NEW Geriatric Trauma: Triage
Citation: J Trauma. 54(2):391-416, Feb 2003
Jacobs, David G. MD; Plaisier, Brian Ray MD; Barie, Philip S. MD; Hammond, Jeffrey S. MD; Holevar, Michele R. MD; Sinclair, Karlene E. MD; Scalea, Thomas M. MD; Wahl, Wendy MD; for the EAST Practice Management Guidelines Work Group
From the Carolinas Medical Center (D.G.J.), Charlotte, North Carolina, Trauma Service, Bronson Hospital (B.R.P.), Kalamazoo, and Trauma Burn Center, University of Michigan Health System (W.W.), Ann Arbor, Michigan, New York Hospital-Cornell Medical Center (P.S.B.), New York, New York, Robert Wood Johnson Medical School (J.S.H.), New Brunswick, New Jersey, Mt. Sinai Hospital (M.R.H.), Chicago, Illinois, Morehouse School of Medicine (K.E.S.), Atlanta, Georgia, and R Adams Cowley Shock Trauma Center, University of Maryland Medical Center (T.M.S.), Baltimore, Maryland.
Submitted for publication October 3, 2001.
Accepted for publication September 16, 2002.
Address for reprints: David G. Jacobs, MD, Carolinas Medical Center, P.O. Box 32861, Charlotte, NC 28232; email: email@example.com.
Advanced age is a well-recognized risk factor for adverse outcomes after trauma. A substantial body of literature, much of it cited within this article, demonstrates increased morbidity and mortality in geriatric trauma patients compared with their younger counterparts. Whether this outcome difference is because of the decreased physiologic reserve that accompanies aging, a higher incidence of preexisting medical conditions in the geriatric patient, or other factors yet to be identified remains unclear. It is clear, however, that good outcomes can be achieved in this patient population when appropriately aggressive trauma care is directed toward geriatric patients with survivable injuries. Implicit in the above statement is the need to identify, as soon as possible after injury, those patients who will benefit from aggressive resuscitation, timely injury management, and posttrauma rehabilitation. It is equally important, however, to limit these intensive and expensive treatment modalities to patients whose injuries are not only survivable but also compatible with an acceptable quality of life.
Our purpose in developing this guideline was to provide the trauma practitioner with some evidence-based recommendations that could be used to guide decision-making in the care of the geriatric trauma patient. We began this process by first developing a series of questions, the answers to which we hoped could be supported by the existing scientific literature. The initial set of questions were as follows:
- Is age itself a marker of increased morbidity/mortality? If so, what age should be used?
- Is age instead a surrogate for increased preexisting conditions (PECs)? If so, which premorbid conditions are particularly predictive of poor outcomes?
- Should age itself be a criterion for triage from the field directly to a trauma center, regardless of Glasgow Coma Scale (GCS) score, Trauma Score (TS), and so forth? If so, what age should be used?
- Do trauma centers have better outcomes with geriatric trauma than nontrauma centers?
- Are there specific injuries, scores (e.g., Injury Severity Score [ISS], TS, GCS score), or PEC/age combinations in geriatric trauma patients that are so unlikely to be survivable that a nonaggressive approach from the outset could be justified?
- What resuscitation end-points should be used for the geriatric trauma patient?
- Should all geriatric trauma patients receive invasive hemodynamic monitoring? If so, what specific types of monitoring should be used? If not, which geriatric patients benefit from invasive monitoring?
Unfortunately, after examining the available literature, it is clear thatevidence-based responses to all of the questions raised above are not possible. As the evidentiary tables demonstrate, there are few, if any, prospective, randomized, controlled trials that definitively address any of the above issues. Second, there is a lack of uniformity as to a specific age criterion for geriatric trauma. As shown in the evidentiary tables, geriatric trauma is variously defined in the literature as age greater than or equal to 55, 60, 65, 70, 75, and even 80 years of age. There is even literature support for increased mortality from trauma beginning at age 45! Furthermore, because age is a continuous variable, and not a dichotomous one, adverse outcomes associated with geriatric trauma are likely to increase in a continuous fashion with age as opposed to a stepwise leap as a given patient reaches a specific age. Third, there is no concise definition of a geriatric trauma patient. In some studies, all patients over a given age are included, whereas in others, patients with penetrating injuries, burns, and minor injuries, such as slip-and-falls, are excluded. Some studies include all patients regardless of hemodynamic instability or injury severity, whereas others impose strict entrance criteria or exclude patients who do not survive for a predetermined period of time after admission. Such lack of uniformity regarding inclusion criteria makes it difficult to compare outcomes across different patient populations. Finally, much of the literature concerning geriatric trauma is relatively old, that is, published more than 10 years ago. Given the significant improvements in patient care that have occurred over the past 10 to 20 years, recommendations made on the basis of outcomes achieved more than 10 years ago may not be applicable to today's geriatric trauma patient.
Despite the above-mentioned shortcomings, our committee still felt that it was important to summarize the available literature and make evidence-based recommendations where satisfactory evidence did exist. In light of the seven questions raised above, two broad areas of focus emerged within this guideline: issues of geriatric trauma triage, and issues of geriatric trauma resuscitation. Although there was considerable overlap between these two areas, each issue has been addressed separately within this guideline and, accordingly, two separate subguidelines, each with its own recommendations, evidentiary table, and areas for future research, constitute this practice management guideline for geriatric trauma. It is hoped that the information provided within this guideline will provide evidence-based support for the difficult decisions that are required to achieve optimal outcomes in this difficult but ever-increasing patient group.
Triage Issues In Geriatric Trauma
I. Statement of the Problem
The process of triage, as it relates to the geriatric trauma patient, is an attempt to provide the patient with the appropriate intensity of medical resources, taking into account the severity of illness, the cost and availability of medical resources, the prognosis for functional survival and, if known, the expressed desires of the patient. For the geriatric trauma patient, this process begins in the prehospital phase of care, where decisions must be made regarding the appropriate patient destination, trauma center versus nontrauma center. In the resuscitative phase of trauma care, triage decisions regarding patient destination must again be made, specifically, whether patient circumstances dictate provision of intensive care resources or whether standard trauma inpatient care will suffice. Throughout the hospital phase of care, the patients must be triaged toward or away from operative procedures, invasive and expensive critical care therapies, and powerful yet potentially dangerous pharmacologic treatment options, decisions which, again, must be made on the basis of the likelihood of achieving a good, long-term outcome for the patient. An increasingly common circumstance, particularly in the geriatric trauma patient, involves the decision to withdraw, or perhaps not even institute, an aggressive course of treatment, when the clinical circumstances are incompatible with a quality of life that all parties concerned would deem acceptable. Fundamental to all of these triage decisions is the ability to predict with reasonable accuracy what a particular patient's outcome might be depending on which triage decision is made. To be of any value to the trauma practitioner, and ultimately to the patient and his or her family, the clinical variables on which these predictions are to be based must be easy to obtain, reliable, and available to the trauma practitioner within a relatively short period of time after injury. The task, therefore, of this particular subcommittee was to determine whether there existed adequate support in the scientific literature to develop recommendations regarding (1) appropriate criteria for triage of the geriatric trauma patient to trauma centers, (2) the clinical variables that would be useful in predicting the need for intensive care resources for the geriatric trauma patient, and (3) those clinical circumstances where a nonaggressive approach from the outset could be justified.
An initial computerized search was undertaken using MEDLINE with citations published between the years 1966 and 1999. Using the search words geriatric, trauma, elderly, and injury, and by limiting the search to citations dealing with human subjects and published in the English language, well over 2,300 citations were identified. From this number were then excluded letters to the editor, case reports, reviews, and a large number of articles dealing with minor injury mechanisms, particularly hip fractures from slip-and-falls. An additional cause for exclusion of references was publication before 1975, as it was felt that the trauma care provided at this time was so different compared with current trauma care that recommendations made on the basis of data from this earlier time period would not be valid. The abstracts of the remaining citations were each reviewed, and those articles that did not address prognostic variables or other issues pertinent to the triage of the geriatric trauma patient were further excluded. This yielded a total of 32 articles that constituted the initial evidentiary table (Table 1). The bibliographies of these 32 articles were then further reviewed and an additional 13 articles meeting the above-mentioned criteria were added, for a total of 45 references within the evidentiary table. Each reference was then reviewed by three trauma surgeons, and consensus was reached regarding appropriate classification of each reference according to the Canadian and United States Preventive Task Force. Criteria for achieving a specific classification and the number of articles for each class (the total number of classified references exceeds the total number of references by one because one two-part study was classified as both a Class II and Class III reference) are shown below:
Class I: Prospective randomized controlled trials-the gold standard of clinical trials. Some may be poorly designed, have inadequate numbers, or suffer from other methodologic inadequacies (0 references).
