Geriatric Blunt Trauma Patients Research Articles

Beyond the short-term relief: Outcomes of geriatric rib fracture patients receiving paravertebral nerve blocks and epidural analgesia

BackgroundAdequate pain control is a critical component of rib fracture management. Our study aimed to evaluate the in-hospital and post-discharge outcomes of geriatric rib fracture patients who received paravertebral nerve block (PVNB) versus epidural analgesia (EA) on a national level. MethodsWe performed a 5-year (2011–15) retrospective analysis of the Nationwide Readmission database. We included all the geriatric (≥65 years) blunt trauma patients with rib fractures who received a paravertebral nerve block (PVNB) or Epidural analgesia (EA) for chest injuries. We excluded patients who were dead on arrival, those with head AIS≥3, spine AIS >0, and those with cognitive impairment. Patients were stratified into two groups (PVNB and EA). A propensity score matching (1:2) was performed, and the two groups were compared. Our outcomes included delirium, hospital length of stay (LOS), 90-day readmissions, 90-day mechanical ventilation, and initial and 90-day mortality. ResultsA total of 2,855 geriatric rib fracture patients were identified, out of which 352 (12 %) received PVNB and 2,503 (87 %) received EA. The mean (SD) age was 78 (8) years and 53 % were female. A total of 1,041 patients were matched (PVNB=347, EA=694 patients). The median [IQR] Injury severity score was 9 [3–15], median chest AIS was 3 [2–4], and 70 % had ≥3 rib fractures. The total mortality during index admission was 6 %, 13 % experienced delirium, and the median hospital LOS was 6 [4–10] days. There was no difference in the primary outcomes of the two groups including rates of index admission mortality (PVNB: 5.2% vs. EA:6.3 %, p = 0.548) and delirium (PVNB: 12.4% vs. EA:12.9 %, p = 0.862). We also found no statistically significant difference between these groups in terms of 90-day respiratory complications (p = 1.000), 90-day readmission (p = 0.111), 90-day mortality (p = 0.718), and 90-day need for mechanical ventilation (p = 1.000). ConclusionThe use of PVNB in geriatric trauma patients with multiple rib fractures is associated with comparable in-hospital and post-discharge outcomes relative to EA. PVNB is relatively easy to perform and has a better side effect profile. The use of PVNB as part of rib fracture management protocols warrants further consideration. Level of evidenceIII Study typeTherapeutic/Care Management

Comments on “Effect of coolant spray on rib fracture pain of geriatric blunt thoracic trauma patients: a randomized controlled trial”

Comments on “Effect of coolant spray on rib fracture pain of geriatric blunt thoracic trauma patients: a randomized controlled trial”

Development of Imaging Criteria for Geriatric Blunt Trauma Patients

IntroductionCurrent decision tools to guide trauma computed tomography (CT) imaging were not validated for use in older patients. We hypothesized that specific clinical variables would be predictive of injury and could be used to guide imaging in this population to minimize risk of missed injury. MethodsBlunt trauma patients aged 65 y and more admitted to a Level 1 trauma center intensive care unit from January 2018 to November 2020 were reviewed for histories, physical examination findings, and demographic information known at the time of presentation. Injuries were defined using the patient's final abbreviated injury score codes, obtained from the trauma registry. Abbreviated injury score codes were categorized by corresponding CT body region: Head, Face, Chest, C-Spine, Abdomen/Pelvis, or T/L-Spine. Variable groupings strongly predictive of injury were tested to identify models with high sensitivity and a negative predictive value. ResultsWe included 608 patients. Median age was 77 y (interquartile range, 70-84.5) and 55% were male. Ground-level fall was the most common injury mechanism. The most commonly injured CT body regions were Head (52%) and Chest (42%). Variable groupings predictive of injury were identified in all body regions. We identified models with 97.8% sensitivity for Head and 98.8% for Face injuries. Sensitivities more than 90% were reached for all except C-Spine and Abdomen/Pelvis. ConclusionsDecision aids to guide imaging for older trauma patients are needed to improve consistency and quality of care. We have identified groupings of clinical variables that are predictive of injury to guide CT imaging after geriatric blunt trauma. Further study is needed to refine and validate these models.

