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.     

Impact of nosocomial infections in trauma: does age make a difference?

BACKGROUND: The effect of age and infection on outcome after trauma is unknown. We evaluated the incidence and impact that nosocomial infection (NI) and age have on morbidity and mortality. Several risk factors were identified and analyzed for correlation with infection. METHODS: Prospective data were collected on patients admitted for > or = 3 days over a 2-year period. Each patient was followed by an infectious disease specialist throughout their hospitalization. Centers for Disease Control and Prevention guidelines were used to diagnose infection. RESULTS: Of the 3,254 patients admitted, 88% were < 65 and 12% were > or = 65 years of age. Injury Severity Score was not significantly different (older vs. younger). Five hundred one (17.4%) of the younger patients developed an NI with a significantly higher hospital length of stay (LOS), intensive care unit (ICU) LOS, and mortality compared with the noninfected group. One hundred forty-seven (39%) of the older group developed an NI and also had significant increases in hospital LOS, ICU LOS, and mortality. Older infected patients had the highest hospital LOS, ICU LOS, and mortality. The greatest relative risk of mortality was demonstrated with the combination of increased age and NI. Once infected, however, younger patients with penetrating trauma had a greater relative risk of mortality in the group-specific comparison. Many risk factors were associated with infection. Only chronic obstructive pulmonary disease in elderly trauma patients was a significant independent risk factor for infection. CONCLUSION: NI significantly increases hospital LOS, ICU LOS, and mortality after injury. Age increases risk of infection matched for injury severity, with a significantly higher hospital LOS, ICU LOS, and mortality. Once infected, however, younger patients with penetrating trauma have the greatest risk of mortality. Chronic obstructive pulmonary disease in elderly trauma patients was found to be an independent predictor of infection.     

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.     

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.     

Medical admission of elderly trauma patients with isolated injuries

We sought to evaluate the outcomes of trauma patients admitted to medical services rather than to the general trauma team, particularly those elderly patients with isolated injuries of a specialty nature. Over the 2-year retrospective study period, 3017 trauma patients were admitted. The trauma service directed care in 2740 (90.8%) of this group versus the 277 (9.2%) admitted to medical services (MS). The patients in each group were then classified according to age younger than 55 years or older than 55 years (elderly). Of the 277 patients admitted to the MS, 177 (63.8%) were elderly compared with only 13 per cent of the trauma service group. Smaller proportions (16.9%) of the elderly medical patients were admitted to the intensive care unit as compared with the trauma group (22.1%). There was a higher morbidity rate, 41.9 per cent, in the trauma service group as compared with the MS group, 20 per cent. No patients on the MS underwent a laparotomy for intraabdominal injuries nor were there any missed injuries of a general surgical nature. Allowing elderly trauma patients with isolated specialty injuries to be managed by the MS is not associated with increased morbidity or mortality.     

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.     

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.     

Dangerous toys

Background: Motorcycles are sources of significant injury for children. There is limited data describing New Zealand's experience. The study's aim was to quantify the burden of motorcycle trauma presenting to Starship Children's Hospital by assessing the annual admission rates, severity and pattern of injuries, and patient mortality, and to compare injury patterns of those riding all‐terrain vehicles (ATV) and two‐wheeled motorbikes (MB). Methods: Retrospective chart review of all motorcycle trauma admissions to Starship Children's Hospital between November 1999 and December 2008. Patients were identified using the Starship Trauma Registry. Results: One hundred forty‐six admissions (123 MBs, 23 ATVs). Admissions have increased threefold in 9 years. Mean age was 10.5 years (range 2–14 years). ATV riders were significantly younger than MB riders (median 9 and 12 years, P = 0.001). Eighty‐five per cent of patients were male and New Zealand European. There were two deaths in the study. Median length of stay was 2 days (1–80 days); 7.4% required intensive care admission. The median injury severity score (ISS) was 4 (1–35). Twenty‐six per cent of ATV riders had an ISS >12, and 8.9% of MB riders had and ISS >12, P = 0.03. Eighty‐five per cent of patients with an ISS >12 were under 12 years. Sixty per cent of patients required an operative procedure. No difference in pattern of injuries between in ATVs and motorbikes. Conclusions: Motorcycle trauma admissions are increasing. ATV riders are more severely injured and younger than MB riders. Children <12 years are more likely to be severely injured in comparison to those >12 years.     