Class II: Clinical studies in which data were collected prospectively, and retrospective analyses that were based on clearly reliable data. Types of studies so classified include observational studies, cohort studies, prevalence studies, and case control studies (two references).
Class III: Studies based on retrospectively collected data. Evidence used in this class indicates clinical series, database or registry review, large series of case reviews, and expert opinion (44 references).
A. Level I:
There are insufficient Class I and Class II data to support any standards regarding triage of geriatric trauma patients.
B. Level II:
1. Advanced patient age should lower the threshold for field triage directly to a trauma center.
C. Level III:
- All other factors being equal, advanced patient age, in and of itself, is not predictive of poor outcomes after trauma, and therefore should NOT be used as the sole criterion for denying or limiting care in this patient population.
- The presence of PECs in elderly trauma patients adversely affects outcome. However, this effect becomes progressively less pronounced with advancing age.
- In patients 65 years of age and older, a GCS score ≤ 8 is associated with a dismal prognosis. If substantial improvement in GCS score is not realized within 72 hours of injury, consideration should be given to limiting further aggressive therapeutic interventions. Because this recommendation is based on Class III data, it should be applied cautiously in individual patients.
- Postinjury complications in the elderly trauma patient negatively impact survival and contribute to longer lengths of stay in survivors and nonsurvivors compared with younger trauma patients. Specific therapies designed to prevent and/or reduce the occurrence of complications (particularly iatrogenic complications) should lead to optimal outcomes in this patient population.
- With the exception of patients who are moribund on arrival, an initial aggressive approach should be pursued with the elderly trauma patient, as the majority will return home, and up to 85% will return to independent function.
- In patients 55 years of age and older, an admission base deficit ≤ -6 is associated with a 66% mortality. Patients in this category may benefit from inpatient triage to a high-acuity nursing unit.
- In patients 65 years of age and older, a Trauma Score < 7 is associated with a 100% mortality. Consideration should be given to limiting aggressive therapeutic interventions. Because this recommendation is based on Class III data, it should be applied cautiously in individual patients.
- In patients 65 years of age and older, an admission respiratory rate < 10 is associated with a 100% mortality. Consideration should be given to limiting aggressive therapeutic interventions. Because this recommendation is based on Class III data, it should be applied cautiously in individual patients.
- Compared with younger trauma patients, patients 55 years of age and older are at considerably increased risk for undertriage to trauma centers, even when these older patients satisfy appropriate triage criteria. The factors responsible for this phenomenon must be identified and strategies developed to counteract it.
IV. Scientific Foundation
Triage is the process whereby the patient's medical needs are matched with the available medical resources. For the geriatric trauma patient, the process begins in the prehospital arena, where prehospital providers must decide on the basis of relatively scant clinical information whether a patient should bypass the local hospital in favor of a trauma center. The American College of Surgeons Committee on Trauma (ACS-COT), among other medical organizations, in its manual Resources for Optimal Care of the Injured Patient, has published a set of triage criteria to aid prehospital providers in identifying appropriate patients for direct transport to trauma centers. Within this document, it is suggested that patients older than age 55 should be considered for direct transport to a trauma center, apparently without regard to the severity of injury. This recommendation is based on a substantial medical literature that demonstrates significantly worse outcomes for geriatric trauma patients compared with their nongeriatric counterparts. One of the earliest studies to look at the influence of age on outcome from major trauma was the Major Trauma Outcome Study, sponsored by the ACS-COT. Data from 3,833 patients aged 65 years and older were compared with those of 42,944 patients less than 65 years of age. Mortality rose sharply between age 45 and 55 and doubled at age 75 years. This age-dependent survival decrement occurred at all ISS values, for all mechanisms of injury, and for all body regions. Numerous other studies have supported the findings that the effect of trauma on the elderly is more serious than that on younger patients.[3-9]
Given these findings, some authors have suggested triaging elderly trauma victims to trauma centers at a much lower threshold than similarly injured younger patients, to minimize mortality and morbidity. Support for this recommendation can be found in a study by Smith et al., documenting fewer complications for elderly femur fracture patients treated at trauma centers versus nontrauma centers. Despite these poorer outcomes, trauma patients 55 years of age and older are frequently triaged to nontrauma hospitals even when they satisfy well-defined anatomic or physiologic criteria. Compliance with physiologic criteria appears to be especially troublesome. In two unrelated studies, undertriage in patients over the age of 55 was twice that of younger patients, and a similar study demonstrated even worse results for patients over the age of 65.
The factors responsible for the increased morbidity and mortality seen in geriatric trauma are not entirely clear. It has been suggested that it is not patient age per se but the high incidence of preexisting medical conditions in the geriatric patient that accounts for the difference. Others have suggested that the elderly, simply by virtue of being more frail, sustain a greater degree of injury in response to a given impact, compared with their younger counterparts. The existing medical literature was therefore reviewed in an attempt to identify clinical factors that might be used to triage geriatric trauma patients to either aggressive versus nonaggressive treatment strategies.
Age and Outcome
It is difficult to find consensus in the existing literature regarding the relationship between patient age and outcome. Many of the reasons for this failure have been mentioned above, and include differences in the age definition of geriatric trauma and differences in inclusion criteria for the various studies. In addition to these two factors, there is a lack of uniformity regarding the length of follow-up required to define a poor outcome. This has been variably defined as death within 24 or 48 hours of injury, death before intensive care unit (ICU) or hospital discharge, and even death/vegetative outcome at 3 or 4 years postinjury. Furthermore, there are wide variances in the statistical methods used to explore the relationship between age and outcome. Many authors have documented a statistically significant difference between the mean age of geriatric survivors compared with the mean age of geriatric non survivors, and thus have concluded that age is significantlyassociated with poor outcome. Other authors have applied logistic regression analysis to their data set to determine which particular factors are predictive of adverse outcomes. Given the wide variation in inclusion criteria, outcome variables, and statistical methods present within the existing literature, the conflicting results regarding age and outcome are not surprising.
Certainly, the largest data set examined to date is that published by Morris et al. in 1990. These authors examined 199,737 trauma admissions, aged 15 and older, to acute care hospitals in the state of California during 1986. Using logistic regression techniques, the ISS was found to be the best predictor of mortality in trauma patients, but age, gender, and PECs were also found to beindependent predictive factors of mortality. Mortality was defined as in-hospital death. The authors also found that although the mortality from minor injury (ISS < 9) begins to increase beyond the age of 65, the mortality for moderate injuries (ISS of 9-24) begins to increase at 45 years of age. This increase in trauma mortality beginning at age 45 had been confirmed by other investigators as well. Several authors have examined the relationship between in-hospital mortality and age, with differing conclusions. Pellicane et al. demonstrated a statistically significant difference in age between elderly nonsurvivors and elderly survivors in a series of 374 geriatric trauma patients, defined as age greater than or equal to 65 years. Five of the deaths in this series occurred in the emergency department, a subset of patients that has been excluded from the analyses in other series. Burn patients, however, were excluded from this series. In a similar study performed by Osler et al., of 100 geriatric trauma patients 65 years or older, no significant difference in age was found between elderly survivors and nonsurvivors. Despite the fact that patients who died before transfer to the operating room or to the ICU were excluded in the series by Osler et al., mortality in this series was more than twice that in the series by Pellicane et al. Perhaps this is explained by the lower mean TS in the series by Osler et al. relative to that of Pellicane et al. (13 vs. 15.4). The series by Pellicane et al. contains nearly four times as many patients, which raises the possibility of a type II statistical error regarding the inability of Osler et al. to demonstrate a statistical difference between the ages of geriatric trauma survivors and nonsurvivors. A large and more recent study of 448 patients, 65 years and older, used a logistic regression analysis and demonstrated age to be significantly predictive of both early (< 24 hours) and late (> 24 hours) mortality. In this analysis, survival was used as the outcome variable, with geriatric status (age ≥ 65 years) entered into the logistic regression equation. In so doing, geriatric status was associated with a 2.46-fold increased likelihood of early mortality and a 4.64-fold increased risk of late mortality. However, an even larger study yet, consisting of 852 patients, reported by Knudson et al., using stepwise discriminant analysis, did not find age to be predictive of in-hospital death. The authors reported a 1.33-fold increased risk of death associated with age status greater than 75 years, just barely missing statistical significance with a p value of 0.06. Interestingly enough, however, the age of 75 years was entered into the discriminant analysis, not the age of 65 or greater, which was the authors' original age definition for entrance into the study. Perhaps statistical significance would have been demonstrated had age 65 or greater been used in the discriminant analysis.