Chest and Pelvis X-Rays as a Screening Tool for Abdominal Injury in Geriatric Blunt Trauma Patients

This study evaluates the utility of chest (CXR) and pelvis (PXR) X-ray, as adjuncts to the primary survey, in screening geriatric blunt trauma (GBT) patients for abdominal injury or need for laparotomy. We performed a retrospective analysis of patients 65-89years in the 2014 National Trauma Data Bank. X-ray injuries were identified by ICD9 codes and defined as any injury felt to be readily detectable by a non-radiologist. X-ray findings were dichotomized as "both negative" (no injury presumptively apparent on CXR or PXR) or "either positive" (any injury presumptively apparent on CXR or PXR). Rates of abdominal injuries and laparotomy were compared and used to calculate sensitivity and specificity. The primary outcomes were abdominal injury and laparotomy. The secondary outcomes included mortality, ventilator days, and hospital days. A total of 202553 patients met criteria. Overall, 9% of patients with either positive X-rays had abdominal injury and 2% laparotomy vs. 1.1% and .3% with both negative (P < .001). The specificity for any positive X-ray was 79% for abdominal injury and 78% for laparotomy. The sensitivity was 69% for abdominal injury and laparotomy. The either positive group had fewer ventilator days (.3 vs. .8, P < .0001), longer length of stay (7 vs. 5, P < .0001), and higher mortality (6% vs. 4%, P < .0001) vs both negative. CXR and PXR can be used to assess for intra-abdominal injury and need for laparotomy. GBT patients with either positive X-rays should continue workup regardless of mechanism due to the high specificity of this tool for abdominal injury and need for laparotomy.

Trauma factors among adult and geriatric blunt trauma patients

BackgroundTrauma is known as a third leading cause of mortality among all-aged patients. ObjectiveThe aim of this study is to investigate pre-trauma physiological factors and trauma-related factors that can increase the risk of mortality among the adult and geriatric patients. MethodIn this longitudinal data analysis study, 500 non-penetrating adult trauma patients who were referred to (Shahid Madani Hospital) from January 2019–December 2019 were enrolled. Information such as age, sex, occupation, place of residence, hospitalization and surgical history, underlying illnesses, medications (such as antihypertensive drugs, etc.), lab findings (complete blood cell and creatinine levels) were recorded in the form of a questionnaire. The patients were divided in group A (aged 65 and above) and group B (aged below 65 years). The data obtained was analyzed statistically using SPSSv18. ResultThe mean age of all patients under study was 51.6 years. Among all participants, 68% (341) were male and 32% (159) were female. Regarding the cause of trauma, group A had significantly greater incidence (p-value = 0.001). The two groups were also significantly different in terms of the region of the injury (p-value = 0.014). Furthermore, underlying diseases were also statistically significant among the two groups (p-value = 0.0093). There was a significant difference between the two groups in terms of smoking and drugs (p-value = 0.01 and 0.001, respectively). Finally, the mortality rate in patients older than 65 years old (4.3%) was significantly higher than those in patients under the age of 65 years (2.9%) (p-value = 0.0001). ConclusionThe results of this study showed that among the trauma patients aged below 65 years and those aged 65 years and above, underlying illness, mortality rate, usage of drugs, cause of trauma, type of injury, vital signs, white blood cell count and platelet count, hemoglobin and serum creatinine vary significantly.

Outcomes after rib fractures in geriatric blunt trauma patients

IntroductionRib fractures after blunt trauma contribute substantially to morbidity and mortality in the elderly. MethodsRetrospective review of 255 patients ≥65 years old at a level 2 trauma center over 6 years, who sustained blunt trauma resulting in rib fractures. Outcomes measured include mortality, hospital length of stay(LOS), intensive care unit(ICU) admission, ICU LOS, need for MV, and MV days. ResultsThere were 24 deaths (9.4%), of which 7 were early (<24 h). 130 patients (51%) were admitted to ICU, and 49 (19.2%) required MV. Mean ICU and MV days were 5.9 and 6.3, respectively. ICU admission was predicted by a base deficit <-2.0, ISS>15, bilateral rib fractures, pneumothorax or hemothorax on chest x-ray (All p < 0.001), as well as hypotension, GCS<15, and 1st rib fractures (All p < 0.05). Mortality was predicted by a base deficit < -5.0, GCS score of 3(Both p < 0.001), as well as hypotension, ISS≥25, RTS <7.0, bilateral pneumothoraces, 1st rib fractures, and >5 rib fractures (All p < 0.05). ConclusionRib fractures in elderly blunt trauma patients are associated with significant mortality and morbidity, but outcomes can be predicted to improve care.