Effect of pre-existing disease on length of hospital stay in trauma patients

Hospital discharge data for all adult trauma admissions (n = 27,029) to acute care hospitals in a five-county area were used to examine the effect of pre-existing chronic conditions (PECs) on length of hospital stay (LOS). The per cent increase in mean LOS and the relative odds of an extended LOS (i.e., greater than or equal to 3 weeks) were estimated for surviving trauma patients with and without one or more of 11 pre-existing medical conditions, taking into account both the ISS severity of injuries and patient age. Nineteen per cent (n = 5,224) of the trauma cases had one or more of the 11 PECs; 5% (n = 1,384) had two or more PECs. Those with one or more PECs stayed significantly longer (p less than 0.001) than those who had none. Mean LOS was shown to be 69% higher for those with versus those without PECs. Furthermore, patients with PECs were more than twice as likely as those without PECs to have stayed in the hospital 3 weeks or longer. The size of the effect, however, varied by patient age and injury severity; the effect of PECs on length of stay was larger among younger patients and patients with less severe injuries. With regionalization, trauma centers treat the majority of these patients and potentially suffer disproportionate financial losses when reimbursement is based on DRGs.     

The new injury severity score is a better predictor of extended hospitalization and intensive care unit admission than the injury severity score in patients with multiple orthopaedic injuries

OBJECTIVE: To compare the scoring efficacy of the injury severity score (ISS) and the new injury severity score (NISS) in predicting extended hospital length of stay (LOS) and intensive care unit (ICU) admission and to determine the effect of multiple orthopaedic injuries (MOI) on the discrepancies between the ISS and NISS and their impact on extended LOS and ICU admission. DESIGN: Prospective cohort study. SETTING: Level 1 university trauma center. PATIENTS: All consecutive trauma admissions during the 2-year period ending on December 31, 2000, with age older than 14 years and survival greater than 24 hours were entered into the study. MAIN OUTCOMES: Extended (>or=10 days) hospital LOS and ICU admission. RESULTS: Of 3,100 patients, 7.5% had a higher NISS than ISS, spent more days in the hospital (22 versus 8; P < 0.001) and in the ICU (3.4 versus 0.1; P < 0.001), and had a higher mortality rate (8% versus 1.2%; P < 0.001) than patients with identical NISS and ISS. The NISS was found to be more predictive of longer (>or=10 days) LOS (receiver operating characteristic [ROC] NISS = 0.794, ISS = 0.782; P < 0.0001) and ICU admission (ROC NISS = 0.944, ISS = 0.918; P < 0.0001). The multivariate predictive model including NISS showed a better goodness of fit compared with the same model that included ISS. Patients with discrepant scores (NISS > ISS) spent a longer time in the hospital and in the ICU in addition to having an increased frequency of ICU admission. In 61% of the cases, MOI were responsible for the discrepant (NISS > ISS) scores. CONCLUSIONS: MOI have a significant effect on trauma outcomes such as LOS and ICU admission. The recognition of this high-risk group is not possible using the traditional ISS alone from retrospective or prospective databases. Considering its easier calculation and better predictive power, it is suggested that the NISS should replace the traditional ISS in trauma outcome research.     