Two studies specifically examined the relationship between age and in-hospital mortality for geriatric trauma patients admitted to the ICU. Neither found any association between age and outcome. In a small series of 39 patients requiring intensive care unit admission and placement of pulmonary and radial artery catheters, Horst et al. reported no significant difference in age between elderly survivors and nonsurvivors. As would be expected, overall mortality (31%) was high in this intensive care population of patients older than 60 years of age. Logistic regression analysis was not performed in this study, probably because of the overall low number of patients. A more recent study by Shabot and Johnson examined two subsets of geriatric trauma patients, those between the ages of 65 and 74 and those 75 years and older. Outcomes in these 99 geriatric trauma patients were then compared with 940 younger patients between the ages of 13 and 64, all of whom were admitted to a surgical intensive care unit (SICU). SICU mortality was then examined by comparing survivors with nonsurvivors, regardless of age. As would be expected, there was no significant difference in age between nonsurvivors and survivors (39.0 years vs. 34.8 years), likely because of the 10-fold larger number of patients seen in the younger patient group.
Finally, several studies have examined the relationship of age to more long-term outcomes, although no clear consensus is evident. DeMaria et al. studied a group of 82 trauma patients over the age of 65 years. Patients with penetrating injury and isolated orthopedic injury were excluded, as were patients sustaining thermal injury. Survival was defined as 6 months postinjury. Not only were nonsurvivors older, but they also demonstrated higher ISSs and more complications. On the basis of these findings, the authors developed the Geriatric Trauma Survival Score (GTSS) and then prospectively tested it on 61 patients, with 92% accuracy. Unfortunately, the GTSS, although perhaps accurate, has little triage value at the time of patient admission, as it requires information not available to the practitioner at that time. Van der Sluis et al. compared early and late mortality between elderly trauma patients and elderly hip fracture patients. Early mortality was higher for the trauma patients, but survival 7 to 8 years after injury was similar between the two groups. Logistic regression analysis was used to identify predictors of late mortality, and demonstrated age to be a significant predictor. Van Aalst et al., in a study of blunt geriatric injury with a mean follow-up of almost 3 years, used logistic regression analysis to demonstrate an association between poor outcome and age > 75. Oreskovich et al., however, failed to demonstrate any relationship between age and outcome at 1 year after injury in a group of 100 patients age 70 and older. Broos et al., in two separate publications examining 6-month outcome in trauma patients aged 65 and older, did not find age to be predictive of mortality. Inclusion criteria for each of these three latter studies were vaguely defined, and the 18% mortality in the study by Broos et al. is inexplicably low compared with other series of similarly injured patients. A larger study, with a more plausible mortality, was published by Battistella et al. in 1998. This study involved 279 geriatric trauma patients, which the authors defined as age greater than 75. Mean ISS in this patient group was 9.4 and associated mortality was 23%. Using logistic regression analysis, the authors found that poor outcome, defined in this study as survival less than 6 months after hospital discharge, was not predicted by patient age. The issue of long-term survival and quality of life in the geriatric trauma patient is discussed more fully below.
Can the age of a geriatric patient, then, be used to predict outcome after trauma? Although age appears to have some value in mortality projections for a population of geriatric trauma patients, there is certainly no literature support for a specific age above which geriatric trauma in-hospital mortality can be predicted with any degree of confidence. It has been suggested, however, that earlymortality may not be the best outcome measure in geriatric trauma, because of a high percentage of poor long-term functional survival in elderly trauma patients surviving hospital discharge. The preponderance of available literature, however, suggests more favorable long-term outcomes, with up to 85% of survivors functioning independently at home at follow-up intervals as long as 6 years postinjury.[27-31] Thus, given reasonable long-term functional outcomes for geriatric trauma patients surviving hospitalization, and the inability of patient age, by itself, to predict in-hospital mortality, advanced patient age should not be used as the sole criterion for denying or limiting care in the geriatric trauma population.
Preexisting Conditions and Outcome
If chronologic age, then, is not useful in predicting geriatric trauma survival, perhaps it is the patient's physiologic age, or the nature and extent of PECs, that determines outcome. Because the frequency of PECs does increase with age, it may be difficult to separate these two factors and their relationships to adverse outcomes in geriatric trauma. Unfortunately, once again because of a wide variety of age definitions for geriatric trauma, statistical methodologies, and outcome measures, the literature addressing the prognostic value of PECs in geriatric trauma outcome is inconclusive. The largest studies, and those with the best statistical methodology, do seem to demonstrate a significant predictive capacity of PECs for adverse outcomes in geriatric trauma. Morris et al., in two separate publications in 1990, examined hospital discharge data for trauma patients in California for the year 1986. Using logistic regression analysis in both studies, Morris et al. were able to demonstrate that PECs were important predictive factors of mortality, independent of age. The effect of PECs on mortality, however, became less important in patients over the age of 65, perhaps because at this age chronologic age becomes the predominant predictor of mortality, and the added presence of PECs does little to increase trauma mortality further. Similarly, Milzman et al., in a study of nearly 8,000 trauma patients, noted a threefold increase in trauma mortality in patients with PECs compared with those without. Once again, the effect of PECs on mortality was noted to be independent of age although, like Morris et al., these authors noted a decreasing influence of PECs on trauma mortality with advanced age. A more recent study published in 1997 by Gubler et al. examined risk factors for mortality among a group of 9,424 trauma patients, aged 67 and greater, who were discharged from acute care hospitals within the state of Washington in 1987. For each trauma patient in the series, four uninjured patients, matched for age and gender, were identified from the same Health Care Financing Administration (HCFA) database. Comorbid diagnoses (PECs) were identified for each patient, and a Comorbid Diagnosis Index Score was calculated. This score is a weighted index that takes into account not only the number but also the severity of PECs. Using Cox proportional hazards regression, Gubler et al. found that patients with PECs were between 2.0 and 8.4 times as likely to die within 5 years of injury compared with those without PECs, depending on the number and severity of PECs. Several smaller studies, each reporting the experience of a single trauma center and using logistic regression analysis, confirmed the value of PECs as predictive factors of poor outcome in geriatric trauma, although inclusion criteria and age and outcome definitions were not uniform among these studies.Other studies have refuted these findings but suffer from methodologic and statistical shortcomings that weaken their conclusions.[22-24]
Severity-of-Injury Scoring and Outcome
A number of physiologic and anatomic scores have been shown to correlate with geriatric outcome. These include TS, Revised Trauma Score (RTS), GCS score, Acute Physiology and Chronic Health Evaluation Score (APACHE), Acute Physiology Score (APS), Simplified Acute Physiology Score (SAPS), ISS, Maximal Abbreviated Injury Score (MAIS), and the GTSS. In addition, although not scores in the typical sense, geriatric trauma outcome has also been correlated with initial blood pressure, respiratory rate, and base deficit. Although most, if not all, of these scores do correlate with geriatric outcome, from the perspective of field or emergency department triage, many of these scores have little value in that they are not derivable at the moment that these particular triage decisions need to be made. This would apply particularly to APACHE, APS, SAPS, MAIS, ISS, and GTSS. These scores, however, perhaps in combination with patient age, may have some value in the prediction of lethal outcomes in geriatric trauma and, therefore, may be valuable triage tools in the intensive care unit. These scores will therefore be discussed solely within that context below.
