Geriatric trauma: injury patterns and outcome

Over a 2-year period, 100 consecutive patients more than 70 years of age with multiple injuries were evaluated at a metropolitan trauma center for injury patterns and factors that affected survival. The analysis incorporated mechanism of injury, body region affected, Injury Severity Score, shock, change from level of prehospital function, and mortality. The mortality for the group was 15%. It was found that the Injury Severity Score was not predictive of survival in the elderly injured. However, central nervous system injury (p less than 0.01) and hypovolemic shock (p less than 0.001) were predictive of survival. While 85% of the injured patients survived, 88% of these did not return to their previous level of independence.     

Complications of preinjury warfarin use in the trauma patient

BACKGROUND: The frequency of use of warfarin anticoagulation increases significantly in the elderly population. It remains controversial whether this puts these patients at increased risk for hemorrhagic complications after trauma. METHODS: We prospectively evaluated consecutive trauma patients who were taking warfarin and compared their outcomes to a group of age-matched patients with head injuries but not taking warfarin. RESULTS: One hundred fifty-nine trauma patients on warfarin were evaluated, 94 (59%) with some type of head trauma; 25 of these 94 patients (27%) had documented intracranial trauma. Fifteen patients died (9.4%); they had an international normalized ratio of 3.3 +/- 1.6 versus 3.0 +/- 2.1 for survivors in the warfarin group (p = 0.585). Twelve deaths were in the group of 25 patients with intracranial injuries (48%). Three patients without head injury died (5%) of other causes not related to warfarin or hemorrhage at a mean of 13 days after admission. Ten of 12 patients on warfarin with intracranial injuries who died had documented loss of consciousness (LOC); two patients who died secondary to an isolated intracranial injury had no LOC. Of 70 age-matched patients with head trauma not taking warfarin, 47 (67%) had intracranial injury and 5 of these died (10%) (p < 0.001 for both values compared with study patients). There were no significant differences for patients with intracranial injury comparing those on warfarin and those who were not in terms of age, gender, mechanism of injury, Injury Severity Score, or Glasgow Come Scale score. CONCLUSION: We conclude that the preinjury use of warfarin does not place the trauma patient at increased risk for fatal hemorrhagic complications in the absence of head trauma. Furthermore, the presence of a head trauma alone is not predictive of mortality. However, the presence of intracranial injury is strongly associated with a mortality rate that is significantly higher than patients with head trauma who are not taking warfarin. LOC is also associated with mortality, but the absence of loss of consciousness does not reliably indicate the absence of intracranial injury or risk of death.     

Prehospital endotracheal intubation for trauma does not improve survival over bag-valve-mask ventilation

BACKGROUND: Few data exist supporting a survival benefit to prehospital endotracheal intubation (ETI) over bag-valve-mask ventilation (BVM) in trauma patients. METHODS: Data were reviewed from all trauma patients transported to our Level I trauma center receiving prehospital ETI or BVM. Mortality was adjusted by age, Revised Trauma Score, Injury Severity Score, and mechanism of injury (penetrating vs. blunt). RESULTS: Of 5,773 patients, 316 (5.5%) had ETI and 217 (3.8%) had BVM. Patients receiving ETI were significantly more like to die (88.9% vs. 30.9%, p < 0.0001). When corrected for Injury Severity Score, Revised Trauma Score, and mechanism of injury, ETI was associated with similar or greater mortality than BVM. ETI patients had longer prehospital times (22.0 vs. 20.1 minutes, p = 0.0241). CONCLUSION: In our trauma system, when corrected for mechanism and severity of anatomic and physiologic injury, ETI confers no survival advantage over BVM and slightly increases prehospital time.     

Urgent airway intervention: does outcome change with personnel performing the procedure?

BACKGROUND: Recent studies indicate that prehospital endotracheal intubation (PHEI) is associated with increased septic morbidity. Because the decision to intubate in the field is considered a life-sustaining mandate we analyzed our experience to validate these reports and to compare field intubation to that done in more controlled circumstances on patient arrival at the trauma center. METHODS: The registry of our Level l trauma center was queried from January 2002 through December 2003 for patients who required emergent EI and had a hospital stay > 2 days. Patients were stratified by site of EI into PHEI and trauma center intubation (TCEI). Demographic data (age, gender, Glasgow Comma Scale, Injury Severity Score) as well as outcome measures (incidence of pneumonia [PNA], Intensive Care Unit length of stay [ICU LOS], hospital length of stay [hospital LOS], and mortality) were compared between groups. Results were subjected to chi2 or unpaired t test, accepting p < 0.05 as significant. RESULTS: The 628 patients requiring EI consisted of 27l in PHEI and 357 in TCEL. When comparing these groups, PHEI were more severely injured (lower Glasgow Comma Scale score and higher Injury Severity Score), but had no other differences in demographics or in measured outcome variables. Within these groups, patients who developed PNA were comparable. They demonstrated similar time of onset of PNA after injury and had similar incidence of resistant organisms (46%). CONCLUSIONS: These data demonstrate no increased risk of PNA for urgent prehospital intubation. Moreover, the onset of PNA and the similar bacteriology is reflective of injury severity and not of additional infectious risk posed by these prehospital lifesaving maneuvers.     

