Intrathoracic displacement of the humeral head in a trauma patient

Fracture and intrathoracic displacement of the humeral head is the result of severe high energy trauma and are extremely rare. Because of the exceedingly limited number of cases, appropriate treatment modality remains unclear. Hitherto, we describe a unique case of thoracic aorta injury caused by fragmented humeral head. Purposeful medical examination and fast locating of the humeral head fragment are crucial for the selection of appropriate treatment modality. Early aggressive intervention, e.g., emergency thoracoscopy exploring, can be performed to treat potential thoracic complications.     

Attempted suicide and the elderly trauma patient: risk factors and outcomes

OBJECTIVE: To analyze the scope and burden of hospitalizations for suicide attempts among elderly patients in the United States. METHODS: The National Trauma Data Bank (NTDB, American College of Surgeons, Chicago, IL, 2002) was used for this study. It is a multistate database of hospitalizations for traumatic injury in the United States. Information on all patients reported to the database from 1995 to 2002 was analyzed. Logistic regression was used to analyze the risk factors for suicide attempt in elderly patients, compared with both a younger suicidal cohort and a cohort of elderly patients injured in a motor vehicle collision (MVC). The impact of age on outcome after failed suicide attempt was also analyzed. RESULTS: A total of 1,812 persons aged 65 and over were hospitalized for suicide attempts during the study period, comprising 9.5% of total hospitalizations for suicide attempts. Regression analysis demonstrated that elderly patients who attempted suicide were more likely to be male, white, to have used a firearm, and to have insurance than younger patients. They were more likely to have a psychiatric condition but less likely to have insurance than elderly patients hospitalized for MVCs. Mortality was higher for elderly patients hospitalized for suicide attempts than for younger patients who attempted suicide. Suicidal elderly were less likely to be discharged to home than either younger suicidal patients or elderly patients hospitalized after MVCs. CONCLUSIONS: The failed suicide attempt is an opportunity for intervention. By better understanding risk factors and outcomes of suicide attempts among elderly patients, we can identify higher risk groups and begin to tailor social service programs, psychiatric interventions, and medical care. A multimodality approach to suicide prevention for the elderly would include compassionate, appropriate, psychosocial interventions, and could be studied prospectively to analyze its impact.     

Management and hospital outcome of the severely head injured elderly patient

Introduction: Severe traumatic head injury in the elderly has been associated with poor outcomes. However, there is currently no consensus to direct management in these patients. This study outlines the demographics, injury characteristics, management and outcome of the elderly trauma patients with severe head injury across a defined population. Materials and Methods: A retrospective review of all elderly patients (age >64 years) with a Glasgow Coma Scale (GCS) score of 8 or less, and confirmed intracranial pathology or fractured skull, was undertaken over a period of 40 months from July 2001 to September 2005. Data on patient demographics, injury cause, presenting clinical features and interventions were collected. In‐hospital mortality was used as the primary outcome. Results: There were 96 patients who met the inclusion criteria. One‐third of the patients were managed palliatively, one‐third supportively without surgery and another third underwent surgery. Overall mortality was 70.8% (n = 68). Older age and brainstem injuries were identified as independent predictors of mortality. Mortality was reported in all patients aged 85 years or older. Conclusions: Although overall outcomes were poor, careful consideration should be given to active treatment as favourable outcomes were possible even in the presence of extremely low GCS scores. Prediction of outcome on the basis of age and anatomical diagnoses may help in this decision‐making.     

Implementation and adoption of advanced care planning in the elderly trauma patient

Background

Geriatric trauma has high morbidity and mortality, often requiring extensive hospital stays and interventions. The number of geriatric trauma patients is also increasing significantly and accounts for a large proportion of trauma care. Specific geriatric trauma protocols exist to improve care for this complex patient population, who often have various comorbidities, pre-existing medications, and extensive injury within a trauma perspective. These guidelines for geriatric trauma care often suggest early advanced care planning (ACP) discussions and documentation to guide patient and family-centered care.

Methods

A provincial ACP program was implemented in April of 2012, which has since been used by our level 1 trauma center. We applied a before and after study design to assess the documentation of goals of care in elderly trauma patients following implementation of the standardized provincial ACP tool on April 1, 2012.

Results

Documentation of ACP in elderly major trauma patients following the implementation of this tool increased significantly from 16 to 35%. Additionally, secondary outcomes demonstrated that many more patients received goals of care documentation within 24 h of admission, and 93% of patients had goals of care documented prior to intensive care unit (ICU) admission. The number of trauma patients that were admitted to the ICU also decreased from 17 to 5%.