In contrast, measures of physiologic derangement, whether obtained by means of physical examination or chemical analysis, may help to identify patients who will perhaps benefit from aggressive resuscitation strategies (and should therefore be triaged to an intensive care unit), and those where further resuscitative efforts are futile (thus facilitating earlier termination of resuscitation). TS (or RTS) and its components (blood pressure, respiratory rate, and GCS score) are the most readily obtainable, objective physiologic data available either to the prehospital provider or to the trauma resuscitation team in the emergency department. The prognostic value of each of these variables as they relate to geriatric trauma outcome will be discussed further below. (The prognostic value of the GCS score is discussed later within the section Outcome from Geriatric Head Injury.) Of those chemical analyses available in the emergency department, only base deficit has been subjected to sufficient scientific study and is sufficiently relevant to geriatric trauma resuscitation that it can be included within the discussion below of potentially useful triage scores.
The TS assesses five physiologic functions (blood pressure, respiratory rate, respiratory effort, GCS score, and capillary refill), yielding a minimal score of 0 and a maximal score of 16. The RTS is a simplified version of the TS, which deletes the assessment of respiratory effort and capillary refill, resulting in a range of scores between 0 and 8. Several studies have demonstrated the predictive value of TS (and RTS) on geriatric trauma mortality, although a specific numeric score signifying a fatal injury has not been identified by these authors. Horst et al. were unable to find any relationship between TS and geriatric trauma patient mortality, although the small number of patients and the rather narrow entrance criteria of the study limit the applicability of this finding.Two other studies, however, suggest that TS may be a useful triage tool in the early stages after geriatric trauma. In a case-matched review of 100 patients age 65 and above that suffered injuries severe enough to necessitate hospitalization, no elderly patient was able to survive a TS < 9. More dramatically, no geriatric patient with a TS < 7 survived long enough to reach the hospital and be included in the study. The authors felt this to be of importance in allowing more realistic counseling of patients and their families. These findings were reinforced by a review from three trauma centers of 852 patients, age 65 and older, in which a TS < 7 was associated with a 100% mortality. These data suggest that aggressive care under these circumstances is likely to be futile, and that consideration should be given to limiting intensive therapy when a geriatric patient presents with a TS < 7. In addition to the prognostic value of TS, the data of Knudson et al. also revealed a 100% mortality in patients 65 years and older who presented with a respiratory rate < 10. Here, too, consideration should be given to limiting aggressive therapeutic interventions. In addition to its role in the prediction of fatal outcomes in geriatric trauma patients, the TS may also have implications for intensive care unit triage. In a study of 374 patients aged 65 and older, mortality was noted to be only 5% in those with a TS of 15 or 16, but was 25% in patients with a TS of 12 to 14 and 65% in patients with a TS < 12. Thus, patients with a TS between 7 and 14 may benefit from aggressive resuscitation strategies and triage to a critical care unit.
Measurement of arterial base deficit may provide useful information regarding the extent of shock and the adequacy of resuscitation in trauma patients, and may therefore be useful in early decision-making and resource allocation. In a series of 274 elderly trauma patients, defined for the purposes of this study as age greater than or equal to 55, arterial blood gases obtained within 1 hour of patient admission were correlated with ICU length of stay and mortality. Base deficits were characterized as mild (-3 to -5), moderate (-6 to -9), and severe (≤ -10). As expected, elderly patients with severe base deficits had a high mortality, 80% in this series. However, geriatric trauma mortality was still markedly elevated at 60% in patients with only moderate base deficits. Even a normal base deficit carried a mortality of 24%. Thus, early determination of admission base deficit in geriatric trauma patients may facilitate early identification of occult shock and identify a subgroup of patients who may benefit from more intensive monitoring and resuscitation.
ISS is probably the most widely studied anatomic or physiologic severity-of-illness score yet to be correlated with geriatric trauma outcome. Most authors have found it to be a strong predictor of outcome in geriatric trauma, and two large studies claimed that it is the best predictor of mortality in geriatric trauma. Others, however, have failed to demonstrate any such relationship.[22-24] Whether or not such a relationship does indeed exist, ISS is severely limited in its prognostic capability because of significant delays in obtaining sufficient data to calculate the score. It therefore probably has very little prognostic value in geriatric trauma and, even then, only in patients in whom the question of futility has been raised. Despite the abundance of literature examining the relationship between ISS and geriatric trauma patient outcome, only two publications contain any ISS data that might be considered useful prognostically. Van der Sluis et al. reported on a series of 121 trauma patients age 60 and greater, all with ISS ≥ 16. No patient with an ISS ≥ 50 survived in this series. The authors, however, do emphasize the importance of not using the ISS to predict outcomes in individual patients. A study by Carrillo et al. published in 1994 reported on 94 blunt trauma victims aged 65 or greater. Mortality correlated well with APACHE II score, but the combination of APACHE II and ISS performed better than APACHE II alone. All patients with APACHE II score ≥ 15 and ISS ≥ 30 died, but this accounted for only one third of all deaths in this series. Thus, it would appear that there is little, if any, support in the literature to justify withdrawal of care on the basis of any combination of age and ISS. Likewise, for SAPS, APS, and MAIS there is no literature support for the use of any of these scores to predict individual patient outcome after geriatric trauma. Finally, mention should be made of the GTSS. This score was derived by DeMaria et al. on the basis of their experience with 82 blunt trauma patients over the age of 65 years. The formula to calculate GTSS uses patient age, ISS, and the presence or absence of cardiac and septic complications to predict patient outcome. Given the inadvisability mentioned above of using ISS to predict individual patient outcome, and the fact that information regarding the presence or absence of complications will not be obtainable before hospital discharge, the GTSS clearly has no role in guiding decision-making, a point that the authors themselves emphasize. Interestingly, a larger and more recent study of blunt trauma patients aged 60 and older failed to demonstrate any relationship between the GTSS and survival.
Complications and Outcome
It is generally acknowledged that when the geriatric trauma patient sustains complications during the initial hospitalization, overall outcome is adversely affected. Both DeMaria et al. and Osler et al., in comparing elderly survivors with nonsurvivors, have noted a statistically higher incidence of cardiac and septic complications and respiratory complications in nonsurvivors. Other authors, using logistic regression statistical methodology, have identified cardiac, infectious, and pulmonary complications as independent predictors of poor outcome after geriatric trauma.In addition to the specific types of complications sustained by the geriatric trauma patient, the number of complications sustained by a given geriatric trauma patient has been identified as a risk factor for poor outcomes. Smith et al., in a study of 456 trauma patients aged 65 and over, reported a 5.4% mortality for those patients with no complications, 8.6% for those with one complication, and 30% for those with more than one complication. Similar results have been noted for geriatric patients sustaining traumatic brain injuries.
Despite the well-documented relationship between complications and outcome in geriatric trauma, triage decisions are rarely, if ever, affected by this information. Early triage decisions, whether in the field or in the emergency department, clearly cannot be made on the basis of the presence or absence of complications yet to occur. Furthermore, there are no data to suggest that any particular number, or type, of complications will allow identification of the individual geriatric trauma patient destined for an outcome so dismal that a nonaggressive course of treatment could be justified. In light of these findings, efforts should be focused on the development and implementation of strategies aimed at the prevention of complications in the geriatric trauma patient. The importance of complication prevention is highlighted in a study by Pellicane et al., which revealed that preventable complications contributed to mortality in 32% of all deaths in this series and 62% of deaths related to multiple organ system failure.