Low falls: an underappreciated mechanism of injury

OBJECTIVE: This is a retrospective study designed to evaluate the pattern and severity of injuries that result from low falls, defined as falls from less than 20 ft, subsequent mortality, and requirements of hospital resources. Our hypothesis is that many of these injuries, even without cardiopulmonary instability, are worthy of trauma center care. METHODS: The records of all patients entered into the hospital trauma registry at an urban Level I trauma center during the years 1991 through 1997 who suffered low falls and who either died after admission or were hospitalized for at least 3 days were reviewed. Patients suffering isolated hip fractures were excluded. One hundred seventy-six patients constituted the study population. This group accounts for about 2% of all admissions for falls at our institution. Patterns of injury were examined. Age, mechanism of injury, Injury Severity Score (ISS), and cardiopulmonary or neurologic instability on admission were documented. Mortality, length of intensive care unit and hospital stays, as well as billed hospital charges, were reviewed. RESULTS: The majority of patients (62%) were younger than 50 years. Sixty patients had ISS >15 and 116 patients had ISS >9. Sixty patients had multisystem injuries requiring specialty care. Head injuries were found in 81 patients (35%), and vertebral fractures or spinal cord injuries were found in 49 patients (22%), including 9 quadriplegics and 5 paraplegics. There were seven patients with intra-abdominal injuries (five spleen and two bowel injuries). There was one patient with a rupture of the thoracic aorta. Seventeen patients had deteriorating neurologic or pulmonary function on arrival, but the majority (90%) were stable. Of the 159 "stable" patients, 48 suffered head injuries, 7 were quadriplegic, and 3 were paraplegic. All intra-abdominal injuries were in this group. Overall, 14 of 176 patients (8%) died. Seven deaths were in patients older than 60 years, and seven deaths were in younger patients (p = 0.04). The majority of deaths (9 of 14) were from head trauma. Care in the intensive care unit was required in 92 of 176 patients. Nine patients had billed charges exceeding $100,000. CONCLUSION: Low falls can cause significant injuries, most commonly to the head and spine. Based on mechanism of injury alone, patients injured in low falls might not be taken to trauma centers. We have found, however, that many of these patients sustain serious multisystem injuries, even though they are stable initially. Although these patients represent only a fraction of those who fall, our study would support adjustment of triage guidelines to recommend transport of such patients, particularly elderly patients, to trauma centers.     

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.     

Severe trauma caused by stabbing and firearms in metropolitan Sydney, New South Wales, Australia

BACKGROUND: Stabbing and firearm trauma causing severe injuries (injury severity score (ISS) >15) and death is uncommon in Australia. The present study describes the experience with stabbings and firearm trauma causing severe injuries at a major Australian urban trauma centre. METHODS: Data from a prospectively generated trauma registry regarding all patients presenting to Royal Prince Alfred Hospital (RPAH), Sydney, Australia with penetrating trauma causing severe injuries from July 1991 to June 2001 was retrospectively analysed. RESULTS: Of all patients presenting to RPAH with stabbing and firearms wounds over the 11 year study period, 28% received an ISS >15. One hundred and forty patients were identified. 94% were male. The mean age was 34 years (15-82 years). The number of cases/year has not shown an increasing trend. Thirty per cent of patients sustained firearm related injuries, with the remainder mainly caused by knives or machetes. Fifteen per cent of injuries were self inflicted. The most common location of injury was on a public street. Fifty-two per cent of patients were injured in more than one anatomical region, with the abdomen being the most common site of injury (53%). On hundred and seventy-four operations were performed - laparotomies (43%), thoracotomies (26%), craniotomies (5%) and orthopaedic, vascular, wound explorations and other procedures (26%). Twenty-eight per cent of patients suffered at least one complication during their admission, with coagulopathy being the most common complication (20%). Mean length of stay was 10.4 days (1-107 days). The total mortality rate for the severely injured patients was 21%, with gun-related injuries having a higher mortality rate than stabbing injury (36%vs 15%). Sixty per cent of deaths were related to exsanguination. CONCLUSIONS: Stabbings and firearm trauma are associated with significant morbidity, mortality and utilization of hospital resources in metropolitan Sydney. Overall mortality rates are similar to institutions with higher volumes of penetrating trauma.     

Cervical spine injuries in children: a review of 103 patients treated consecutively at a level 1 pediatric trauma center

