Futility of Resuscitation among Geriatric Trauma Patients: Do We Need to Define When to Withdraw Care?

Abstract

Introduction: Survival<10% has been described as the point where risks outweigh benefits for trauma patients, and where withdrawal-of-care may be considered. There is little to no data describing futility of resuscitation (FR) in geriatric trauma. Such data would inform withdrawal-of-care decision-making for injured geriatric patients and their families while reducing potentially inappropriate healthcare resource-use. Study aims to identify characteristics associated with FR among geriatric trauma patients. Methods: We analyzed the 2018 ACS-TQIP. We included all severely injured (ISS>15) geriatric trauma patients(≥65yrs). FR was. Patients were stratified into decades of age and resuscitative endpoints and intervention employed were identified. Outcome was FR (any intervention/endpoint that was associated with >90% mortality). Results: 46,339 patients were identified (65-75yrs: 42%; 75-85yrs: 40%; ≥85yrs: 18%). Mortality was 18%, ISS was 21[17-26], 57% male, and 85% blunt-injury. ED-thoracotomy among those >65yrs, and prehospital cardiac-arrest and REBOA among those >85yrs were associated with FR. Transfusion of >40U PRBC or FFP within 24hrs was associated with FR. 4-hour PRBC volumes associated with FR were: 65-75yrs:>30U; 75-85yrs:>27U; >85yrs:>21U. Increasing age was associated with increasing mortality among those who received emergency laparotomy or vasopressors, but did not reach FR. Lowest in-hospital SBP < 50mmHg was associated with FR among those>85yrs. Conclusion: ED-thoracotomy and transfusions >40U of product are futile in anyone over 65. REBOA is futile in anyone over 85. Resuscitation is futile in all super-elderly with prehospital cardiac arrest or an episode of profound hypotension. Further studies redefining FR among the geriatric trauma patient population to include lower mortality rates may be warranted.