Financial aspects of providing trauma care at the extremes of life

BACKGROUND: Children and the elderly are more likely to be underinsured compared with the general population of trauma patients. We performed financial analysis on all trauma patients admitted during an 18-month period to a Level I adult and pediatric trauma center to evaluate the financial impact of providing trauma care for children and the elderly. METHODS: Patients were categorized by age: PEDI<17 years, GERI>64 years and MID = 17 to 64 years. Reimbursement ratio (RR = reimbursement/cost; RR>1 = profit, RR<1 = loss), length of stay (LOS), and Injury Severity Score (ISS) were calculated for each age group. RESULTS: RR for GERI (RR = 0.99) was significantly lower than for PEDI (RR = 1.15) and MID (RR = 1.16). There was no difference in ISS, but the LOS of GERI was greater than that of PEDI and MID (p<0.05). Cost per patient and LOS were less in PEDI versus MID and GERI (p<0.05). CONCLUSION: Trauma care reimbursement for the elderly is inadequate, whereas pediatric trauma care costs less to deliver and is profitable to the trauma center.     

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.     

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.     

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.     

Changing patterns of severe craniomaxillofacial trauma in Auckland over eight years

BACKGROUND: This study was performed to review the changing pattern of incidence of severe craniomaxillofacial (CMF) trauma in Auckland over 8 years (1989-1997) and to audit the involvement of the regional plastic surgery service. METHODS: A review of prospectively collected admission data of patients admitted to the Auckland Hospital Department of Critical Care Medicine (DCCM) with severe CMF trauma during 1997. A comparison is made with similar data from 1989. Injury severity was defined using the Injury Severity Score (ISS). RESULTS: Twenty-six patients with severe CMF trauma were admitted to Auckland Hospital DCCM in 1997. Their average ISS was 35. Eighty per cent had a significant head injury. Sixty-two per cent had injuries due to road traffic accidents (RTA) and 42% had positive blood alcohol levels, including 37% of the RTA victims. Twenty-three per cent had their surgical care provided by the regional plastic surgery service. In 1989, 55 patients were admitted to DCCM with severe CMF trauma. The average ISS was 36. Ninety-five per cent had a significant head injury. Seventy-three per cent had injuries due to RTA and 55% had positive blood alcohol, including 60% of the RTA group. CONCLUSIONS: Patients with severe CMF trauma make up a significant proportion of trauma admissions to DCCM and have a high incidence of life-threatening injuries. A multidisciplinary approach is essential. The nature and severity of these injuries has not changed over the last decade. There has been a clear decrease in the incidence of these injuries. This seems to be due to a profound decrease in the rate of RTA associated with alcohol intoxication.     

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.     

Age-adjusted outcomes in traumatic flail chest injuries in the elderly

Severe chest trauma does not independently predict poor outcome in elderly patients. We chose a specific injury, flail chest, to determine whether age factored into outcome of these patients. A retrospective chart review of all trauma admissions to our Level I trauma center between January 1994 and January 1998 sustaining flail chest was undertaken. Sixty-eight patients were identified, but ten patients were excluded because of death on arrival. Fifty-eight patients were included in the study and separated into groups. The first group comprised those under the age of 55 (n = 32) and the second comprised those over age 55 (n = 26). Parameters evaluated were age, Injury Severity Score (ISS), neurologic injury, the need for mechanical ventilation, need for tracheostomy, length of stay, and death. Statistical analysis was performed with Wilcoxon t test, chi2, and logistic regression where appropriate. A 95 per cent confidence interval was sought as determinant of significance. Of the 58 surviving patients analyzed there was no significant difference between the groups regarding ISS, length of stay, days on the ventilator, head injury, tracheostomy, or development of pneumonia or adult respiratory distress syndrome. The likelihood of death was shown to increase by 132 per cent for every 10 years starting at the second decade and continuing to the eighth decade of life. The likelihood of death also increased by 30 per cent for each unit increase in ISS. The likelihood of death decreased by 23 per cent for every day survived in the hospital. Blunt chest trauma directly impacts respiratory mechanics. Elderly patients are more likely to have comorbid conditions and less likely to tolerate traumatic respiratory compromise. Age (and its effects on the body) is the strongest predictor of outcome with flail chest and is associated with an increased mortality (P < or = 0.05).     