Outcome from Geriatric Head Injury
The topic of geriatric head injury has received more attention in the literature than any other aspect of geriatric trauma. Unfortunately, all of it is retrospective in nature and, therefore, suffers from many of the same methodologic shortcomings discussed above for the remainder of the geriatric trauma literature. These include lack of a specific age definition for geriatric head injury, lack of standardized definitions for specific subpopulations of geriatric head-injured patients, and lack of standardized outcome measures. In addition, much of the geriatric head injury literature provides either insufficient details regarding head injury management or results based on head injury management that would be considered outdated by today's standards. Therefore, it is difficult, and perhaps even dangerous, to make meaningful recommendations regarding the triage of current day geriatric neurotrauma patients on the basis of the existing literature. Despite these shortcomings, there is little question that outcomes after traumatic brain injury are much worse in geriatric patients than in their younger counterparts. Vollmer, in a study from the Traumatic Coma Databank, reported on 661 patients aged 15 and older with severe brain injuries, defined as GCS score < 8. Mortality for the entire series was 38%, but it was 80% for patients older than 55 years of age. Multivariate analysis revealed age to be an independent and significant predictor of death and vegetative outcome, beginning at age 45. Another study examined the effect of age on outcome in patients with acute subdural hematomas. Mortality was 18% in patients between the ages of 18 and 40, but was 74% in patients older than age 65. Once again, advanced age was noted to be predictive of poor outcomes. In addition to age, a number of other factors have been examined as potential predictors of poor outcome after head injury in geriatric patients. Not surprisingly, the most extensively studied factor is that of admission GCS score. Many other factors predictive of poor outcome have been examined, including anatomy of the brain injury (epidural vs. subdural),need for craniotomy,[40-43] subdural hematoma volume, midline shift, pupillary status, and intracranial pressure. None of these factors has been examined in sufficient detail to allow us to make any recommendations regarding their potential role as triage tools in geriatric head injury. Therefore, they will not be considered further within this article.
Low admission GCS score is clearly associated with poor outcomes in elderly head-injured patients. Reuter documented a mortality rate of 87% in elderly patients (age ≥ 60) with traumatic intracranial hemorrhage and an admission GCS score < 8, although no details regarding head injury management were provided. The available scientific literature, however, does not support the use of a specific GCS score that will reliably identify patients destined for poor outcomes. Zietlow et al., in a study of patients aged 65 and older with multisystem injury, identified a GCS score ≤ 8 as being predictive, and van Aalst et al., in a similar study, found a GCS score ≤ 7 to be associated with death or dependent living status. Published studies limited to geriatric patients with head injuries likewise yield no consensus. Rozzelle et al. identified a GCS score ≤ 7 to be predictive of hospital mortality in patients with subdural hematomas, and Kilaru et al. noted that this same GCS score was associated with a universally poor long-term outcome. Cagetti et al. found that a GCS score ≤ 11 was associated with a 100% mortality, although this study involved patients 80 years of age and older. Amacher and Bybee, however, in a similar study of head-injured patients 80 years of age and older, did achieve an excellent/good outcome in a single patient with an admission GCS score in the 3 to 6 range. Thus, although low GCS scores are indeed associated with poor outcomes, it does not seem possible, or advisable, on the basis of the existing literature, to make triage decisions in head-injured geriatric patients solely on the basis of the admission GCS score. It does seem reasonable to conclude that head-injured patients 65 years and older, as a group, have very poor outcomes when the admission GCS score is ≤ 7 or 8.
Other authors have examined the prognostic value of the delayed GCS score, that is, the GCS score determined 24 hours or more after injury. Both Pennings et al. and Kotwica and Jakubowski have advocated a limited course of aggressive therapy in geriatric trauma patients with severe head injuries, although their GCS score definitions of futility differ greatly. Kotwica and Jakubowski, in a study of head-injured patients 70 years of age and older, noted a 90% mortality in patients with a GCS score < 9 when craniotomy was required and 76% when craniotomy was not required. On the basis of this finding in 136 patients, they recommend aggressive treatment for 24 hours only for those patients without space-occupying lesions. Aggressive treatment, then, is continued only in those patients who show significant improvement within this time frame. Pennings et al., in their study of 42 patients aged 60 and older with a GCS score ≤ 5, concluded that these patients have an extremely poor prognosis, and that if they have not regained substantial neurologic function within 24 hours, they are unlikely to do so. Similarly, Ross et al. reported a 100% 6-month mortality among patients 65 years of age and older who had a persistent GCS score ≤ 8 at 72 hours after admission. Even though the overall prognosis from geriatric head injury may have improved since these publications because of improvements in head injury management, it is reasonable to expect that these new therapies will exert their maximum effect in the early stages after injury. Thus, in geriatric head injury, it seems reasonable to adopt an initial course of aggressive treatment (with the possible exception of the patient who is moribund on arrival), followed by a reevaluation of the patient's neurologic status at 72 hours after admission. The intensity of the subsequent care provided can then be based on the initial response to therapy.
Although multiple clinical and demographic factors have demonstrated an association with outcome after trauma in geriatric patients, the ability of any specific factor alone or in combination with other factors to predict an unacceptable outcome for any individual geriatric trauma patient is quite limited. An initial course of aggressive therapy (see following section, Parameters for Resuscitation of the Geriatric Trauma Patient) seems warranted in all geriatric trauma patients, regardless of age or injury severity, with the possible exception of those patients who arrive in a moribund condition. Geriatric trauma patients who do not respond to aggressive resuscitative efforts within a timely fashion are likely to have poor outcomes even with continued aggressive treatment. Modification of the intensity of treatment provided to these nonresponders should be considered. For those geriatric trauma patients who do respond favorably to aggressive resuscitative efforts, the prognosis, not only for survival but also for return to their preinjury level of function, is quite good and certainly justifies the effort.
VI. Future Investigations
There are no Class I data that address triage issues in geriatric trauma. Prospective, randomized, controlled trials are desperately needed that address the prognostic values of age, injury severity, and injury physiology on ultimate outcome after geriatric trauma. Before conducting these studies, there must be agreement concerning the specific age definitions to be used for geriatric trauma, the outcomes to be measured, and the specific clinical criteria that will be used to define preexisting medical conditions. Furthermore, data generated in such a fashion should be subjected to rigorous and appropriate statistical analysis. Only when a substantial body of literature exists that meets these criteria will trauma practitioners succeed in providing an appropriate level of care to the geriatric trauma patient on the basis of that patient's predicted outcome.
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Evidentiary Table: Triage Issues in Geriatric Trauma
|First Author||Year||Reference||Data Class||No. of Patients||Age (yr)||Pt. Population||Mortality (%)||Conclusion|
|Gubler KD||1997||Long-term survival of elderly trauma patients. Arch Surg; 132:1010-14.||II||9424||≥67||All (HCFA data base)||4.1% (inhospital)||Determined 5-year survival of injured cohort compared to 4:1 uninjured cohort matched for age and gender. Injured cohort had more PEC’s. Five-year risk of death in injured cohort was 1.7 times that of uninjured cohort and was related to age, gender, ISS and PEC’s. Adverse effect of trauma on survival remains long after traumatic episode.|