Reanalysis of prehospital intravenous fluid administration in patients with penetrating truncal injury and field hypotension

In 1994, Bickell et al. published a prospective study recommending restricting prehospital intravenous fluids (IVF) to less than 100 cc in patients with penetrating truncal injuries and field hypotension, reporting a 30 per cent mortality with IVF restriction and a 38 per cent mortality with liberal IVF use. However, since this study, few papers have investigated whether emergency medical systems (EMS) adhere to these IVF guidelines. The purpose of this study was to determine whether a policy of IVF restriction is being followed and whether the volume of prehospital and emergency department (ED) IVF affects outcome in patients with penetrating truncal injury and field hypotension at a Level I trauma center in Los Angeles County. A retrospective analysis of a trauma database from 1998 to 2005 of all patients with penetrating truncal injury and field hypotension (systolic blood pressure less than 90 mm Hg) was performed. Multiple variables, including originating EMS agency, mechanism of injury, transport time, Injury Severity Score, field and ED vital signs, and IVF volume infused, complications, and mortality were compared. One hundred ninety-four patients with a median age of 26 years with penetrating truncal injury and field hypotension were analyzed. The most common mechanisms of injury were gunshot (73%) and stab (22%) wounds. The median field systolic blood pressure was 80 mm Hg. The median transport time was 11 minutes. The median prehospital IVF was 500 cc with only 25 per cent receiving less than 100 cc of IVF. There were no differences in the amount of IVF administered by the degree of field hypotension or by originating EMS agency. Median ED IVF was 1000 cc. The overall mortality rate was 25 per cent. When a comparison was made of those receiving less than 100 cc prehospital IVF in comparison to those receiving greater than 100 cc, there were no differences detected with respect to median age, systolic blood pressure, Injury Severity Score, transport time, or morbidity rate. The mortality rate was 21 per cent in the group that received greater than 100 cc of IVF in comparison to a 37 per cent mortality rate in the group that received less than 100 cc IVF (P = 0.04). On multivariate analysis, after adjusting for Trauma Injury Severity Score, there were no differences in survival by the amount of prehospital or ED IVF administered. It appears that the recommendations of IVF restriction for patients with penetrating truncal injuries and field hypotension are not being followed by Los Angeles County EMS. There were no differences in survival with respect to the amount of prehospital or ED IVF. Given the retrospective nature of this study, further investigation is needed to define the role of prehospital IVF resuscitation in these patients.     

Endotracheal intubation in the field does not improve outcome in trauma patients who present without an acutely lethal traumatic brain injury

OBJECTIVES: There is an absence of prospective data evaluating the impact of prehospital intubation in adult trauma patients. Our objectives were to determine the outcome of trauma patients intubated in the field who did not have an acutely lethal traumatic brain injury (death within 48 hours) compared with patients who were intubated immediately on arrival to the hospital. METHODS: Prospective data were collected on 191 consecutive patients admitted to the trauma center with a field Glasgow Coma Scale score < or = 8 and a head Abbreviated Injury Scale score > or = 3 who were either intubated in the field or intubated immediately at admission to the hospital. Patients who died within 48 hours of admission and transfers were excluded from the study. RESULTS: Of the 191 patients, 176 (92%) sustained blunt trauma and 25 (8%) were victims of penetrating trauma. Seventy-eight (41%) of the 191 patients were intubated in the field and 113 (59%) were intubated immediately at admission. There was no significant difference in age, Glasgow Coma Scale score, head Abbreviated Injury Scale score, or Injury Severity Score between the two groups. Patients who were intubated in the field had a significantly higher morbidity (ventilator days, 14.7 vs. 10.4; hospital days, 20.2 vs. 16.7; and intensive care unit days, 15.2 vs. 11.7) compared with patients intubated on immediate arrival to the hospital and nearly double the mortality (23% vs. 12.4). Field-intubated patients had a 1.5 times greater risk of nosocomial pneumonia compared with hospital-intubated patients. CONCLUSION: Prehospital intubation is associated with a significant increase in morbidity and mortality in trauma patients with traumatic brain injury who are admitted to the hospital without an acutely lethal injury. A randomized, prospective study is warranted to confirm these results.     

