Session VI - Geriatric Trauma

Saturday, October 18, 1997 Session VI, 4:34 p.m.

Morbidity and Mortality in Elderly Trauma Patients

Paul Tornetta, III, MD, Hamid Mostafavi, MD, Joseph Riina, MD, Cliff Turen, MD, Barry Riemer, MD, Richard Levine, MD, Fred Behrens, MD, Jeffrey Geller, Christopher Ritter

University Hospital, Brooklyn, New York, USA

Introduction: Despite an increasing incidence, relatively few studies have examined the factors that predict morbidity and mortality in older patients and several reports have found standard predictors such as ISS to be less useful in this patient population. Similarly, the effect of skeletal injury has not been examined as it relates to complications and mortality.

Purpose: The purpose of this study is to review a large multicenter experience with elderly trauma patients in order to isolate factors which may predict morbidity and mortality. The potential effect of skeletal long bone injury was of particular interest.

Methods: The charts of all patients older than 60 who were admitted to one of 4 level one trauma centers after sustaining blunt trauma were reviewed. Mechanisms of injury included in the study were: motor vehicle accident, pedestrian struck, fall from a height, or crush injury. Slip and fall injuries were excluded. Three hundred twenty-four patients met inclusion criteria. Variables studied included: age, sex, mechanism of injury, injury severity score (ISS), revised trauma score (RTS), Glasgow coma scale (GCS), blood transfusion, fluid resuscitation, surgery performed (laparotomy, long bone fracture stabilization, both), and timing of surgery. Outcome variables measured included incidence of ARDS, pneumonia, sepsis, myocardial infarction, DVT, GI complications, and death. Chi-square, linear regression, t-tests, and nonparametric analyses were done as appropriate for the type of variable.

Results: The average age of the patients was 72.2 ± 8 years. Overall, 59 (18.2%) of the patients died, of which 52/59 survived at least 24 hours. Statistical significance for continuous variables (p < 0.05) using univariate analysis was reached for the following factors for the patients who died: higher ISS (33.1 vs. 16.4) [table #1], lower GCS (11.5 vs. 13.9), greater transfusion requirement (10.9 u vs. 2.9 u), and greater fluid infused (12.4L vs. 4.9L). Linear regression analysis was performed to determine the factors which predict mortality. They included (odds ratio in parenthesis): transfusion (1.13, p=.002), ISS (1.04, p=.03), GCS (.88, p=.02), fluid requirement (1.06, p=.04). Regarding surgery (table #2), orthopedic surgery alone had an odds ratio of .276 and those requiring both general surgery and orthopedic procedures had an odds ratio of 0.077, indicating that these groups were less likely to die than patients who did not have any surgery. Patients who had only a general surgery procedure were 1.6 times more likely to die than those who did not require surgery. Early ( 24°) vs. late (> 24°) surgery for bony stabilization did not have a statistical affect on mortality (11% early vs. 18% late).

Mortality of ISS Score (table #1)
 ISS  n

 Mortality (n)

  Mortality
 0 - 18  177  8  4.5%
 19 - 30  79  23  29.%
 > 30  59  27  46%

With regards to complications, regression analysis revealed that ISS predicted ARDS, pneumonia, sepsis, and GI complications; fluid transfusion predicted myocardial infarction; and need for surgery and transfusion requirements predicted sepsis. These complications, in turn, were significant risk factors for mortality (table #3).

Statistics by Type of Surgery (table #2)
 Surgery needed  n  Age  ISS  PRC (u)  Fluid (L)  Mortality
 Orthopedic only  88  71  16.7  4.4  5.6  10%
 General only  34  72  27.1  7.0  9.6  41.%
 Both  36  72  30.4  10.5  11.8  20.%
 None  160  73  7.4  1.7  4.3  18.%

Mortality by Presence of Complication (table #3)
 Complication  Complication present  Complication absent  p value
 ARDS  81%  13%  <.000001
 Sepsis  39%  13%  .00001
 Myocardial infarction  62%  18%  .002
 Pneumonia  25%  18%  NS

Discussion: This large series of elderly patients demonstrates that mortality correlates closely with ISS score and is influenced by blood and fluid requirements and by GCS. The institution specific mortality was the same when adjusted for ISS. The need for orthopedic surgery and the timing of the surgery was not a risk factor for systemic complications or mortality in this series.

Conclusion: Mortality is predicted by ISS score and by complications in older patients. Seventy-seven percent of the orthopedic injuries were stabilized early, but the timing of surgery did not have any statistical effect on the incidence of complications or mortality. Patients who required only general surgery procedures were at the highest risk for mortality which, after closer look, correlates with a higher AIS for abdominal, chest and head injury. Further efforts are needed to evaluate the proper resuscitation for elderly patients.