Multiple trauma in elderly patients. Factors influencing outcome: importance of aggressive care

Injury (1993) 24, (6), 365-368

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Multiple trauma in elderly patients. Factors influencing outcome: importance of aggressive care P. L. 0. Broos’, A. D’Hoorel, P. Vanderschot’, P. M. Rommensl and K. H. Stappaerts’ ‘Department Belgium

of Traumatology

and Emergency

Surgery, ‘Department

From 1978 fo 1991, 126 multiply-injured patients of 65 years and over were admitted fo fhe Department of Traumafology and Emergency Surgery of the Universify Hospitals of Leuven. The seriousness of the injury was evaluated using fhe Injury Severity Score (KS) and fhe Glasgow Coma Scale (GCS). Trafic accident (57 per cenf) anA a simple fall af home (30 per cenfj were the main causes of injury. T?w overall mortality rate within 6 months was 17 per cent. Mulfiple sysfem organ failure (MSOF) was responsible for the fatal outcome in 48 per cenf of the cases ana’ in 71 per cent of the deaths more than ? days after trauma. Of the survivors still living at home before injuy, 78 per cent were able fogo back to their normal suwoundings. Survivors were compared with nonsurvivors. There was no significant difference in age or in IS, nor in pre-existing diseases. On fhe other hand, fheGCS was of imporfanf prognosfic value, bofh for survival and Jclncfional recovery (IF’<0.001). Also, the need for early intubafion and continued ventilation were predictive of survival (PC 0.001). Nevertheless, this need for respiratory assistance was not an indication for withdrawing supporf as 9 per cent of the survivors also required endofracheal infubafion for s days or longer. In our opinion, aggressive trauma care for the elderly is justified.

Introduction Elderly persons are seriously injured less frequently than any other segment of the population (Hogue, 1982). However, the mortality rate of elderly patients after trauma is higher than for any other age group (Hogue, 1982; Trunkey et al., 1983; Broos et al., 1988). A trauma system that is to serve the needs of society effectively must be prepared to deal also with elderly patients. Despite their lower injury rate these patients consume nearly one-third of all health care resources expended on trauma care (Mueller and Gibson, 1976). Oreskovich et al. (1984) reported that elderly trauma patients have a poor long-term prognosis, with 72 per cent requiring continued nursing home care I year after discharge. These data have raised questions about the ethics and cost benefit of trauma care for elderly patients. Furthermore, the elderly segment of the population is growing rapidly. This elderly population is projected to increase by 18 per cent over the next 10 years and by more than 50 per cent within 50 years (Fischer and Miles, 1986; DeMaria et al., 1987a). Clearly, trauma in elderly patients will become an increasingly important health care issue in the future. The goals of this paper are to determine the prognostic criteria in elderly multiply-injured patients, and show 0 1993 Butterworth-Heinemann Ltd 0020-1383/93/060365-04

of Rehabilitation,

U.Z. Gasthuisberg,

whether routine aggressive indicated.

Leuven,

trauma care for this age group is

Materials and methods From 1978 to 1991, 126 multiply-injured patients of 65 years and over were admitted to the Department of Traumatology and Emergency Surgery of the University Hospitals of Leuven, Belgium. Multiple trauma was defined as injuries of the abdomen, chest or head associated with important fractures or, if there were no visceral injuries, as at least two major fractures of long bones or one main bone fracture in combination with a pelvic fracture (Marx et al., 1986). Excluded from this study were patients dead on admission or who died during resuscitation before any investigation could be carried out. The Injury Severity Score (ISS) was calculated for each patient. The severity of the brain injury was evaluated using the Glasgow Coma Scale (GCS). Age made no difference to treatment: the emergency procedures after resuscitation were, if necessary, followed by primary laparotomy, craniotomy or thoracotomy. As we are convinced that primary operative stabilization of fractures is an important factor in the prevention of complications and late death due to multiple system organ failure (MSOF), the majority of long bone fractures were operated on. Survivors and non-survivors were examined. All surviving patients were followed up for at least 6 months. For statistical calculations, we used Pearson’s x2 test or the x2 test with continuity correction according to Yates, with P< 0.05 as the level of significance.

