Abstract
BackgroundTraditional vital signs (TVS), including systolic blood pressure (SBP), heart rate (HR) and their composite, the shock index, may be poor prognostic indicators in geriatric trauma patients. The purpose of this study is to determine whether lactate predicts mortality better than TVS.MethodsWe studied a large cohort of trauma patients age ≥ 65 years admitted to a level 1 trauma center from 2009-01-01 - 2011-12-31. We defined abnormal TVS as hypotension (SBP < 90 mm Hg) and/or tachycardia (HR > 120 beats/min), an elevated shock index as HR/SBP ≥ 1, an elevated venous lactate as ≥ 2.5 mM, and occult hypoperfusion as elevated lactate with normal TVS. The association between these variables and in-hospital mortality was compared using Chi-square tests and multivariate logistic regression.ResultsThere were 1987 geriatric trauma patients included, with an overall mortality of 4.23% and an incidence of occult hypoperfusion of 20.03%. After adjustment for GCS, ISS, and advanced age, venous lactate significantly predicted mortality (OR: 2.62, p < 0.001), whereas abnormal TVS (OR: 1.71, p = 0.21) and SI ≥ 1 (OR: 1.18, p = 0.78) did not. Mortality was significantly greater in patients with occult hypoperfusion compared to patients with no sign of circulatory hemodynamic instability (10.67% versus 3.67%, p < 0.001), which continued after adjustment (OR: 2.12, p = 0.01).ConclusionsOur findings demonstrate that occult hypoperfusion was exceedingly common in geriatric trauma patients, and was associated with a two-fold increased odds of mortality. Venous lactate should be measured for all geriatric trauma patients to improve the identification of hemodynamic instability and optimize resuscitative efforts.
Highlights
Traditional vital signs (TVS), including systolic blood pressure (SBP), heart rate (HR) and their composite, the shock index, may be poor prognostic indicators in geriatric trauma patients
Venous lactate (VL) is an accessible, accurate, validated measurement, and the measurement of admission lactate level may facilitate the recognition of occult hypoperfusion (OH) and shock [9,10,11], as VL is a metabolic indicator of circulatory hemodynamic instability (cHI)
Thirty-two patients (9.64%) with an elevated VL presented with abnormal TVS; the remaining 300 patients (90.36%) presented with OH
Summary
Traditional vital signs (TVS), including systolic blood pressure (SBP), heart rate (HR) and their composite, the shock index, may be poor prognostic indicators in geriatric trauma patients. Trauma team activation, and early resuscitation of trauma patients is often directed by the presence of abnormal traditional vital signs (TVS) such as systolic blood pressure (SBP) and heart rate (HR), as these measures are physical signs of circulatory hemodynamic instability (cHI). Geriatric patients respond to trauma and shock differently than their younger counterparts due to the presence of comorbid conditions, decreased physiologic reserve, elasticity of the vascular system, and concomitant medication use. Decreased physiologic reserve reduces the ability to respond to injury or tolerate aggressive resuscitation [4], while polypharmacy can alter the hemodynamic response to shock and complicate the patient’s clinical picture [5]. Venous lactate (VL) is an accessible, accurate, validated measurement, and the measurement of admission lactate level may facilitate the recognition of occult hypoperfusion (OH) and shock [9,10,11], as VL is a metabolic indicator of cHI
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