The impact of pre-existing end-stage renal disease on survival in acutely injured trauma patients.

End-stage renal disease and associated dialysis procedures alter homeostatic mechanisms and adversely affect the respiratory, cardiac, and central nervous systems. Currently outcomes research in acutely injured trauma patients utilizes Trauma and Injury Severity Score methodology with the Injury Severity Score and Revised Trauma Score, which do not account for comorbidities. Literature has yet to emerge that analyzes the effects of end-stage renal disease on acutely injured trauma patients. A retrospective review at an urban Level I trauma center was performed of all end-stage renal disease patients' medical records who were admitted for acute traumatic injury from 1994 through 1997. The charts were abstracted for age, sex, race, method of dialysis, specific injury, need for operation, etiology of trauma, length of stay, disposition from hospital, morbidity, and mortality. The Injury Severity Score; probability of survival; and W, M, and Z statistics were then calculated. The data collected were then compared with the overall data for the trauma center including patients with and those without end-stage renal disease during this time period. Mortality for patients with end-stage renal disease after suffering an acute traumatic injury is 2.45 that of the general population. Increased mortality was most prevalent in operative patients and those with Injury Severity Score >15. The average length of stay in the hospital was 55.3 per cent longer for patients with end-stage renal disease. Pre-existing end-stage renal disease negatively impacts survival after traumatic injury. A prospective multicentered study comparing renal patients with nonrenal patients is warranted. This would confirm the need for databases to account for the increased morbidity and mortality associated with end-stage renal disease when calculating probability of survival values for acutely injured trauma patients. Similarly future studies analyzing the affects of other comorbidities such as diabetes, chronic obstructive pulmonary disease, and hypertension on acutely injured trauma patients would help develop a more accurate method of predicting outcomes.     

Effect of prehospital advanced life support on outcomes of major trauma patients

OBJECTIVE: Determine whether prehospital advanced life support (ALS) improves the survival of major trauma patients and whether it is associated with longer on-scene times. METHODS: A 36-month retrospective study of all major trauma patients who received either prehospital bag-valve-mask (BVM) or endotracheal intubation (ETI) and were transported by paramedics to our Level I trauma center. Logistic regression analysis determined the association of prehospital ALS with patient survival. RESULTS: Of 9,451 major trauma patients, 496 (5.3%) had either BVM or ETI. Eighty-one percent received BVM, with a mean Injury Severity Score of 29 and a mortality rate of 67%; 93 patients (19%) underwent successful ETI, with a mean Injury Severity Score of 35 and a mortality rate of 93%. Adjusted survival for patients who had BVM was 5.3 times more likely than for patients who had ETI (95% confidence interval, 2.3-14.2, p = 0.00). Survival among patients who received intravenous fluids was 3.9 times more likely than those who did not (p = not significant). Average on-scene times for patients who had ETI or intravenous fluids were not significantly longer than those who had BVM or no intravenous fluids. CONCLUSION: ALS procedures can be performed by paramedics on major trauma patients without prolonging on-scene time, but they do not seem to improve survival.     

Intensive care unit outcome of vehicle-related injury in elderly trauma patients

Vehicle-related trauma is a common mechanism of injury in elderly (age > or = 65 years) trauma patients. Several hospital-based studies have shown that patients with pedestrian injury have a higher mortality compared with those with motor vehicle collision (MVC) injury partially because of older patients found in the former group. In addition the injury patterns also differ significantly between these two mechanisms of vehicle-related trauma. The purpose of the present study is to compare the demographics, injury severity, injury patterns, and outcomes of elderly patients with pedestrian injury admitted to a surgical intensive care unit (SICU) of a Level I trauma center between January 1, 1994 and December 31, 2000 with those admitted with MVC injury. During the study period there were 187 elderly patients admitted to the surgical intensive care unit with vehicle-related injury. Fifty-one per cent of the patients had MVC injury. Patients were divided into two groups based on their mechanisms of injury (pedestrian vs MVC) for comparison. There was no difference in the mean age and gender between the two groups. Injury Severity Score, admission Simplified Acute Physiology Score, and mortality were significantly higher in the pedestrian group compared with the MVC group. Using logistic regression analysis three factors were found to be independently predictive of mortality: Simplified Acute Physiology Score, intracranial hemorrhage with mass effect on CT scan, and cardiac complications.     