PURPOSE: Cervical spine (C-spine) injuries occur infrequently in children but may be associated with significant disability and mortality. The purpose of this study was to review the experience of a level 1 pediatric trauma center to determine the epidemiology, risk factors, mechanisms, levels, types of injury, comorbid factors, and outcomes associated with these potentially devastating injuries. METHODS: A retrospective analysis of 103 consecutive C-spine injuries treated at a level 1 pediatric trauma center over a 9(1/2)-year period (January 1991 through August 2000) was performed. RESULTS: The mean age was 10.3 +/- 5.2 years, and the male-to-female ratio was 1.6:1. The most common mechanism of injury was motor vehicle related (52%), followed by sporting injuries (27%). Football injuries accounted for 29% of all sports-related injuries. Sixty-eight percent of all children sustained injuries to C1 to C4; 25% to C5 to C7; and 7% to both. Spinal cord injury without radiographic abnormality (SCIWORA) occurred in 38%. Five patients had complete cord lesions involving the lower C-spine (C4 to C7); 4 of these were motor vehicle related, and all 4 patients died. Isolated C-spine injuries occurred in 43%, whereas 38% had associated closed head injuries (CHI). The overall mortality rate was 18.5%, most commonly motor vehicle related (95%), occurring in younger children (mean and median age 5 years) and associated with upper C-spine injuries (74%) and CHI (89%). C1 dislocations occurred in younger children (mean age, 6.6 years), most often as a result of motor vehicle-related trauma (especially pedestrians) and were associated with the highest injury severity score (ISS), longest length of stay (LOS), most CHIs, and the highest mortality rate (50%). C-spine fractures with or without SCI occurred most commonly as a result of falls and dives. Sporting injuries occurred almost exclusively in adolescent boys (mean age, 13.8 years) and were isolated injuries associated with a relatively low ISS and shorter LOS. Interestingly, 75% of sporting injuries showed SCIWORA, and all infants suffering from child abuse had SCIWORA. CONCLUSIONS: Mechanisms of injury are age related, with younger children sustaining C-spine injuries as a result of motor vehicle-related trauma and older adolescents commonly injured during sporting activities. C-spine injuries in children most commonly involve the upper C-spine, but complete lesions of the cord are associated more frequently with lower C-spine injuries. The type of C-spine injury is related to the mechanism of injury: SCIWORA is associated with sporting activities and child abuse, C-spine dislocations most commonly result from motor vehicle-related trauma (especially among pedestrians), and C-spine fractures occur most commonly as a result of falls and dives. Predictors of mortality include younger age, motor vehicle-related mechanism, C1 dislocations, high ISS greater than 25, and associated CHI. A high index of suspicion for SCIWORA is essential when evaluating adolescents with neck trauma associated with sporting injuries or victims of child abuse.     

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.     

Systemic inflammatory response syndrome score at admission independently predicts mortality and length of stay in trauma patients

BACKGROUND: Recent studies have documented that the systemic inflammatory response syndrome (SIRS) score is a useful predictor of outcome in critical surgical illness. The duration and severity of SIRS are associated with posttrauma multiple organ dysfunction and mortality. We sought to determine whether the severity of SIRS at admission is an accurate predictor of mortality and length of stay (LOS) in trauma patients. METHODS: Prospective data of 4,887 trauma admissions to a Level I trauma center over a 18-month period (January 1997 to July 1998) were analyzed. Patients were stratified by age and Injury Severity Score (ISS), and a SIRS severity score (1 to 4) was calculated at admission (1 point for each component present: fever or hypothermia, tachypnea, tachycardia, and leukocytosis). The SIRS score was evaluated as an independent predictor of mortality and LOS by chi2 and multivariate logistic regression. RESULTS: Trauma patients (n = 4,887, 83% blunt injuries, 72% male) had the following characteristics: 73.1% were age 18 to 45 years, 17.5% were age 46 to 65 years, and 9.4% were age > or =66 years; 77.7% had ISS less than 15, 18.8% had ISS 16 to 29, and 3.5% had ISS greater than 29. Analysis of variance adjusting for age and ISS determined that SIRS score of 2 was a significant predictor of LOS. Furthermore, the relative risk of death increased significantly with SIRS score of 2 when age and ISS were held constant. CONCLUSION: Logistic regression analysis confirmed that a SIRS score of 2 was a significant independent predictor of increased mortality and LOS in trauma patients. These data suggest that admission SIRS scoring in trauma patients is a simple tool that may be used as a predictor of outcome and resource utilization.     