|Oreskovich MR||1984||Geriatric trauma: injury patterns and outcome. J Trauma; 24:565-72.||III||100||≥70||"severe" injury; [mean ISS = 19]||14% @ 1 month; 15% @ 1 yr||Factors affecting survival included "serious" CNS injury, shock (BP < 80), and burn mechanism. Survival was NOT affected by age, ISS, gender or presence of PEC's. Profile of the non-survivor: required pre-hospital intubation, was in shock at some time, was intubated > 5 days, and developed pulmonary sepsis. Less than 8% of patients were independent at one-year follow-up. Vague definitions of PEC's and entry criteria into study.|
|Horst HM||1986||Factors influencing survival of elderly trauma patients. Crit Care Med; 14:681-4.||III||39||≥60||ICU admits w/ PAC & Arterial Catheter||31%||Survival related to sepsis and the number of failed organ systems, but NOT age, ISS, TS, APS (Acute Physiology Score), injury mechanism, PEC, presence of shock at admission, or initial cardiopulmonary variables. Small number of patients in this study raises questions regarding the validity of its conclusions.|
|Amacher AL||1987||Toleration of head injury by the elderly. Neurosurgery; 20:954-8.||III||56||≥80||All head-injury admissions||25%||Overall mortality 25%, but CNS-related mortality was 16%. Seven of eight patients with admission GCS of 3-6 died (87.5% mortality), but the single survivor had an excellent/good outcome. Conversely, 5 of 42 (12%) of patients with GCS of 13 or more died.|
|DeMaria EJ||1987||Survival after trauma in geriatric patients. Ann Surg; 206:738-43.||III _____ II||82 _____ 61||>65||Excluded burns, penetrating, and isolated ortho injury [ISS=17.9]||21% _____ 16.4%||Non-survivors were older, had higher ISS’s and AIS’s for the head and neck, and had more complications. Developed formula to predict outcome based on age, ISS and the presence/absence of cardiac and septic complications. Prospectively tested formula on 61 pts with 92% accuracy. Authors counsel against use of formula (Geriatric Trauma Survival Score) to predict mortality or to limit resuscitative efforts.|
|DeMaria EJ||1987||Aggressive trauma care benefits the elderly. J Trauma; 27:1200-06.||III||63||> 65||Excluded burns, penetrating, and isolated ortho injury||Study of survivors only||Examines factors related to home vs nursing home (NH) disposition in elderly trauma survivors. NH pts were older, had higher ISS, more complications, longer LOS’s, more severe head and neck trauma, and required surgery more frequently after trauma. These factors are probably not useful for triage purposes as the majority of NH pts ultimately returned home. Overall, 89 % of pts returned home and 57% returned to independent living.|
|Broos PL||1988||Polytrauma in patients of 65 and over. Injury patterns and outcome. Int Surg 1988; 73:119-22.||III||49||≥65||Excluded DOA’s and pts who expired prior to any intervention||18% [6 mos] ***** [mean ISS = 33.2]||Factors predicting mortality included coma (not defined) and “early and continued intubation” (intubated pre-hospital or at admission and continued for 5 days or more). Age, ISS and PEC’s were not significantly predictive of mortality. Small number of patients on which to make any recommendations. Vague definition of “polytrauma”. 76% of survivors returned home.|
|Osler T||1988||Trauma in the elderly. Am J Surg; 156:537-43.||III||100||≥65||Excluded if pt expired before O.R. or ICU||17%||Factors distinguishing elderly survivors from non-survivors included TS, GCS, ISS, shock, pulmonary sepsis and prolonged ventilation (> 5 days), but not age. Using logistic regression analysis, shock and GCS were found to be the best predictors of geriatric trauma death. No elderly pt survived a TS < 9.|
|Finelli FC||1989||A case control study for major trauma in geriatric patients. J Trauma; 29: 541-8.||III _____ III||3669 _____ 180||≥65 ____ ≥65||All (MTOS) __________ All (Washington Hospital Center)||18.3% _____ 26.7%||MTOS data reveals increased trauma mortality beginning at age 45. In the Washington Hospital Center dataset, overall mortality in pts > 65 was twice that of younger pts. ISS-adjusted mortality was greater in the elderly at all ISS levels. ISS was much higher in elderly non-survivors than survivors. Older pts also had higher complication rates. Although no predictive factors for elderly mortality were given, authors recommend triaging elderly trauma victims to trauma centers at a much lower threshold.|
|Howard MA||1989||Acute subdural hematomas: an age-dependent clinical entity. J Neurosurg; 71:858-63.||III||67||>65||All patients with acute subdural hematoma > 0.5 cm||74%||Mortality rate of 74% compared to 18 % in patients aged 18-40 years. Older patients died significantly later than younger patients (11.2 days vs 2.0 days). Admission GCS was similar for the two groups, but elderly patients had larger subdural hematoma (SDH) volume and more midline shift than younger patients. Advanced age, large SDH volume and midline shift were each predictive of poor outcome, although not independently. The effect, if any, of PEC's on outcome was not studied.|
|McCoy GF||1989||Injury to the elderly in road traffic accidents. J Trauma; 29:494-7.||III||312||> 65||All traffic incidents||9.3%||Overall higher mortality in elderly group, even after correcting for ISS. AIS much better predictor of mortality if 1 point is added to the MAIS for patients > 65 years. All pts > 65 yrs w/ MAIS >5 died. Small number of patients.|
|Reuter F||1989||Traumatic intracranial hemorrhages in elderly people. Advances in Neurosurgery; 17:43-8.||III||64||≥60||Included only patients requiring surgery||76%||Mortality was 87% in patients with admission GCS < 8. Mortality also affected by complications with 90% mortality in patients with complications. Description of head injury management not provided.|
|Morris JA||1990||Mortality in trauma patients: the interaction between host factors and severity. J Trauma; 30:1476-82.||III||199, 737||≥15||All trauma discharges excluding transfers||1.9%||Mortality from minor injury (ISS < 9) increases at age > 65, while for moderate injuries (ISS :9-24), mortality begins to increase at 45 years. ISS is best predictor of mortality in trauma patients, but age, gender and PEC's are also important independent predictive factors of mortality.|
|Morris JA||1990||The effect of preexisting conditions on mortality in trauma patients. JAMA; 263:1942-6.||III||3074||≥15||All hospitalized trauma deaths in California in 1983||N/A||Case-control study with 4:1 match (survivors:deaths). Trauma mortality increases with increasing numbers of PEC's. PEC's contributing significantly to mortality included liver disease, congenital coagulopathy, COPD, ischemic heart disease and diabetes. . The effect of PEC on mortality was greater in patients w/ ISS < 13, and in pts < 65 years.|
|Smith DP||1990||Trauma in the elderly: determinants of outcome.||III||456||≥65||All patients with||8.6% [mean||Factors associated with outcome included mechanism of injury (burns > MVC > pedestrian struck > assault > falls), and number of|
|South.Med J ; 83:171-7.||traumatic injuries||ISS = 10.8]||complications. The presence of PEC’s was not associated with adverse outcomes, but definition of "PEC" was vague. Low mortality series. PEC's may not influence outcome when ISS and mortality rates are low.|
|Smith JS||1990||Do trauma centers improve outcome over non-trauma centers: the evaluation of regional trauma care using discharge abstract data and patient management categories. J Trauma; 30:1533-8.||III||1332||N/A||All patients with femoral shaft fractures||1.0% @ trauma centers vs 2.2% @ non-trauma centers||Compares outcomes in trauma centers vs non-trauma centers for patients with femoral shaft fractures. Trauma center patients had significantly fewer overall complications (21% vs 33%), and lower mortality. In the subset of patients > 55 years of age, complication rates were 35% at trauma centers, and 47% at non-trauma centers. Elderly trauma patients (age > 55) with significant injuries in addition to their femur fractures were much less likely to be triaged to trauma centers than their younger counterparts (38% vs 70%).|
|Van Aalst JA||1991||Severely injured geriatric patients return to independent living: a study of factors influencing function and independence. J Trauma; 31:1096-1101.||III||98||≥65||Blunt trauma; ISS > 16||44% in hospital||1 to 6 year follow-up (mean 2.82 years) of 54 elderly blunt trauma patients with ISS > 16, who survived initial hospitalization. 11% of these died during the follow-up period, and only 17% regained their pre-injury function. 67% however returned to independent living. Factors associated with a poor outcome (death or dependent living status) included GCS < 7, age > 75, shock on admission, presence of head injury (AIS-Head > 3), and sepsis.|