Clinical and autopsy analysis of delayed diagnosis and missed injuries in trauma patients

Delayed diagnosis of injury (DDI) during hospitalization and missed injuries (MI) on autopsy in trauma deaths result in untoward outcomes. Autopsy is an effective educational tool for health care providers to evaluate trauma care. A retrospective study of trauma registry patients and coroner's records was categorized into groups 1 (alive patients) and 2 (trauma deaths) and analyzed. DDI incidence was similar in group 1 (1.8%) and group 2 (1.9%). Autopsy analysis (163 patients) yielded 139 MI in 94 patients (57.6%), <3 per cent of MI had negative impact on survival. Bony injuries comprised 68 per cent of DDI and 19 per cent of MI. Group 1 DDI patients were sicker with higher injury severity score (ISS: 16.07) than their cohorts (ISS 7.13, P value <0.05). These patients had higher Glasgow Coma Scale (14.41) and lower ISS (16.07) as compared with group 2 MI patients (ISS: 33.49, GCS: 6.45, P value < 0.05). Autopsy rate was 99.5 per cent in trauma deaths, 57 per cent for nontrauma deaths, and 79 per cent for all deaths. Less than 3 per cent of MI had negative impact on survival. Routine ongoing patient assessment with pertinent diagnostic workup is essential in reducing DDI. Trauma autopsies reveal MI, which aid performance improvement (PI).     

Cirrhosis and trauma: a deadly duo

It has been previously reported that trauma patients with cirrhosis undergoing emergency abdominal operations exhibit a fourfold increase in mortality independent of their Child's classification. We undertook this review to assess the impact of cirrhosis on trauma patients. We reviewed the records of patients from 1993 to 2003 with documented hepatic cirrhosis and compared them to a 2:1 control population without hepatic cirrhosis and matched for age, sex, Injury Severity Score (ISS), and Glasgow Coma Score (GCS). Demographic, severity of injury, and outcome data were recorded. Student's t test and X2 were used for statistical analysis and a P < 0.05 was significant. Sixty-one patients had documented cirrhosis and were compared to 156 matched controls. Comparing the two groups demonstrates there was no difference in age, ISS, or GCS. Intensive care stay, hospital length of stay, blood requirements in the first 24 hours postinjury, and mortality (33% vs 1%) was significantly greater in the trauma patients with cirrhosis. Fifty-five per cent of deaths in the cirrhosis group was due to sepsis, and, as the Child's class increases, so does the mortality (Child's A, 15%; B, 37%; and C, 63%). In 64 per cent of cirrhotics without an emergent abdominal operation, mortality was 21 per cent. In the 36 per cent of cirrhotics who had emergent abdominal operation, mortality was 55 per cent. Hepatic cirrhosis in trauma patients, regardless of severity of injury or the need for an abdominal intervention, is a poor prognostic indicator. The necessity of an abdominal operative intervention further amplifies this effect. Trauma and cirrhosis is, in fact, a deadly duo.     