The Effect of Sarcopenia on Outcomes in Geriatric Blunt Trauma

Elderly patients are at a higher risk of morbidity and mortality after trauma, which is reflected through higher frailty indices. Data collection using existing frailty indices is often not possible because of brain injury, dementia, or inability to communicate with the patient. Sarcopenia is a reliable objective measure for frailty that can be readily assessed in CT imaging. In this study, we aimed to evaluate the effect of sarcopenia on the outcomes of geriatric blunt trauma patients. Left psoas area (LPA) was measured at the level of the third lumbar vertebra on the axial CT images. LPA was normalized for height (LPA mm2/m2) and after stratification by gender, sarcopenia was defined as LPA measurements in the lowest quartile. A total of 1175 patients consisting of 597 males and 578 females were studied. LPAs below 242.6 mm2/m2 in males and below 187.8 mm2/m2 in females were considered to be sarcopenic. We found sarcopenia in 149 males and 145 females. In multivariate analysis, sarcopenia was associated with a higher risk of in-hospital mortality (odds ratio [OR]: 1.61, 95% confidence interval [CI]: 1.01-2.56) and a higher risk of discharge to less favorable destinations (OR: 1.42, 95% CI: 1.05-1.97). Lastly, sarcopenic patients had an increased risk of prolonged hospitalization (hazard ratio: 1.21, 95% CI: 1.04-1.40).

A Comprehensive Investigation of Comorbidities, Mechanisms, Injury Patterns, and Outcomes in Geriatric Blunt Trauma Patients

The geriatric population is growing and trauma providers are often tasked with caring for injuries in the elderly. There is limited information regarding injury patterns in geriatric trauma patients stratified by mechanism of injury. This study intends to investigate the comorbidities, mechanisms, injury patterns, and outcomes in geriatric blunt trauma patients. A retrospective study of the 2012 National Trauma Databank was performed. Adult blunt trauma patients were identified; geriatric (>/=65) patients were compared with younger (<65) patients regarding admission demographics and vital signs, mechanism and severity of injury, and comorbidities. The primary outcome was injuries sustained and secondary outcomes included mortality, length of stay in the intensive care unit and hospital, and ventilator days. There were 589,830 blunt trauma patients who met the inclusion criteria, including 183,209 (31%) geriatric and 406,621 (69%) nongeriatric patients. Falls were more common in geriatric patients (79 vs 29%, P < 0.0001). Geriatric patients less often had an Injury Severity Score >/=16 (18 vs 20%, P < 0.0001) but more often a head Abbreviated Injury Scale >/=3 (24 vs 18%, P < 0.0001) and lower extremity Abbreviated Injury Scale >/=3 (24% vs 8%, P < 0.0001). After logistic regression older age was an independent risk factor for mortality for the overall population and across all mechanisms. Falls are the most common mechanism for geriatric trauma patients. Geriatric patients overall present with a lower Injury Severity Score, but more often sustain severe injuries to the head and lower extremities. Injury patterns vary significantly between older and younger patients when stratified by mechanism. Mortality is significantly higher for geriatric trauma patients and older age is independently associated with mortality across all mechanisms.

The Role of Abdominal and Pelvic Computed Tomography Scans for Geriatric Blunt Trauma Patients on Antiplatelet and/or Anticoagulation Medications

Blunt trauma is the most common mechanism of injury in the geriatric population. The benefits of computed tomography (CT) scanning have demonstrated improved outcomes for blunt trauma patients with head injuries. The purpose of our study is to evaluate the clinical value of using a CT scan of the abdomen and pelvis on geriatric blunt trauma patients on antiplatelet/anticoagulation (AP/AC) therapy. A retrospective study reviewing geriatric patients admitted to our urban level 1 trauma center from December 2012 to September 2014 was performed. The inclusion criteria for the study included patients older than 65 years of age, admission after a blunt trauma, and on AP/AC therapy. Male and female patients with dementia were more likely to have a CT scan of the abdomen and pelvis (P = 0.002 and P = 1 × 10−6, respectively). There was no statistical significance in the difference in outcomes between the demented patients who received a CT scan of the abdomen and pelvis and the ones who did not. Our study demonstrated that there is no benefit in terms of length of stay, morbidity, or mortality, regardless of sex, after a CT scan of the abdomen and pelvis.