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.     

Prognosis of penetrating trauma in elderly patients: a comparison with younger patients

BACKGROUND: It has previously been shown that elderly patients have a worse prognosis than their younger counterparts after sustaining blunt trauma. This is due in part to a higher incidence of comorbid conditions as well as less physiologic reserve in an elderly population sustaining largely blunt trauma. We compared the outcome after penetrating trauma in elderly patients to matched "younger" patients to determine whether they had a similarly poor prognosis. METHODS: Elderly patients (> or = 65 years) were identified from our trauma registry. Sex, mechanism of injury, and Abbreviated Injury Score/Injury Severity Score were determined from the registry. Patients presenting with traumatic arrest were excluded. The registry was then searched for patients aged 15 to 40 years with the same sex, mechanism of injury, and Abbreviated Injury Score in each region. A chart review was then performed to determine additional details of their hospital stay. The two groups were then compared using Student's t test and Fisher's exact chi2 test, as appropriate. RESULTS: Eighty-five elderly patients (OLD group) were admitted with penetrating trauma between 1983 and 1998. They were compared with 85 matched young patients (YOUNG group). Each group included 66 male and 19 female patients. In each group, gunshot wounds occurred in 45.9%, stab wounds in 52.9%, and shotgun wounds in 1.2% of patients. The average Injury Severity Score in each group was 5.5 +/- 5.6 (range, 1-29) and the regional Abbreviated Injury Scores were likewise equal in both groups. The OLD patients had an average hospital stay of 6.9 +/- 9.1 days compared with 4.3 +/- 5.7 days in the YOUNG patients (p < 0.05). Twenty-seven OLD patients spent 7.3 +/- 9.2 days in the intensive care unit compared with 19 YOUNG patients who stayed 3.4 +/- 3.2 days (p < .05). A total of 91 comorbidities were identified in 58 OLD patients compared with 18 in 15 YOUNG patients (p < .0001). Eighty-six invasive procedures were performed in the OLD group compared with 96 in the YOUNG group (p = not significant). Nineteen OLD patients (22.3%) and 15 YOUNG patients (17.6%) suffered one or more complications, including death (p = not significant). A total of 91% of surviving OLD patients were discharged to home compared with 100% of surviving YOUNG patients (p < .01). CONCLUSION: Elderly patients who sustain penetrating trauma have more comorbidities than their younger counterparts. This may account for their longer hospital stay and lesser ability to be discharged home. These patients do not have an increased complication rate and should continue to be managed aggressively.     

Effects of antiplatelet agents on outcomes for elderly patients with traumatic intracranial hemorrhage

BACKGROUND: Recent literature on elderly patients with traumatic intracranial hemorrhage receiving preinjury antiplatelet agents shows a mortality rate of 47%. METHODS: In a retrospective analysis, patients older than 50 years presenting to the hospital over the past 4 years with traumatic intracranial hemorrhage and the use of aspirin, clopidogrel, or a combination were compared with a control group that had hemorrhage but no antiplatelet medications. Patient demographics, mechanism of injury, and injury scores were recorded. RESULTS: No significant differences were found between the 90 study patients and the 89 control subjects in terms of demographics, mechanism of injury, Injury Severity Score, Glasgow Coma Score, or hospital length of stay. Patients receiving antiplatelet therapy had significantly more comorbid conditions (71% vs. 35%; p < 0.001). In this series, 21 study patients and 8 control patients died (23% vs. 8.9%; p = 0.016). Age older than 76 years and a Glasgow Coma Score lower than 12 were correlated significantly with increased mortality. CONCLUSIONS: The use of antiplatelet agents with elderly trauma patients significantly increases the risk of mortality when head injury involves intracranial hemorrhage.     