Pelvic fracture in the elderly is associated with increased mortality

OBJECTIVE: The elderly population is currently the fastest growing sector in America. The purpose of this study was to examine the age-related outcome in patients after blunt pelvic injury. METHODS: All patients admitted with a pelvic fracture during a 5-year period were identified from the trauma registry. Data retrieval included: demographics, shock (BP < 90 mm Hg) on admission, injury severity score (ISS), abbreviated injury score (AIS) for head, chest, and abdomen, intensive care unit (ICU) length of stay (LOS), hospital LOS, and mortality. All pelvic fracture patterns were classified. Patient data were then stratified by age for comparison: young (< 55 years) and elderly (> or = 55 years). Statistical analysis was performed using the Student t test, Wilcoxon rank-sum test, multiple logistic regression analysis, and chi-square test with significance set at P <.05. RESULTS: Three hundred five patients sustained a pelvic fracture (young [n = 248, 81.3%]; elderly [n = 57, 18.7%]). The only predictor of mortality was age. The 2 groups differed by gender (elderly = 54.4% females; young = 62.5% males) but not frequency of shock, ISS, or AIS for head, chest, and abdomen. Motor vehicle collision was the most common mechanism of injury (elderly = 68.4%; young = 73.8%). Lateral compression was the most common fracture pattern in both groups (elderly = 54.4%; young = 45.6%). There was no difference in transfusion (elderly = 2.5 +/- 0.7 vs young = 2.0 +/- 0.3; ns) but the elderly group was more frequently admitted to the ICU (elderly = 61.4% vs young = 46.8%; P =.065). Significantly more of the elderly group had a diagnosis of cardiovascular disease (43.9% vs 10.1%, P <.001) and diabetes mellitus (10.5% vs 2.4%, P <.014). Mortality was significantly greater in the elderly group (12.3% vs 2.3%). CONCLUSION: Elderly patients sustaining a pelvic fracture were more likely to have a lateral compression fracture pattern, longer hospital LOS, and die despite aggressive resuscitation. This difference in outcome should help trauma surgeons recognize that the elderly patient sustaining a pelvic fracture is at increased risk of death.     

The injury severity score or the new injury severity score for predicting mortality, intensive care unit admission and length of hospital stay: experience from a university hospital in a developing country

INTRODUCTION: Limited research has been performed to compare the predictive abilities of the injury severity score (ISS) and the new ISS (NISS) in the developing world. PATIENTS AND METHODS: From January 2001 until January 2003 all trauma patients admitted to the American University of Beirut Medical Centre were enrolled. The statistical performance of the ISS/NISS in predicting mortality, admission to the intensive care unit (ICU) and length of hospital stay (LOS dichotomised as <10 or > or =10 days) was evaluated using receiver operating characteristic and the Hosmer-Lemeshow calibration statistic. RESULTS: A total of 891 consecutive patients were enrolled. The ISS and NISS were equivalent in predicting survival, and both performed better in patients younger than 65 years of age. However, the ISS predicted ICU admission and LOS better than the NISS. However, these predictive abilities were lower for the geriatric trauma patients aged 65 years and above compared to the other age groups. DISCUSSION: There are conflicting results in the literature about the abilities of ISS and NISS to predict mortality. However, this is the first study to report that ISS has a superior ability in predicting both LOS and ICU admission. CONCLUSION: The scoring of trauma severity may need to be individualised to different countries and trauma systems.     

Results after laparoscopic fundoplication: does age matter?

Antireflux fundoplications are undertaken with hesitation in older patients because of presumed higher morbidity and poorer outcomes. This study was undertaken to determine if symptoms of gastroesophageal reflux disease (GERD) could be safely abrogated in a high-risk/reward popu lation of older patients. One hundred eight patients more than 70 years of age (range, 70-90 years) underwent laparoscopic Nissen fundoplications undertaken between 1992 and 2005 and were compared with 108 concurrent patients less than 60 years of age (range, 18-59 years) to determine relative outcomes. Before and after fundoplication, patients scored the severity of reflux and dysphagia on a Likert Scale (0 = minor, 10 = severe). Before fundoplication, older patients had lower reflux scores (P < 0.01), but not lower dysphagia scores or DeMeester scores. One patient (86 years old) died from myocardial infarction; otherwise, complications occurred infrequently, inconsequentially, and regardless of age. At similar durations of follow-up, reflux and dysphagia scores significantly improved (P < 0.01) for older and younger patients. After fundoplication, older patients had lower dysphagia scores (P < 0.01) and lower reflux scores (P < 0.01). At the most recent follow-up, 82 per cent of older patients rated their relief of symptoms as good or excellent. Similarly, 81 per cent of the younger patients reported good or excellent results. Ninety-one per cent of patients 70 years of age or more versus 85 per cent of patients less than 60 years would undergo laparoscopic Nissen fundoplication again, if necessary. With fundoplication, symptoms of GERD improve for older and younger patients, with less symptomatic dysphagia and reflux in older patients after fundoplication. Laparoscopic fundoplication safely ameliorates symptoms of GERD in elderly patients with symptomatic outcomes superior to those seen in younger patients.