Mortality Factors in Geriatric Blunt Trauma Patients: Creation of a Highly Predictive Statistical Model for Mortality Using 50,765 Consecutive Elderly Trauma Admissions from the National Sample Project

Elderly patients are at high risk for mortality after injury. We hypothesized that trauma benchmarking efforts would benefit from development of a geriatric-specific model for risk-adjusted analyses of trauma center outcomes. A total of 57,973 records of elderly patients (age older than 65 years), which met our selection criteria, were submitted to the National Trauma Database and included within the National Sample Project between 2003 and 2006. These cases were used to construct a multivariable logistic regression model, which was compared with the American College of Surgeons Committee on Trauma's Trauma Quality Improvement Project's (TQIP) existing model. Additional spline regression analyses were performed to further objectively quantify the physiologic differences between geriatric patients and their younger counterparts. The geriatric-specific and TQIP mortality models shared several covariates: age, Injury Severity Score, motor component of the Glasgow Coma Scale, and systolic blood pressure. Our model additionally used temperature and the presence of mechanical ventilation. Our geriatric-specific regression mode generated a superior c-statistic as compared with the TQIP approximation (0.85 vs 0.77; P = 0.048). Spline analyses demonstrated that elderly patients appear to be less likely to tolerate relative hypotension with higher observed mortality at initial systolic blood pressures of 90 to 130 mmHg. Although the TQIP model includes a single age component, these data suggest that each variable needs to be adjusted for age to more accurately predict mortality in the elderly. Clearly, a separate geriatric model for predicting outcomes is not only warranted, but necessary.

Normal Presenting Vital Signs Are Unreliable in Geriatric Blunt Trauma Victims

Normal vital signs are typically associated with improved outcomes in trauma patients. Whether this association is true for geriatric patients is unclear. A Level 1 trauma center retrospective chart review of vital signs on presentation (heart rate [HR] and blood pressure) in young (aged 17-35 years) and geriatric (aged 65 years or older) blunt trauma victims from September 2003 to September 2008 was preformed. Generalized nonlinear using piecewise regression for the linear portion of standard logistic models was used to model risk of mortality as a function of HR and blood pressure. Independent models were selected for elderly and young trauma patients based on blood pressure and HR. Models of the same complexity were then fit within each gender and age. There were 2,194 geriatric and 2,081 young patients. Two hundred fifty-one (11.4%) geriatric and 49 (2.4%) young patients died. At all points of "normality," the mortality of the geriatric patients was higher than the young group. Mortality increases considerably in the elderly patients for HRs >90 beats per minute (bpm), an association not seen until HR of 130 bpm in the young group. Mortality significantly increases with systolic blood pressure (SBP) <110 mm Hg in the geriatric patients but not until a SBP of 95 mm Hg in the young patients. HR and mortality association was most variable in the male geriatric patients. Vital signs on presentation are less predictive of mortality in geriatric blunt trauma victims. Geriatric blunt trauma patients warrant increased vigilance despite normal vital signs on presentation. New trauma triage set points of HR >90 or SBP <110 mm Hg should be considered in the geriatric blunt trauma patients.

Cervical spine fractures in geriatric blunt trauma patients with low-energy mechanism: are clinical predictors adequate?

BackgroundStudies have identified clinical predictors to guide radiologic evaluation of the cervical spine in geriatric patients. We hypothesized that clinical predictors are not adequate in the identification of cervical spine fractures in geriatric blunt trauma patients with low-energy mechanism. MethodsA retrospective case-control study was performed on geriatric blunt trauma patients sustaining low-energy trauma from January 2000 to January 2006. A data form including 8 clinical predictors was completed for each group. ResultsThere were 35 study and 64 control patients identified. Both groups were similar in age (study 83.6 vs control 81.2) and injury severity score (study 9.06 vs control 9.61). Only neck tenderness exceeded the expected occurrence in the presence of a cervical spine injury (χ2 = 18.1, P = .001) in just 45.5% of the study group. ConclusionsClinical predictors appear inadequate for the evaluation of the cervical spine in geriatric trauma patients with low-energy mechanism.

Detection of Cervical Spine Injuries in Alert, Asymptomatic Geriatric Blunt Trauma Patients: Who Benefits from Radiologic Imaging?