|Vollmer, DG||1991||Age and outcome following traumatic coma: why do older patients fare worse? J Neurosurg; 75:S37-49.||III||661 _____ 71||≥15 ____ ≥56||Traumatic Coma Data Bank (TCDB) patients;. [age >15, GCS < 8, gunshot wounds to head and patients meeting brain death criteria on arrival were excluded]||38% _____ 80%||Reports outcomes at 6 months post injury for patients with severe brain injuries (GCS< 8). Overall mortality was 38%, but was 80% for patients > 55 years of age. No "elderly" patient made a "good" recovery, and there were fewer "elderly" patients with moderate disability, severe disability and vegetative survival compared to younger patients. Early (<48 hours) mortality was similar among all age groups, but late (>48 hours) mortality was significantly higher in older patients. Although preexisting medical conditions and complications were more frequent in elderly patients and, thus, were associated with poor outcome, multivariate analysis revealed age to be an independent and significant predictor of death and vegetative outcome, beginning at age 45. Whether pre-existing medical conditions and complications remain as independent predictors of poor outcome is not stated. The authors conclude that the poor outcome following head injury in "elderly" patients is primarily due to the limited capacity of the aging brain to recover following injury.|
|Cagetti B||1992||The outcome from acute subdural and epidural intracranial haematomas in very elderly patients. Br J Neurosurg; 6:227-32.||III||28||≥80||Excluded patients with intracerebral hematomas and contusions without significant extra-axial clots||88%, (compared to 57% in pts < 80)||All patients with GCS < 11 died. Pre-existing diseases and multiple systems organ failure accounted for the majority of deaths. All surviving patients successfully returned to their pre-injury state of health No significant difference between the volume of clot or the frequency of associated cerebral contusions between those patients > or < 80 years. The authors conclude the level of consciousness at the time of operation correlates with outcome better than do other parameters. No description of management was provided, making it difficult to determine whether care provided to the two populations was equivalent.|
|Jamjoom A||1992||Outcome following surgical evacuation of traumatic intracranial haematomas in the elderly. Br J Neurosurg; 6:27-32.||III||66||≥65||All patients undergoing craniotomy for evacuation of posttraumatic hematoma||61%||Increased mortality (86%) in the subset of patients > 80 years of age. Outcome also worse if craniotomy performed within 24 hours of injury. Authors feel craniotomy not justified in patients with a pre-operative GCS of 4 or less or in those with unilateral or bilateral pupillary dilatation since all patients in these 2 categories had poor outcomes (Glasgow Outcome Score of 1-3).|
|Kotwica Z||1992||Acute head injuries in the elderly. An analysis of 136 consecutive patients. Acta Neurochir (Wien.); 118:98-102.||III||136||> 70||Head Injury Only||52%||For pts with GCS < 9, mortality was 90% when craniotomy was required, and 76% when craniotomy was not required. Based on these results, authors recommend limiting therapy in pts with GCS < 9 with space-occupying lesions. In patients without space-occupying lesions and GCS < 9, authors recommend aggressive treatment for 24 hours, and limiting further treatment to those with significant improvement by this time. No statistical analysis performed. Small number of patients on which to base such critical recommendations.|
|Milzman DP||1992||Pre-existing disease in trauma patients: a predictor of fate independent of age and injury severity score. J Trauma; 32:236-43.||III||7798||≥15||All admissions w/ ISS > 1; Excluded if survival < 24 hours or cardiac arrest on arrival||9.2% (PEC+) _____ 3.2% (PEC-)||4 year retrospective study at a single Level I trauma center. Trauma mortality increases with increasing numbers of PEC's. The effect of PEC on mortality is independent of age and ISS, but becomes less important at age > 55 years or at ISS > 20.|
|Pellicane JV||1992||Preventable complications and death from multiple organ failure among geriatric trauma victims. J Trauma; 33:440-4.||III||374||≥65||Burns Excluded||8%||Elderly non-survivors were significantly older , had higher ISS and lower TS than elderly survivors. TS < 15 was associated with a 45 % mortality, but 52 % of deaths occurred in pts w/ a TS > 15. Potentially preventable complications contributed to mortality in 62 % of organ failure deaths, and one third of sudden deaths. 70% of organ failure deaths in the TS 15-16 group were contributed to by potentially preventable complications.|
|Ross AM||1992||Prognosticators of outcome after major head injury in the elderly. J Neurosci Nurs; 24:88-93.||III||195||≥65||GCS ≤8 or intracranial hematoma requiring evacuation||20% @ 72 hours -------75% @ 6 months||In patients w/ admission GCS < 8, 83% were still in coma after 72 hours. All of these patients died within 6 months. Patients with ICP’s > 20 had higher 72 hour and 6 month mortality, and greater 72 hour neurologic diasbility compared to patients with ICP’s < 20. However, incidence of shock and apnea were greater in elevated ICP group, which could have adversely affected neurologic outcome and mortality. Study describes patients treated between 1978 and 1988. Conclusions might therefore have limited applicability to current patient care.|
|Broos PL||1993||Multiple trauma in elderly patients. Factors influencing outcome: importance of aggressive care. Injury; 24:365-8.||III||126||≥65||Excluded DOA’s and pts who expired prior to any intervention||17% [6 mos] ***** [mean ISS = 33.2]||Factors predicting mortality included GCS < 8 and “early and continued intubation” (intubated pre-hospital or at admission and continued for 5 days or more). Age, ISS and PEC’s were not significantly predictive of mortality. Vague definition of “multiple trauma”. Within 6 months of discharge, 78% of patients had returned to their pre-injury surroundings.|
|Carrillo EH||1993||Long term outcome of blunt trauma care in the elderly. Surg Gynecol Obstet;176:559-64.||III||94||≥65||Excluded burns, penetrating, isolated ortho injury, and pts with minimal injuries.||13%||Mortality correlated well with APACHE II, but combination of APACHE II and ISS performed better than APACHE II alone. All patients with APACHE II > 15 and ISS > 30 died, but this accounted for only 1/3 of all deaths in the series. At 1 to 3 year follow-up, 84 % of patients surviving hospital discharge were independent at home.|
|Pennings JL||1993||Survival after severe brain injury in the aged. Arch Surg; 128:787-93.||III||42||≥60||Excluded if GCS > 5, penetrating injury, pts w/ nl CT, pts expiring w/i 6 hours||79%||Of 9 survivors, 6 were in a persistently vegetative state, and 2 were severely disabled. The final survivor was moderately disabled and was discharged home. After discharge, older pts tended to deteriorate neurologically, while younger pts tended to improve or remain stable. Factors predictive of mortality were a decreased 6 hour GCS, age > 60, lack of need for craniotomy, cerebral edema, and non-reactive pupils. Authors conclude that pts > 60 years w/ GCS < 5 have an extremely poor prognosis, and that if they do not regain substantial neurologic function within 24 hours, they are unlikely to do so.|
|Day RJ||1994||Major trauma outcomes in the elderly. Med J Aust; 160:675-8.||III||118||>60||ISS > 15||30.5% (early); 31% (late)||Mean ISS =25. Minimum 2 year (average 3 year) follow-up obtained. Late mortality much higher in patients > 70 years old (50%) than in patients 61-70 years old (8%). Of survivors, 81% were living independently, and 76% scored maximally on ADL testing. Authors claim "that age is a significant factor in long term survival after major trauma", but no supporting statistical analysis provided.|
|Johnson CL||1994||Trauma in the elderly: an analysis of outcomes based on age. Am Surg; 60:899-902.||III||289||≥65||SICU admits only||16.3%||Despite similar mean ISS, elderly had higher SICU and overall mortality. For a given ISS, elderly pts had higher admission SAPS (Simplified Acute Physiology Score) compared to younger pts. SICU mortality increased with increasing ISS and SAPS, though ISS-adjusted mortality not statistically different between elderly and younger pts. Authors conclude that injury physiology (SAPS) better predictor of early death, while age still important predictor of death after ICU discharge.|
|Knudson MM||1994||Mortality factors in geriatric blunt trauma patients. Arch Surg; 129:448-53.||III||852||> 65||Blunt Trauma Only||18.4%||Factors predictive of in-hospital mortality were: male gender; injury mechanism; ISS; injuries to brain, chest or abdomen; TS; and RTS. Admission physiologic factors associated with death included: BP < 90; RR < 10, TS ,<7; and a GCS = 3. A TS < 7 was associated with 100 % mortality , as was a RR < 10. ISS was best predictor of mortality, although ISS not "available" as a prognostic variable at admission.|
|Shapiro MB||1994||Geriatric trauma: aggressive intensive care unit management is justified. Am Surg; 60:695-98.||III||170||≥60||All trauma admissions||21.8%||All deaths were in ICU patients. ICU mortality correlated with the number of organ systems failing and with severe head injury (not defined). Survival not related to the presence of PEC’s.|
|Zietlow SP||1994||Multisystem geriatric trauma. J Trauma; 37:985-8.||III||94||≥65||ISS > 10 [mean ISS = 18]||23%, in-hospital||Factors predictive of death (univariate): severe brain injury (GCS< 8), inotropic/ventilatory support, previous MI, shock, chronic renal insufficiency and bradycardia. Factors predictive of death (multivariate): severe brain injury (GCS< 8) and previous MI. At mean follow-up of 12 months, 75% of pts were at home and independent and 49% were back to their normal level of activity.|