Conclusion

Early advanced care planning is crucial for geriatric trauma patients to improve patient and family-centered care. Here, we have outlined our approach with modest improvements in goals of care documentation for our geriatric population at a level 1 trauma center. We also outline the benefits and drawbacks of this approach and identify the areas for improvement to support improved patient-centered care for the injured geriatric patient. Here, we have provided a framework for others to implement and further develop.

     

Successful management of an elderly patient with multiple trauma

An elderly female patient with multiple trauma and flail chest received thoracic and lumbar epidural analgesia and anesthesia, respectively, in the surgical ICU and the operating room. This technique provided segmental analgesia with minimal amounts of narcotics. This allowed for the very important early ambulation and absence of respiratory complications, the main cause of increased morbidity in this age group.     

Steroids and head trauma

A review of recent experimental and clinical trials on the effect of steroids on the outcome of head-injured patients reveals no statistical benefit in double-blind trials. Small subgroups of patients may benefit, but this needs further evaluation.     

Worsening head bleeds in elderly blunt head trauma patients taking antithrombotics: Delayed CT head fails to change management

Background

Most elderly trauma patients suffer blunt head injury and many utilize antithrombotic (AT) medications. The utility of delayed CT-head (D-CTH) in neurologically intact elderly patients using AT who have an intracranial hemorrhage (ICH) on presentation is unknown. We hypothesized that D-CTH would not alter clinical management and aimed to evaluate the role of D-CTH in this population.

Defining the major trauma patient and trauma severity

Criteria for defining the major trauma patient have been specified by physicians using Injury Patient Management Categories (PMCs), a computerized classification that can be used effectively with routinely collected discharge abstract data from non-trauma center hospitals as well as trauma centers. These criteria for major trauma not only include the more severe and complex single injuries, but also include criteria for identifying combinations of injuries that require tertiary level care. Major trauma patients identified as tertiary using PMCs are compared with existing and frequently used measures of injury severity such as AIS and ISS. Analyses suggest that the Injury PMCs identify major trauma patients accurately and more specifically than other indicators of severity that are commonly used. In addition, unlike other measures that are generally limited to registries, PMC tertiary patient criteria differentiate major trauma patients at both trauma centers and non-trauma centers without additional data collection. Using this method thus facilitates trauma systems evaluation and patient outcome assessment.     

Improving early identification of the high-risk elderly trauma patient by emergency medical services

Study objectiveWe sought to (1) define the high-risk elderly trauma patient based on prognostic differences associated with different injury patterns and (2) derive alternative field trauma triage guidelines that mesh with national field triage guidelines to improve identification of high-risk elderly patients.MethodsThis was a retrospective cohort study of injured adults ≥65 years transported by 94 EMS agencies to 122 hospitals in 7 regions from 1/1/2006 through 12/31/2008. We tracked current field triage practices by EMS, patient demographics, out-of-hospital physiology, procedures and mechanism of injury. Outcomes included Injury Severity Score ≥ 16 and specific anatomic patterns of serious injury using abbreviated injury scale score ≥3 and surgical interventions. In-hospital mortality was used as a measure of prognosis for different injury patterns.Results33,298 injured elderly patients were transported by EMS, including 4.5% with ISS ≥ 16, 4.8% with serious brain injury, 3.4% with serious chest injury, 1.6% with serious abdominal-pelvic injury and 29.2% with serious extremity injury. In-hospital mortality ranged from 18.7% (95% CI 16.7–20.7) for ISS ≥ 16 to 2.9% (95% CI 2.6–3.3) for serious extremity injury. The alternative triage guidelines (any positive criterion from the current guidelines, GCS ≤ 14 or abnormal vital signs) outperformed current field triage practices for identifying patients with ISS ≥ 16: sensitivity (92.1% [95% CI 89.6–94.1%] vs. 75.9% [95% CI 72.3–79.2%]), specificity (41.5% [95% CI 40.6–42.4%] vs. 77.8% [95% CI 77.1–78.5%]). Sensitivity decreased for individual injury patterns, but was higher than current triage practices.ConclusionsHigh-risk elderly trauma patients can be defined by ISS ≥ 16 or specific non-extremity injury patterns. The field triage guidelines could be improved to better identify high-risk elderly trauma patients by EMS, with a reduction in triage specificity.     