Intracranial complications of preinjury anticoagulation in trauma patients with head injury

BACKGROUND: We have evaluated our recent experience as a Level I trauma center to test the hypothesis that preinjury anticoagulation adversely affects the morbidity and mortality of trauma patients with an intracranial injury. METHODS: Records of 380 patients admitted to the trauma service from January 1997 to December 1998 who at the time of admission were taking warfarin, low-molecular-weight heparin, aspirin, nonsteroidal anti-inflammatory drugs, clopidogrel, dipyridamole, pentoxifylline, or naproxen were reviewed. Thirty-seven patients with intracranial injuries were identified and compared with a matched (age, gender, mechanism, and severity of injury) control group of 37 patients with similar head injury but not taking any anticoagulant randomly selected from the trauma registry for that same time period. RESULTS: The control and anticoagulated groups were comparable in terms of age, 75 +/- 8 versus 74 +/- 11 years (p = 0.655); gender, 22 men/15 women versus 21 men/16 women; mechanism of injury, 30 falls/7 motor vehicle crashes versus 30 falls/7 motor vehicle crashes; and length of hospital stay, 11 +/- 14 versus 10 +/- 11 days (p = 0.853). In the anticoagulated group, the mean Injury Severity Score was 17.0 +/- 7.8 and the mean Glasgow Coma Scale score was 11.8 +/- 4.0; these were not significantly different from the control group, which had a mean Injury Severity Score of 19.8 +/- 8.1 (p = 0.143) and a Glasgow Coma Scale score of 12.5 +/- 2.6 (p = 0.378). There were 14 deaths (38%) in the anticoagulation group, versus 3 deaths in the control group (8%) (p = 0.006). In the anticoagulation group, 4 of 12 patients (33%) taking warfarin died, whereas 9 of 19 patients (47%) taking aspirin died (p = 0.285). All deaths were secondary to head injuries; all deaths in the control group and all but one in the anticoagulated group were the result of a fall; 6 of 10 anticoagulated patients who fell on stairs died, and 5 of these were taking aspirin only. CONCLUSION: These data indicate that the trauma patient with preinjury anticoagulation such as warfarin or even aspirin who has an intracranial injury has a four- to fivefold higher risk of death than the nonanticoagulated patient. The efficacy of reversing the anticoagulant effect at the time of hospital admission remains to be evaluated.     

Acute traumatic coagulopathy

BACKGROUND: Traumatic coagulopathy is thought to be caused primarily by fluid administration and hypothermia. METHODS: A retrospective study was performed to determine whether coagulopathy resulting from the injury itself is a clinically important entity in severely injured patients. RESULTS: One thousand eight hundred sixty-seven consecutive trauma patients were reviewed, of whom 1,088 had full data sets. Median Injury Severity Score was 20, and 57.7% had an Injury Severity Score > 15; 24.4% of patients had a significant coagulopathy. Patients with an acute coagulopathy had significantly higher mortality (46.0% vs. 10.9%; chi2, p < 0.001). The incidence of coagulopathy increased with severity of injury, but was not related to the volume of intravenous fluid administered (r2 = 0.25, p < 0.001). CONCLUSION: There is a common and clinically important acute traumatic coagulopathy that is not related to fluid administration. This is a marker of injury severity and is related to mortality. A coagulation screen is an important early test in severely injured patients.     

Long-term fetal outcomes in pregnant trauma patients

BACKGROUND: Trauma during pregnancy is associated with significant maternal and fetal morbidity and mortality, typically occurring during the hospital admission. Less is known about the delayed effects of trauma on pregnancy outcome once the patient has been discharged from the hospital with a viable fetus. METHODS: A retrospective cohort study was conducted of pregnant trauma patients who were discharged from the trauma center with a viable fetus. Risk of preterm delivery (PTD) and low birth weight (LBW) were compared between injured patients (Injury Severity Score > 0) and those without identified injury (Injury Severity Score = 0), for the remainder of pregnancy. RESULTS: Even after trauma center discharge, injured patients had a nearly 2-fold higher risk of PTD (relative risk, 1.9; 95% confidence interval, 1.1-3.3) and LBW (relative risk, 1.8; 95% confidence interval, 1.04-3.2) for the remainder of the pregnancy. The risk was higher with increasing injury severity and among those injured early in gestation. CONCLUSION: The risk of PTD and LBW in pregnant trauma patients who were discharged from trauma centers with a viable fetus remains increased throughout the remainder of the pregnancy. A history of trauma during gestation is a risk factor for poor pregnancy outcome.     