Old age as a criterion for trauma team activation

BACKGROUND: Elderly trauma patients have been shown to have a worse prognosis than young patients. Age alone is not a criterion for trauma team activation (TTA). In the present study, we evaluated the role of age > or = 70 years as a criterion for TTA. METHODS: The present study was a trauma registry study that included injured patients 70 years of age or older. Patients who died in hospital, were admitted to the intensive care unit (ICU) within 24 hours, or had a non-orthopedic operation were assumed to benefit from TTA. RESULTS: During a 7.5-year period, 883 elderly (> or = 70 years) trauma patients meeting trauma center criteria were admitted to our center. Overall, 223 patients (25%) met at least one of the standard TTA criteria. The mortality in this group was 50%, the ICU admission rate was 39%, and a non-orthopedic operation was required in 35%. The remaining 660 patients (75%) did not meet standard TTA criteria. The mortality was 16%, the need for ICU admission was 24%, and non-orthopedic operations were required in 19%. Sixty-three percent of patients with severe injuries (Injury Severity Score > 15) and 25% of patients with critical injuries (Injury Severity Score > 30) did not have any of the standard hemodynamic criteria for TTA. CONCLUSION: Elderly trauma patients have a high mortality, even with fairly minor or moderately severe injuries. A significant number of elderly patients with severe injuries do not meet the standard criteria for TTA. It is suggested that age > or = 70 years alone should be a criterion for TTA.     

Relationship between serum glucose and injury severity score in childhood trauma.

PURPOSE: The aim of this study was to examine the relationship between initial serum glucose and injury severity score (ISS) in children with multiple trauma. METHODS: Charts from all patients 0 to 19 years of age admitted to a children's hospital in 1995 with acute multiple trauma were reviewed. Data collected included initial serum glucose level, heart rate (HR), systolic blood pressure (SBP), Injury Severity Score (ISS), age, gender, location of trauma, and need for intravenous fluids or epinephrine. Data were analyzed using multiple linear regression. RESULTS: A total of 185 charts were reviewed. The mean ISS was 11.3; the mean glucose was 162.8 mg/dL. After adjusting for age, gender, HR, SBP, and administration of epinephrine or fluid bolus, a significant direct relationship between serum glucose and ISS was found (r = 0.52, P < .01). A stronger relationship was found in children less than 2 years old (r = 0.60, P = .04). CONCLUSIONS: A significant direct relationship exists between glucose and ISS in children with multiple trauma. High glucose values may indicate more severe injury, especially in children less than 2 years old.     

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.     

Improved removal rates for retrievable inferior vena cava filters with the use of a 'filter registry'

The American Association for the Surgery of Trauma challenged the trauma community to improve a 22 per cent average removal rate for retrievable inferior vena cava filters (r-IVCFs). Since 2006, we maintained a "filter registry" documenting all IVCFs placed in trauma patients. Our goal was to improve removal rates for r-IVCF. Patients receiving an IVCF before implementation of filter registry, 2003-2005, comprised the control group. Patients receiving an IVCF after implementation of filter registry, 2006-2009, comprised the study group. Data obtained included age, gender, Injury Severity Score (ISS), length of stay (LOS), mortality, filter inserted, placement indication, removal rates, and reasons why removal did not occur. Fisher exact test and chi square were used for nominal variables. Stepwise logistic regression analysis was used to define predictors of removing and not removing an IVCF. Three hundred seven patients received an IVCF, 142 preregistry and 165 postregistry. No significant difference existed between groups in age, gender, ISS, placement indication, or mortality. A significant difference existed between groups in LOS and presence of deep vein thrombosis (DVT) and pulmonary embolism. A total of 98.2 per cent of postregistry patients received a Günther Tulip filter and all retrievals were performed by Interventional Radiology. Retrieval rates improved, 15.5 to 31.5 per cent post registry (P < 0.001). No differences existed in lost to follow-up (LTF) between groups. Univariate analysis identified age, IVC clot, DVT, and LTF as predictors for not removing a filter. Stepwise logistic regression revealed the filter registry independently predicts the removal of an r-IVCF. A filter registry is effective in improving rates of removal for r-IVCFs.     

