). There was no difference in mortality based on mechanism of injury. Management was primarily nonoperative [n = 30 (57%)]. Of those with perforation (n = 22), 64 per cent underwent primary repair (n = 14), 23 per cent duodenal resection (n = 5), 9 per cent duodenal exclusion (n = 2), and one patient pancreaticoduodenectomy. The method of initial surgical management was not related to patient outcome. Univariate analysis demonstrated that nonsurvivors were older, more, hypotensive in the emergency department, had a more negative initial base deficit, had a lower initial arterial pH, and had a higher Injury Severity Score. Nonsurvivors were also more likely to have an associated inferior vena cava (IVC) injury. Multivariate regression analysis revealed age, initial lowest pH, and Glasgow Coma Score to be independent predictors of mortality, suggesting that the physiologic presentation of the patient is the most important factor in predicting mortality in patients with traumatic DIs.     

Obesity does not affect mortality after trauma

Although obesity has been proposed as a risk factor for adverse outcomes after trauma, numerous studies report conflicting results. The objective of this study was to compare outcomes of obese and nonobese patients after trauma. The study population consisted of all trauma patients admitted to a surgical intensive care unit in a Level I trauma center from January 1999 to December 2002. Admission data, demographics, injury severity score (ISS), severity of illness, hospital course, complications, and outcomes were compared between obese (OB; body mass index [BMI] > or = 30), and nonobese patients (NOB; BMI < or = 29). A total of 918 patients was included in the study, 135 OB (14.7%) and 783 NOB (85.3%). There was no significant difference in demographic data, ISS, APACHE II score, and hospital stay. Intensive care unit stay was longer for OB patients (6.8 vs 4.8 days, P = 0.04). Overall mortality was 5.9 per cent for OB and 8.0 per cent for NOB patients (P = 0.48). Mortality by mechanism of injury was 3.4 per cent OB versus 7.4 per cent NOB (P = 0.26) for blunt and 10.6 per cent OB versus 10.2 per cent NOB (P = 0.9) for penetrating injury. The three most common complications associated with death were pulmonary, cardiovascular, and neurological deterioration. Using logistic regression analysis, age and ISS and APACHE II scores were associated with mortality, but BMI was not. We conclude that obesity does not appear to be a risk factor for adverse outcomes after blunt or penetrating trauma. Further research is warranted to uncover the reason for discrepant findings between centers.     

Perils of rib fractures

Rib fractures (RF) are noted in 4 to 12 per cent of trauma admissions. To define RF risks at a Level 1 trauma center, investigators conducted a 10-year (1995-2004) retrospective analysis of all trauma patients. Blunt chest trauma was seen in 13 per cent (1,475/11,533) of patients and RF in 808 patients (55% blunt chest trauma, 7% blunt trauma). RF were observed in 26 per cent of children (< 18 years), 56 per cent of adults (18-64 years), and 65 per cent of elderly patients (> or = 65 years). RF were caused by motorcycle crashes (16%, 57/347), motor vehicle crashes (12%, 411/3493), pedestrian-auto collisions (8%, 31/404), and falls (5%, 227/5018). Mortality was 12 per cent (97/808; children 17%, 8/46; adults 9%, 46/522; elderly 18%, 43/240) and was linearly associated with a higher number of RF (5% 1-2 RF, 15% 3-5 RF, 34% > or = 6 RF). Elderly patients had the highest mortality in each RF category. Patients with an injury severity score > or = 15 had 20 per cent mortality versus 2.7 per cent with ISS < 15 (P < 0.0001). Increasing age and number of RF were inversely related to the percentage of patients discharged home. ISS, age, number of RF, and injury mechanism determine patients' course and outcome. Patients with associated injuries, extremes of age, and > or = 3 RF should be admitted for close observation.