Normal Presenting Vital Signs Are Unreliable in Geriatric Blunt Trauma Victims

Heffernan, Daithi S.; Thakkar, Rajan K.; Monaghan, Sean F.; Ravindran, Radhika; Adams, Charles A.; Kozloff, M.; Gregg, Shea C.; Connolly, Michael D.; Machan, Jason T.; Cioffi, William G.

doi:10.1097/ta.0b013e3181f41af8

Cited by 168 publications

(113 citation statements)

References 18 publications

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“…While the cut-points we identified in SBP were similar to those proposed in other studies, 31,33 the yield of such triage revisions appeared small. The lack of predictive value of SBP and heart rate among injured older adults has been previously demonstrated.…”

Section: Discussionsupporting

confidence: 79%

“…Previous studies on this topic are limited by the use of hospital-based physiologic data, single-center trauma registries, exclusion of certain types of patients (e.g., penetrating injury, traumatic brain injury), and use of mortality as the primary outcome. 30–33 Each of these factors introduces bias and reduces the ability to extrapolate findings to the out-of-hospital setting. We undertook the current study to help fill this void and better inform the next revision of the national field triage guidelines.…”

Section: Discussionmentioning

confidence: 99%

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Physiologic Field Triage Criteria for Identifying Seriously Injured Older Adults

Newgard

Richardson

Holmes

et al. 2014

Prehospital Emergency Care

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Objective To evaluate the ability of out-of-hospital physiologic measures to predict serious injury for field triage purposes among older adults and potentially reduce the under-triage of seriously injured elders to non-trauma hospitals. Methods This was a retrospective cohort study involving injured adults 55 years and older transported by 94 emergency medical services (EMS) agencies to 122 hospitals (trauma and non-trauma) in 7 regions of the western United States from January 1, 2006 to December 31, 2008. We evaluated initial out-of-hospital Glasgow Coma Scale (GCS) score, systolic blood pressure (SBP), respiratory rate, heart rate, shock index (SBP ÷ heart rate), out-of-hospital procedures, mechanism of injury, and patient demographics. The primary outcome was “serious injury,” defined as Injury Severity Score (ISS) ≥ 16, as a measure of trauma center need. We used multivariable regression models, fractional polynomials and binary recursive partitioning to evaluate appropriate physiologic cut-points and the value of different physiologic triage criteria. Results A total of 44,890 injured older adults were evaluated and transported by EMS, of whom 2,328 (5.2%) had ISS ≥ 16. Nonlinear associations existed between all physiologic measures and ISS ≥ 16 (unadjusted and adjusted p ≤ 0.001 for all,), except for heart rate (adjusted p = 0.48). Revised physiologic triage criteria included GCS score ≤ 14; respiratory rate < 10 or > 24 breaths per minute or assisted ventilation; and SBP < 110 or > 200 mmHg. Compared to current triage practices, the revised criteria would increase triage sensitivity from 78.6 to 86.3% (difference 7.7%, 95% CI 6.1–9.6%), reduce specificity from 75.5 to 60.7% (difference 14.8%, 95% CI 14.3–15.3%), and increase the proportion of patients without serious injuries transported to major trauma centers by 60%. Conclusions Existing out-of-hospital physiologic triage criteria could be revised to better identify seriously injured older adults at the expense of increasing over-triage to major trauma centers.

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Section: Discussionsupporting

confidence: 79%

Section: Discussionmentioning

confidence: 99%

Physiologic Field Triage Criteria for Identifying Seriously Injured Older Adults

Newgard

Richardson

Holmes

et al. 2014

Prehospital Emergency Care

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“…Elderly patients are also more likely to have more co-morbidities and use of anticoagulants and/or antiplatelet agents (20% vs. 1% in this study). It has also been well established that elderly patients have decreased physiologic reserve and present with less reliable vital signs [26, 37]. Despite normal admission vitals, elderly patients are more prone to decompensation over time; clinicians may therefore more aggressively resuscitate these patients, particularly in the period before internal bleeding has been reliably excluded.…”

Section: Discussionmentioning

confidence: 99%

“…Specifically, our study aimed to determine how age impacts blood transfusion during trauma resuscitations. It has been shown that geriatric trauma patients tend to be under-triaged, but what is unclear is whether they are under-resuscitated or over-resuscitated, given misleading vital signs secondary to pre-existing medical conditions and medication use [26]. Second, we hypothesized that the acute coagulopathy of trauma varies with age.…”