Beneficial effect of helicopter emergency medical services on survival of severely injured patients

BACKGROUND: In Rotterdam, the Netherlands, a helicopter-transported medical team (HMT), staffed with a trauma physician, provides additional therapeutic options at the scene of injury. This study evaluated the influence of the HMT on the chance of survival of severely injured trauma victims. METHODS: This was a 2-year prospective observational study of consecutive adults who suffered multiple trauma (Injury Severity Score (ISS) 16 or more) and presented to the Erasmus Medical Centre emergency ward. The effect of the HMT was quantified by an odds ratio (OR), adjusted for confounding variables in logistic regression models. RESULTS: Complete data for a total of 346 patients were available for analysis. Two hundred and thirty-nine patients were treated by ambulance personnel alone and 107 received additional HMT assistance. Patients in the HMT group had significantly lower Glasgow Coma Scale scores (mean 8.9 versus 10.6; P = 0.001) and a higher ISS (mean 30.9 versus 25.3; P < 0.001). The unadjusted OR for death was 1.7 in favour of the group treated by ambulance staff only (OR for survival 0.61 (95 per cent confidence interval (c.i.) 0.37 to 1.0, P = 0.048)). After adjustment, however, patients in the HMT group had an approximately twofold better chance of survival (all injuries: OR 2.2 (95 per cent c.i. 0.92 to 5.9), P = 0.076; blunt injuries: OR 2.8 (95 per cent c.i. 1.07 to 7.52), P = 0.036). CONCLUSION: The presence of the HMT may increase chances of survival for patients suffering multiple trauma, especially for those with blunt trauma.     

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.     

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.     

Preexisting conditions and mortality in older trauma patients

BACKGROUND: Among older trauma patients, those with preexisting chronic medical conditions (CMCs) appear to have an elevated risk of death. Whether this association is dependent on the severity of injury or other occult factors remains unanswered. This study evaluated the association between preexisting CMCs and risk of death among older trauma patients according to injury severity. METHODS: This was a retrospective cohort study using data from the National Trauma Data Bank, a registry of trauma patients admitted to 131 trauma centers across the United States. The main outcome measure was in-hospital mortality. RESULTS: In patients 50 to 64 years of age who sustain severe (Injury Severity Score [ISS] of 26+) and moderate injuries (ISS of 16-25), the presence of one or more CMCs is not associated with an increased relative risk (RR) of death (RR, 0.80 and 95% confidence interval [CI], 0.71-0.90; RR, 1.09 and 95% CI, 0.95-1.24, respectively). Those with minor injuries (ISS < 16) have increased risk of death (RR, 2.80; 95% CI, 2.33-3.36). For those patients 65 years of age and older who sustain severe, moderate, and minor injuries, the pattern of results is similar (RR, 0.91 and 95% CI, 0.83-1.00; RR, 1.13 and 95% CI, 1.04-1.23; and RR, 1.88 and 95% CI, 1.73-2.05, respectively). CONCLUSION: Older trauma patients with CMCs who present with minor injuries should be considered to have an increased risk of death when compared with their nonchronically ill counterparts.     

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.     

The effects of methamphetamine use on trauma patient outcome

A retrospective review was conducted to analyze the effect of methamphetamine use in trauma patients. Charts of all trauma patients admitted to Kern Medical Center from January 1, 2003, to January 5, 2006 (36 months) were analyzed for length of stay, intensive care unit (ICU) admission rate and number of ICU days, ventilator days, and mortality. Results were compared in patients testing positive for methamphetamine (M+) with those who tested negative (M-). Data were then stratified according to six Injury Severity Score (ISS) groups: 1-5, 6-10, 11-15, 16-20, 21-25, and 26-30. A total of 4759 patients were admitted to the trauma unit, 971 of whom had available urine toxicology results. Six hundred seventy-four tested M- and 297 tested M+. There were no differences in total ICU days or ventilator days in the M+ versus M- patients. There was a higher incidence of assault in the M+ group (P = 0.0001). A trend toward decreased mortality was noted in M+ patients (P = 0.0778). ISS subset analysis demonstrated an increased ICU admission rate in M+ patients in ISS group 1-5 (P = 0.0002). There was also an increased length of stay in M+ patients within the ISS 6-10 group (8 versus 5 days, respectively, P = 0.015).