Blunt chest trauma in the elderly patient: how cardiopulmonary disease affects outcome

Blunt trauma patients with rib fractures have significant risk of morbidity and mortality. The risk of complications increases with age and cardiopulmonary disease. We reviewed our experience at a community hospital Level II trauma center over a 5-year period. A review of the trauma registry revealed 62 patients over the age of 65 with multiple rib fractures and no associated injuries. Thirty-one patients with cardiopulmonary disease (CPD+) were compared with 31 patients without cardiopulmonary disease (CPD-). Charts were reviewed for morbidity, mortality, the need to upgrade level of care (readmission to the hospital or intensive care unit), and length of hospitalization. Complications occurred in 17 of 31 CPD+ patients and in four of 31 CPD- patients (P < 0.001). The only three deaths were in CPD+ patients. Ten CPD+ patients and four CPD- patients required an upgrade in the level of care (P < 0.05). The CPD+ patients had longer hospitalization than the CPD- patients: 8.5 versus 4.3 days (P < 0.05). We conclude that elderly patients with multiple rib fractures and cardiopulmonary disease are at significant risk for complications that result in readmission to the hospital and intensive care unit and prolonged length of hospitalization. Admission to the intensive care unit with attention to cardiac and pulmonary status upon transfer to the ward is warranted.     

The role of delayed head CT in evaluation of elderly blunt head trauma victims taking antithrombotic therapy

Introduction

Increasing active longevity has created an increasing surge of elderly trauma patients. The majority of these patients suffer blunt trauma and many are taking antithrombotic agents. The literature is mixed regarding the utility of routine repeat head CT in patients taking antithrombotic medications with a GCS of 15 and initial negative head CT. We hypothesized that scheduled delayed CT head 12 h after admission (D-CTH) in elderly blunt trauma victims would not identify clinically significant new hemorrhages or change management.

Methods

A retrospective chart review using our institutional trauma registry of patients ≥65 years sustaining blunt head injuries from 2010 to 2012 was performed. By hospital protocol, all such patients on antithrombotic therapy receive a routine D-CTH. All of these patients were included. Demographics, injuries, medications, laboratory values, LOS, mental status, and management were analyzed.

Results

Of the 234 patients meeting inclusion criteria, 8 initially were identified as having D-ICH. Upon further review, five patients had the same findings on both initial and delayed CT scans and one patient was determined to actually have had a hemorrhage stroke. Ultimately, only two patients (0.85%, 95% CI 0.1–3.1%) had new ICH discovered on D-CTH. None of the patients on warfarin demonstrated any new injury on D-CTH (95% CI ≤ 4.6%). Only one patient taking aspirin as a sole agent had a delayed injury on D-CTH (1.1%, 95% CI 0–4.2%). The remaining patient was taking a combination of aspirin and clopidogrel representing 2.2% of 45 patients on combination therapy (95% CI 0.1–11.8%). Only two patients taking a direct thrombin inhibitor (dabigatran) met inclusion criteria and neither endured a bleed (95% CI ≤ 77.6%). Further analysis revealed no cases with clinical changes or surgical intervention for new ICH on delayed imaging. No inference could be made to predict which patients would suffer D-ICH.

Conclusions

D-CTH in elderly trauma patients taking antithrombotic agents shows no statistically significant or clinical benefit for diagnosing delayed intracranial hemorrhage after minor head injury. In those with delayed imaging showing new ICH, management was not significantly altered. Not enough data were available to predict which patients would develop D-ICH, even if asymptomatic.

     

Geriatric trauma: special considerations in the anesthetic management of the injured elderly patient

Modern society is characterized as having an ever enlarging population of older adults. There are more elderly patients, and the average age of this group is increasing. The anesthetic management of surgery for the elderly trauma victim is more complicated than in younger adults. Evaluation of the physiologic status of the geriatric patient should take into account the variability of the changes associated with advancing age. Care of the injured elderly patient requires thorough preoperative assessment and planning and the involvement of a multidisciplinary clinical team knowledgeable about and interested in the management of the elderly surgical patient.     

Immunity, trauma and the elderly

It is believed that an uncontrolled or poorly coordinated immune reaction can be stimulated by major trauma and be responsible for the development of the multiple organ dysfunction syndrome (MODS). The elderly have a reduced ability to mount an effective immune reaction with deficiencies involving both humoral and cellular aspects of immunity that involve poor function of both the stimulatory and immuno-suppressive sides of the immune process. However, there is currently no hard evidence that the excess mortality after major trauma in the elderly is associated with an impaired or excessive immune response. It is possible that their poor resistance to infection is important and immune modulated but the dominant factor in the excess mortality in the elderly population is probably associated with their lack of physiological reserve to respond to a major physiological challenge.