There are differing recommendations in the literature regarding cervical spine imaging in alert, asymptomatic geriatric patients. Previous studies also have not used computed tomography routinely. Given that cervical radiographs may miss up to 60 per cent of fractures, the incidence of cervical spine injuries in this population and its implications for clinical management are unclear. We conducted a retrospective study of blunt trauma patients 65 years and older who were alert, asymptomatic, hemodynamically stable, and had normal neurologic examinations. For inclusion, patients were required to have undergone computed tomography and plain radiographs. The presence and anatomic location of potentially distracting injuries or pain were recorded. Two hundred seventy-four patients were included, with a mean age of 76 +/- 10 years. The main mechanisms of injury were falls (51%) and motor vehicle crashes (41%). Nine of 274 (3%) patients had cervical spine injuries. The presence of potentially distracting injuries above the clavicles was associated with cervical injury when compared with patients with distracting injuries in other anatomic locations or no distracting injuries (8/115 vs 1/159, P = 0.03). There was no association of cervical spine injury with age greater or less than 75 years or with mechanism of injury. The overall incidence of cervical spine injury in the alert, asymptomatic geriatric population is low. The risk is increased with a potentially distracting injury above the clavicles. Patients with distracting injuries in other anatomic locations or no distracting injuries may not need routine cervical imaging.

Vital Capacity as a Predictor of Outcome in Elderly Patients with Rib Fractures

This study tests the relationships between early bedside vital capacity (VC) measurement and morbidity, mortality, and resource consumption in geriatric blunt chest trauma patients with rib fractures. This was a retrospective study examining all patients > or = 65 years old with rib fractures who had a VC measured within 48 hours of their emergency department evaluation. Outcome variables included pulmonary complications, death from pulmonary complications, hospital length of stay (LOS), intensive care unit length of stay (ICU LOS), and discharge disposition. Thirty-eight patients met the study criteria. The mean age was 80.2 (+/-7.4) years, the mean number of rib fractures was 3.6 (+/-1.6), and the mean ISS was 6.9 (+/-4.7). VC and the percentage of the predicted vital capacity (pVC) were both inversely correlated with LOS (p = 0.0076 and p = 0.0172, respectively). Linear regression analysis suggested that patients with a VC < 1.4 L or < 55% of their pVC had a LOS > 3 days. Mean VC was 36% higher in patients who were discharged home versus those discharged to an extended care facility (ECF; p = 0.025). There was a trend toward significance when comparing VC to ICU LOS (p = 0.079), but none in predicting pulmonary complications (p = 0.3299). No correlations between VC and mortality can be drawn given the single death in the cohort. Bedside VC is a simple measurement which could predict LOS in elderly patients with rib fractures and may identify those patients requiring ECF upon discharge. Further prospective study may highlight the utility of emergency room VC in determining the disposition of these patients.

Mortality Factors in Geriatric Blunt Trauma Patients

Mortality Factors in Geriatric Blunt Trauma Patients

Mortality Factors in Geriatric Blunt Trauma Patients

To examine various clinical factors for their ability to predict mortality in geriatric patients following blunt trauma. In this retrospective study, trauma registries and medical records from three trauma centers were reviewed for patients 65 years and older who had sustained blunt trauma. The following variables were extracted and examined independently and in combination for their ability to predict death: age, gender, mechanism of injury, admission blood pressure, and Glasgow Coma Scale score, respiratory status, Trauma Score, Revised Trauma Score, and Injury Severity Score. Three urban trauma centers. Geriatric trauma patients entering three trauma centers (Stanford [Calif] University Hospital, Vanderbilt University Medical Center, Nashville, Tenn, and Maryland Institute for Emergency Medical Services Systems, Baltimore) following blunt trauma during a 7-year period (1982 to 1989). The Injury Severity Score was the single variable that correlated most significantly with mortality. Mortality rates were higher for men than for women and were significantly higher in patients 75 years and older. Admission variables associated with the highest relative risks of death included a Trauma Score less than 7; hypotension (systolic blood pressure, < 90 mm Hg); hypoventilation (respiratory rate, < 10 breaths per minute); or a Glasgow Coma Scale score equal to 3. Admission variables in geriatric trauma patients can be used to predict outcome and may also be useful in making decisions about triage, quality assurance, and use of intensive care unit beds.