Section: Introductionmentioning

confidence: 99%

Blood transfusion and coagulopathy in geriatric trauma patients

Mador

Nascimento

Hollands

et al. 2017

Scand J Trauma Resusc Emerg Med

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BackgroundTrauma resuscitation has undergone a paradigm shift with new emphasis on the early use of blood products and increased proportions of plasma and platelets. However, it is unclear how this strategy is applied or how effective it is in the elderly population. The study aim is to identify differences in transfusion practices and the coagulopathy of trauma in the elderly.MethodsData was prospectively collected on all consecutive patients that met trauma activation criteria at a Level I trauma centre. Data fields included patient demographics, co-morbidities, injury and resuscitation data, laboratory values, thromboelastography (TEG) results, and outcome measures. Elderly patients were defined as those 55 and older. Propensity-score matched analysis was completed for patients receiving blood product transfusion. Patients were matched by gender, mechanism, injury severity score (ISS), head injury, and time from injury.ResultsTotal of 628 patients were included, of which 142 (23%) were elderly. Elderly patients were more likely to be female (41% vs. 24%), suffer blunt mechanism of trauma (96% vs. 80%), have higher ISS scores (mean 25.4 vs. 21.6) and mortality (19% vs. 8%). Elderly patients were significantly more likely to receive a blood transfusion (42% vs. 30%), specifically for red cells and plasma. Propensity-matched analysis resulted in no difference in red cell transfusion or mortality. Despite the broad similarities between the matched cohorts, trauma coagulopathy as measured by TEG was less commonly observed in the elderly.DiscussionOur results suggest that elderly trauma patients are more likely to receive blood products when admitted to a trauma centre, though this may be attributed to under-triage. The results also suggest an altered coagulopathic response to traumatic injury which is partially influenced by increased anticoagulant and antiplatelet medication use in the geriatric population.ConclusionIt is not clear whether the acute coagulopathy of trauma is equivalent in geriatric patients, and further study is therefore warranted.

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“…This type of accident is traditionally considered a minor mechanism of injury and deemed not to necessitate transfer to a trauma centre. However, many of these patients can sustain severe multisystem injuries, even if initially appearing stable [2, 3]. The combination of a greater likelihood of extensive medical comorbidities and a difficult, less-thorough assessment means that elderly trauma victims have significantly worse outcomes compared to their younger counterparts [4].…”

Section: Introductionmentioning

confidence: 99%

Ground-Level Geriatric Falls: A Not-So-Minor Mechanism of Injury

Parker

Afsharpad

2014

Case Reports in Orthopedics

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Introduction. Ground-level falls are typically regarded as a minor mechanism of injury that do not necessitate trauma team activation; however, they represent a significant proportion of hospitalised trauma and can result in multisystem injury. Case Presentation. A 79-year-old nursing home resident was brought to the emergency department following an unwitnessed fall. She suffered dementia and had a seizure in the department resulting in a reduced GCS, making history and examination difficult. She was diagnosed with a right proximal humerus fracture and admitted under joint orthopedic and medical care. Following orthopedic review, further X-rays were requested which showed bilateral neck of femur fractures. The following day she had bilateral hip hemiarthroplasties and K-wire stabilisation of the right shoulder. Several days later, when cognition had improved, she was noted to be avoiding use of the left arm and was found to also have a left proximal humerus fracture which was managed conservatively. Conclusion. Trauma patients with reduced cognitive function should undergo full ATLS assessment, and a prospective trial is required to see if age should be incorporated as a criteria for trauma team activation. More liberal use of advanced imaging such as a full body CT-scan may be beneficial.

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Normal Presenting Vital Signs Are Unreliable in Geriatric Blunt Trauma Victims

Cited by 168 publications

References 18 publications

Physiologic Field Triage Criteria for Identifying Seriously Injured Older Adults

Physiologic Field Triage Criteria for Identifying Seriously Injured Older Adults

Blood transfusion and coagulopathy in geriatric trauma patients

Ground-Level Geriatric Falls: A Not-So-Minor Mechanism of Injury

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