Liver cirrhosis in patients undergoing laparotomy for trauma: effect on outcomes

BACKGROUND: There is little published work on the effect of cirrhosis on outcomes in trauma patients undergoing laparotomy. The aim of this study was to evaluate the risk of death or serious complications in cirrhotic trauma patients undergoing laparotomy as compared with that in a similar group of patients without cirrhosis. STUDY DESIGN: During a 12-year period, there were 46 patients with the diagnosis of liver cirrhosis made during laparotomy for trauma. Each patient was matched with two noncirrhotic controls on the basis of 7 criteria: age (>55, 25), head Abbreviated Injury Score (<3, >/=3), chest Abbreviated Injury Score (<3, >/=3), and abdominal Abbreviated Injury Score (<3, >/=3). Six cirrhotic patients were excluded because matching was not possible. The remaining 40 patients were matched with 80 noncirrhotic control patients selected from a pool of 4,771 patients who had trauma laparotomies. Outcomes included mortality, ARDS, pneumonia, renal failure, abdominal sepsis, disseminated intravascular coagulopathy, ICU and hospital stay, and hospital charges. Outcomes between the two study groups were compared with conditional logistic analysis. Hazard ratio (95% CI) and adjusted p value with the stepdown Bonferroni method were derived. RESULTS: The overall mortality in the cirrhotic group was significantly higher than that in the matched noncirrhotic group (45% versus 24%, hazard ratio: 7.60 [2.00, 28.94], p = 0.021). Mortality in patients with Injury Severity Score 相似文献   

Morbid obesity impacts mortality in blunt trauma

Twenty-six per cent of adults in the Unites States are obese and trauma remains a major cause of death. We assessed the impact of morbid obesity on mortality in patients with blunt trauma. We reviewed the records of patients with a body mass index 40 kg/m2 or greater injured by blunt trauma from 1993 to 2003 and compared them with a 4:1 control population with a normal body mass index and matched for sex and constellation of injuries. For comparison, patients were categorized by Injury Severity Score 9 or less or Injury Severity Score 10 or greater. Student t test and chi2 were used for statistical analysis. P < 0.05 was considered significant. One hundred seven morbidly obese patients were identified and compared with 458 control subjects with a normal body mass index and matched for sex and constellation of injuries. Although the morbidly obese patients were found to be significantly younger, those who incurred multiorgan injury experienced a significantly longer hospital length of stay and displayed a greater than fourfold increase in mortality when compared with the control subjects. Furthermore, the number of morbidly obese patients admitted over the 10-year period significantly increased by fourfold (0.4% to 1.5%). Over the last decade, there has been a significant increase in morbidly obese patients cared for in our trauma center. Although these patients were significantly younger with a similar Glasgow Coma Score as that of the control population, morbid obesity significantly increased mortality when the injury from blunt trauma transitioned from a single to a multiorgan injury.     

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.     

Does the presence of an upper extremity injury affect outcomes after major trauma?

BACKGROUND: There is a paucity of information about the impact of upper extremity (UE) injuries on patient outcomes, particularly after major trauma. METHODS: Data were obtained from a statewide trauma registry. Cases were defined as major trauma cases (Injury Severity Score > 15) with (UE group) and without (no-UE group) an associated upper extremity injury. Multivariate analysis was performed to identify independent predictors of outcome. RESULTS: Major trauma patients with UE injury were 1.5 times (p = 0.011) more likely than the no-UE group to have a length of stay greater than 7 days. After adjusting for age, mechanism of injury, and Injury Severity Score, UE injury was not an independent predictor of discharge destination. CONCLUSION: In major trauma patients, the presence of an upper extremity injury is a significant predictor of length of stay, indicating a greater complexity and cost of care associated with this group of major trauma patients.     

The outcome of open pelvic fractures in the modern era

BACKGROUND: Recent series have reported that the mortality rate of open pelvic fractures has decreased to < 10%. These injuries are often associated with intra-abdominal visceral damage, although few series have documented the prognostic significance of this injury complex. METHODS: A retrospective review in an urban level I trauma center of all patients who sustained open pelvic fracture between 1995 and 2004. RESULTS: Forty-four patients were identified as having sustained open pelvic fracture. Average Injury Severity Score was 30, with 77% of patients having a score > or = 16. Overall mortality was 45% (n = 20): 11 early deaths and 9 late deaths at an average of 17 days. Vertical shear injuries, although rare, were universally fatal. Other risk factors for overall mortality included revised trauma score, Injury Severity Score, transfusion requirement, Faringer zones I or II injury, Gustilo grade III soft tissue injury, need for therapeutic angiography, and presence of intra-abdominal injury, the latter of which conferred 89% mortality. Risk factors for late deaths also included pelvic sepsis, which occurred in 5 patients and was fatal in 3 (60%). CONCLUSIONS: The morbidity of open pelvic fractures remains high. Associated intra-abdominal injury or active arterial bleeding requiring therapeutic angiography is associated with a grim prognosis. There is a continuing need for new therapeutic approaches to this injury complex.