LAKE BUENA VISTA, FLA. Mortality was sharply reduced in elderly patients undergoing trauma care with an aggressive protocol marked by multidisciplinary teamwork and prompt identification of occult shock.
The survival benefit was significant even among patients older than 75 years, a group with notoriously high mortality rates, Dr. Eric Bradburn said at the annual meeting of the Eastern Association for the Surgery of Trauma.
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Dr. Eric Bradburn
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Injured geriatric patients pose unique challenges to the trauma team because of their abnormal responses to shock and injury and frequent polypharmacy. They are also increasing in numbers with todays active geriatric population, comprising 36% of all admissions at his own level II trauma center, said Dr. Bradburn, an acute care surgeon at Lancaster General Hospital in Hershey, Pa.
With the protocol, patients older than 65 years were screened on admission for high-risk injuries, comorbidities, and/or physiologic parameters associated with increased geriatric mortality in the literature. If one or more high-risk indicator was present, a high-risk protocol was initiated that included:
ICU admission.
STAT arterial blood gas (ABG).
An ABG every 4 hours, if base deficit is 6 mmol/L or more, until base deficit is 2 mmol/L.
STAT echocardiogram (EKG).
Basic metabolic profile; magnesium and phosphorus tests in morning.
Prothrombin time, partial thromboplastin time, and international normalized ratio in morning.
Neurologic checks every hour for 24 hours.
For unexplained hemodynamic instability, obtain a STAT EKG.
Geriatric medicine consult.
The protocol was initiated in January 2006, with all 4,534 geriatric trauma patients admitted from 2000 to 2010 included in the analysis. Of these, 309 patients died for an overall mortality rate of 6.8%, Dr. Bradburn said.
Mortality rates increased sharply at age 75 years consistent with the literature from less than 4% to more than 6% and rose steadily to more than 11% by age 95 years.
In multivariate adjusted analysis of 3,902 patients with full data available, mortality significantly improved for geriatric patients on the protocol (odds ratio, 0.63), he said. The receiver operating curve was 0.86. Variables includes in the analysis were Injury Severity Score (ISS), trauma level, Revised Trauma Score (RTS), and age.
Patients on the protocol had significantly lower mortality rates regardless of whether they were 75-84 years (OR, 2.72), older than 85 years (OR, 4.62), had an Injury Severity Score of 17-25 (OR, 6.45) or ISS greater than 25 (OR, 15.93).
Furthermore, mortality was significantly lower among patients who received the full protocol even at the highest ISS categories, compared with those who did not receive the protocol or received either the protocol or the geriatric consult, "demonstrating the synergy and impact our full protocol has on this population," Dr. Bradburn said.
"We believe the implications of this study demonstrate that an aggressive approach to the geriatric trauma patient can result in a positive outcome in this population," he concluded.
Invited discussant Dr. Carl Schulman, a trauma and burn surgeon at the University of Miamis Ryder Trauma Center, pointed out that geriatric consultations alone have been shown to improve mortality.
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