Age-Dependent Association of Occult Hypoperfusion and Outcomes in Trauma

Background Motor vehicle collisions (MVCs), particularly those associated with entrapment, are a common cause of major trauma. Current extrication methods are focused on spinal movement minimisation and mitigation, but for many patients self-extrication may be an appropriate alternative. Older drivers and passengers are increasingly injured in MVCs and may be at an increased risk of entrapment and its deleterious effects. The aim of this study is to describe the injuries, trapped status, outcomes, and potential for self-extrication for patients following an MVC across a range of age groups. Methods This is a retrospective study using the Trauma Audit and Research Network (TARN) database. Patients were included if they were admitted to an English hospital following an MVC from 2012 to 2019. Patients were excluded when their outcomes were not known or if they were secondary transfers. Simple descriptive analysis was used across the age groups: 16–59, 60–69, 70–79 and 80+ years. Logistic regression was performed to develop a model with known confounders, considering the odds of death by age group, and examining any interaction between age and trapped status with mortality. Results 70,027 patients met the inclusion criteria. Older patients were more likely to be trapped and to die following an MVC (p < 0.0001). Head, abdominal and limb injuries were more common in the young with thoracic and spinal injuries being more common in older patients (all p < 0.0001). No statistical difference was found between the age groups in relation to ability to self-extricate. After adjustment for confounders, the 80 + age group were more likely to die if they were trapped; adjusted OR trapped 30.2 (19.8–46), not trapped 24.2 (20.1–29.2). Conclusions Patients over the age of 80 are more likely to die when trapped following an MVC. Self-extrication should be considered the primary route of egress for patients of all ages unless it is clearly impracticable or unachievable. For those patients who cannot self-extricate, a minimally invasive extrication approach should be employed to minimise entrapment time.

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“…Patients, and particularly older patients may have occult injuries [ 20 ]. As such, predicting a patient’s ability to self-extricate is complex.…”

Section: Discussionmentioning

confidence: 99%

Do entrapment, injuries, outcomes and potential for self-extrication vary with age? A pre-specified analysis of the UK trauma registry (TARN)

Nutbeam

Kehoe

Fenwick

et al. 2022

Scand J Trauma Resusc Emerg Med

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“…Over 50% of trauma ICU patients at the study center present with either shock or occult hypoperfusion due to hemorrhage. 29 Hemostasis is achieved by a median of 120 minutes from hospital arrival if emergent hemorrhage control is required. 30 In contrast, patients with AKI related to sepsis or cardiogenic shock more commonly found in the general ICU literature likely have prolonged renal insults.…”

Section: Discussionmentioning

confidence: 99%

Importance of duration of acute kidney injury after severe trauma: a cohort study

Hatton

Harvin

Wade

et al. 2021

Trauma Surg Acute Care Open

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BackgroundAcute kidney injury (AKI) is common after severe trauma. AKI incidence and AKI stage have previously been shown to be associated with poor outcomes after trauma. However, AKI duration may also be important for outcomes after trauma, given that it is associated with long-term morbidity and mortality in general intensive care unit (ICU) and hospitalized patients. We hypothesized that duration of AKI is independently associated with poor outcomes after trauma.MethodsA cohort study was conducted at a single, level 1 trauma center. Patients admitted to the ICU between 2009 and 2018 were included. Data were extracted from the trauma registry and electronic medical records. AKI within 7 days from presentation was defined according to the Kidney Disease Improving Global Outcomes guidelines. Multivariable analyses were performed to assess the association between AKI incidence, AKI stage, and AKI duration with outcomes including prolonged ICU and hospital length of stay, discharge to home, and mortality.ResultsOf 7049 patients included, 72% were male, the median age was 41 years (IQR 27–58), and 10% died. The AKI incidence was 45%, with 69% of these patients presenting with AKI on arrival. The majority (73%) of patients who suffered AKI recovered within 2 days. After adjustment in separate models, AKI incidence, AKI stage and AKI duration were each associated with prolonged hospitalization, an unfavorable discharge disposition, and mortality. AKI stage and duration were not used in the same model due to collinearity.ConclusionsPost-traumatic AKI was common on arrival and frequently short lasting. Duration correlated with highest AKI stage, and both were separately associated with prolonged hospitalization, discharge destination other than home, and mortality on adjusted analyses. Given the high incidence of AKI on arrival, stage or duration may be better targets for future interventions and quality improvement initiatives to improve outcomes after post-traumatic AKI.Level of evidenceIII. Prognostic.

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“…Additionally, Hatton et al have previously demonstrated that the elderly might suffer from occult hypoperfusion even with normal vital signs. This is accompanied by worse outcomes compared with patients presenting with shock, because of either worsened underlying physiology or lack of timely detection and prompt treatment of this hypoperfusion [ 22 ]. This might partly explain worse outcomes in elderly with similar physiological parameters compared to their younger counterparts.…”

Section: Discussionmentioning

confidence: 99%

Geriatric polytrauma patients should not be excluded from aggressive injury treatment based on age alone

Wessem

Leenen

2020

Eur J Trauma Emerg Surg

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Purpose Age in severely injured patients has been increasing for decades. Older age is associated with increasing mortality. However, morbidity and mortality could possibly be reduced when accurate and aggressive treatment is provided. This study investigated age-related morbidity and mortality in polytrauma including age-related decisions in initial injury management and withdrawal of life-sustaining therapy (WLST). Methods A 6.5-year prospective cohort study included consecutive severely injured trauma patients admitted to a Level-1 Trauma Center ICU. Demographics, data on physiology, resuscitation, MODS/ARDS, and infectious complications were prospectively collected. Patients were divided into age subgroups (< 25, 25–49, 50–69, and ≥ 70 years) to make clinically relevant comparisons. Results 391 patients (70% males) were included with median ISS of 29 (22–36), 95% sustained blunt injuries. There was no difference in injury severity, resuscitation, urgent surgeries, nor in ventilator days, ICU-LOS, and H-LOS between age groups. Adjusted odds of MODS, ARDS and infectious complications were similar between age groups. 47% of patients ≥ 70 years died, compared to 10–16% in other age groups (P < 0.001). WLST increased with older age, contributing to more than half of deaths ≥ 70 years. TBI was the most common cause of death and decision for treatment withdrawal in all age groups. Conclusions Patients ≥ 70 years had higher mortality risk even though injury severity and complication rates were similar to other age groups. WLST increased with age with the vast majority due to brain injury. More than half of patients ≥ 70 years survived suggesting geriatric polytrauma patients should not be excluded from aggressive injury treatment based on age alone.

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Age-Dependent Association of Occult Hypoperfusion and Outcomes in Trauma

Cited by 20 publications

References 32 publications

Do entrapment, injuries, outcomes and potential for self-extrication vary with age? A pre-specified analysis of the UK trauma registry (TARN)

Do entrapment, injuries, outcomes and potential for self-extrication vary with age? A pre-specified analysis of the UK trauma registry (TARN)

Importance of duration of acute kidney injury after severe trauma: a cohort study

Geriatric polytrauma patients should not be excluded from aggressive injury treatment based on age alone

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