|Rakier A||1995||Head injuries in the elderly. Brain Inj; 9:187-93.||III||263||≥65||Consecutive series of head injuries, including concussions||17.5%||High mortality rates noted in patients with cerebral contusions (~28% mortality), and acute subdural hematomas (33% mortality). All patients with acute epidural hematomas had poor outcomes. Overall conclusions weakened by lack of data on admission GCS, author's grouping of patients according to predominant finding on head CT (only one finding allowed per patient), and lack of long-term follow-up.|
|Rozzelle CJ||1995||Predictors of hospital mortality in older patients with subdural hematoma. J Am Geriatr Soc; 43:240-4.||III||157||≥65||Pts w/ traumatic subdural hematomas||30.6%||Factors predictive of hospital mortality included GCS < 7, age > 80 , acute duration of hematoma,and need for craniotomy. Presence of comorbidities, use of antithrombotics, and midline shift on CT did not influence outcome.|
|Shabot MM||1995||Outcome from critical care in the "oldest old" trauma patients. J Trauma; 39:254-9.||III||45 _____ 54||? 75 ____ 6574||All trauma admissions to the SICU||28.9% _____ 13.0%||“Oldest” patients had significantly higher ISS values. Although TS was similar between all age groups, SAPS (both on the first SICU day and also maximum SICU SAPS) increased significantly with age. In general, increases in ISS in the “oldest” group translated into larger increases in SAPS, indicating that these patients have a progressively greater physiologic response to a given level of injury. Factors predictive of overall SICU mortality (all ages) included ISS, TS, SAPS, and day of maximum SAPS. Age itself not predictive of overall SICU mortality, and when stratified by SAPS, mortality in “oldest” patients is similar to younger patients.|
|Zimmer-Gembeck MJ||1995||Triage in an established trauma system. J Trauma; 39:922-8.||III||26025||N/A||ISS ≥1||N/A||Examines success of pre-hospital trauma triage. Assumes all pts w/ ISS between 1and 9 should have been triaged to a non-trauma hospital, while all pts with ISS > 16 should have been triaged to a trauma center. Undertriage rate for entire study population was 21%, but was 56 % for patients > 65 years of age. Overtriage of elderly trauma patients was only 10% (28% for entire study population). In addition to the problem of undertriage in the elderly trauma patient, this study also found that most trauma deaths in non-trauma hospitals were in elderly patients with ISS between 1 and 9.|
|Kilaru S||1996||Long-term functional status and mortality of elderly patients with severe closed head injuries. J Trauma; 41:957-63.||III||40||> 65||GCS ≤8; DOA's and inaccurate GCS'S were excluded||68%||Overall mortality at average 38 month follow-up was 73%. Factors predictive of mortality were GCS, GCS-motor response, and fixed pupils. ISS was not found to be predictive of mortality, but age and TS showed a trend towards significance. With multiple regression analysis, only GCS and heart rate correlated with death. All pts w/ admitting GCS = 3 died in hospital, and all with GCS < 7 either died, were vegetative, or had severe disabilities. On long-term follow-up, neurologic function improved very little after hospital discharge. Overall weak conclusions due to small number of patients and limited use of ICP monitoring.|
|Phillips S||1996||The failure of triage criteria to identify geriatric patients with trauma: results from the Florida Trauma Triage Study. J Trauma; 40:278-83.||III||3980||≥55||Excluded if burns, isolated hip fx, interhospital transfers, and incomplete data||2.4 %||Study uses AIS data and several assumptions to determine pt’s “ideal” triage destination (trauma center vs non-trauma center), and then compares actual pt triage destination with “ideal” destination. Overtriage in the elderly population was 7.4% (compared to 11.3% in younger patients, and target overtriage rate of 20%). Undertriage in the elderly group was 71% (compared to 36% in younger group, and target undertriage rate of 5%). Triage criteria failed to identify nearly all elderly major trauma cases from falls.|
|Van der Sluis CK||1996||Major trauma in young and old: what is the difference?||III||121||≥60||ISS ≥16||38.8%||Compares outcome of elderly with that of younger patients, all with ISS > 16. Mortality in both groups increased with increasing ISS, and ISS was similar for the 2 groups. ISS in elderly non-survivors was higher|
|J Trauma; 40:78-82.||(34.3) compared to elderly survivors (23.9), but unable to determine from manuscript whether this is a statistically significant difference. An ISS > 50 was fatal for all elderly patients. Young non-survivors died much earlier than old non-survivors (2.6 days vs 14.4 days). The percentage of elderly patients discharged home was similar to that of younger patients, and the functional outcome at 2 years post-discharge was also similar. Therefore, elderly should be treated aggressively.|
|Van der Sluis CK||1997||Outcome in elderly injured patients: injury severity versus host factors. Injury; 28:588-92.||III||42||> 60||ISS ≥16||31%||Compares outcomes between elderly trauma pts and elderly hip fracture pts. In-hospital mortality was much higher for the trauma elderly (31%) than for the hip fracture elderly (3%), but long-term survival (7-8 years post-trauma) was similar (29%). Higher late mortality in hip fracture group ascribed to higher incidence of poor "pre-injury medical status" (very loosely defined) in this pt population (53% vs 12%). Predictors of late mortality included age, poor pre-injury medical status, and male gender, while early mortality is more a function of ISS.|
|Battistella FD||1998||Trauma patients 75 years and older: long-term follow-up results justify aggressive management. J Trauma; 44:618-23.||III||279||≥75||All Trauma Service admissions. Mean ISS = 9.4||23%, including DOA’s||4 year follow-up obtained on 81 % of the 279 patients who survived to hospital discharge. Poor outcome (survival < 6 months following discharge) predicted by pre-existing dementia, hypertension and COPD, but not by age or ISS. Of long term survivors, 83% living independently.|
|Davis JW||1998||Base deficit in the elderly: a marker of severe injury and death. J Trauma; 45:873-7.||III||274||≥55||Excluded pts w/ initial ABG obtained > 1 hour after injury||varied with base deficit||Correlated admission base deficit (aBD) with mortality, ISS and ICULOS. Higher mortality in elderly despite similar ISS and aBD. In pts > 55 yrs, an aBD < -6 was associated with a 67% mortality and a 78% PPV for an ISS > 16. However, less severe aBD’s (> -6) were still associated with significant mortality (24%). Even a normal aBD (-2 to 2) in this age group was associated with an 18% mortality.|
|Perdue PW||1998||Differences in mortality between elderly and younger adult trauma patients: geriatric status increases risk of delayed death. J Trauma;45: 805-10.||III||448||≥65||Excluded if isolated single-system injury admitted to non-trauma service||14%||Elderly mortality twice that of younger patients., and was more delayed, with the majority occurring more than 24 hours after admission. Factors predictive of early (< 24 hours) mortality included ISS, RTS , and age. Factors predictive of late (>24 hours) mortality were ISS, RTS, age, preexisting cardiovascular or liver disease, and the development of cardiac, infectious or renal complications.|
|Ma MH||1999||Compliance with prehospital triage protocols for major trauma patients. J Trauma; 46:168-75.||III||32950||≥55||All trauma transports||N/A||Documents compliance of pre-hospital providers with pre-hospital trauma triage criteria. Compliance with anatomic criteria was 86%, and did not vary with patient age. Compliance with physiologic and mechanism criteria was poor (34% and 46% respectively), and was statistically worse for pts > 55 years of age, compared to younger pts.|
|Tornetta P||1999||Morbidity and mortality in elderly trauma patients. J Trauma; 46:702-6.||III||326||≥60||Blunt trauma only; slip-and-fall injuries were excluded||18.1%||Factors predictive of mortality included transfusion, ISS (particularly AIS-Head and Neck and AIS-Thorax), GCS and fluid requirement. In addition, sepsis, ARDS and MI were significant risk factors for mortality. Geriatric Trauma Survival Score was not predictive of survival.|
DOA, dead on arrival; PAC, pulmonary arterial catheter; HCFA, Health Care Financing Administration; CNS, central nervous system; BP, blood pressure; NH, nursing home; LOS, length of stay; pts., patients; OR, operating room; MTOS, Major Trauma Outcome Study; SDH, subdural hematoma; COPD, chronic obstructive pulmonary disease; MVC, motor vehicle crash; CT, computed tomographic; ICP, intracranial pressure; ADL, activities of daily living; SAPS, Simplified Acute Physiology Score; MI, myocardial infarction; fx, fracture; ABG, arterial blood gas; aBD, admission base deficit; PPV, positive predictive value.