Results Traffic accidents (5 7 per cent) were the main cause of injury (TableI). Of the elderly accident victims, 44 per cent were involved as pedestrians (Table II). Table I also shows that in old people a simple fall at home is the cause of multiple trauma in more than 30 per cent of the cases. The visceral lesions are listed in TubleIII. Of the 68 patients with a brain injury, the lesion had to be considered as severe (GCS between 3 and 8) in 21 and moderate (GCS between 9 and 12) in 25 cases. The mean ISS was 33.2.( f 14.1). The overall mortality rate within 6 months was 17 per cent. The time of death and its causes are listed in TablelV. MSOF was responsible for

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Injury: International Journal of the Care of the Injured (1993) Vol.

Table I. Elderly trauma victims (N= 126) Cause Traffic accident Fall (at home) Work Sport Attempted suicide

N

%

72 38 9 2 5

57 30 7 2 4

N

%

32 15

44 21 7 28

2:

Table III. Visceral lesions in 126 elderly trauma victims N

Lesions Brain injury Severe Moderate Mild Thoracic injury Abdominal injury (needing laparotomy) Major vascular lesion Urinary tract lesion

% 54

68 21 25 22

26 6 2 9

33 8 2 11

Table IV. Mortality in 126 elderly trauma victims (N= 21 (17%)) Time of death

Cause Brain injury Haemorrhage Cardiac failure MSOF Total

Within 24h 2 1 3

24h to 7 days

After 7 days

1

2

3 -

-2 IO

5 1 5 IO

4

14

21

-

Of the 105survivors, 101were still living at home before injury. Within 6 months, 78 of these (78 per cent) were back in their normal surroundings. The 23 other patients had to b e permanently institutionalized because of the sequelae of brain damage or persistent impairment of their locomotor system. Between these institutionalized patients, we find all the seven surviving patients had an initial GCS between 3 and 8.

Discussion

Table II. Traffic accidents in 72 elderly trauma victims

Pedestrian Bicycle Motorcycle Car

24/No.6

Total

the fatal outcome in 48 per cent of the patients and in 71per cent of all the late deaths more than 7 days after trauma. The 105 survivors were compared with the 21 nonsurvivors. There was no significant difference in age between the two groups; the mean age of the survivors was 70.3 years and that of the non-survivors 74.1 years. The ISS tended to be slightly higher in the surviving group (mean 35.1uerms32.7inthe non-surviving group). Pre-existing diseases are listed in Table V. None of the differences was statistically significant. At the time of admission to hospital, 14 of the nonsurvivors (67per cent) suffered from a severe head injury (GCS between 3 and 8). Only seven out of the survivors group (7 per cent) had a GCS in the range of 3 to 8 (PC 0.001). Early intubation and continued ventilation proved to be another predictive factor for the fatal outcome; 16 non-survivors (78 per cent) had to be intubated during transport or on admission and to be ventilated for at least 5 days or until death, while only 11 survivors (10 per cent) needed such treatment (PC 0.001).

Trauma is only the fifth most common cause of death in patients aged 65 years and over (Broos et al., 1988; Martin and Teberian, 1990; Bai.imer et al., 1991), while accidents cause more than half of the deaths in the 15-20 years age group; for those of 65 years and over the rate is only 6 per cent and only 0.8 per cent of these accidental deaths occur after multiple trauma (Zollinger, 1982). Nevertheless, since the proportion of elderly people in Western Europe and the USA is increasing, the number of those who sustain multiple trauma after the age of 65 years can be expected to rise in the future. Our study confirms the findings of other authors that traffic accidents are the main cause of injury (DeMaria et al., 1987a,b; Broos et al., 1988; Martin and Teberian, 1990). As drivers, the elderly have a high rate of accidents, which is due to impaired driving skills and sometimes due to actual syncopal episodes while behind the wheel. As occupants in motor vehicles, older victims sustain a similar distribution of injuries as do younger occupants, but with considerably more serious consequences (McCoy and Johnstone, 1989). Nevertheless, in our study the typical multiple trauma elderly patient is a pedestrian hit by a car or a motorcycle (more than 44 per cent of the traffic accident victims TubleII). Frequently, this accident is caused by the elderly pedestrian himself, who is not careful enough when leaving the footpath and who is slower to recognize and respond to danger (Broos et al., 1988; Martin and Teberian, 1990). A simple fall at home is also a major cause of multiple injuries. Elderly people suffer falls at home, at an incidence of 35 per cent per year over the age of 75 years (Tinetti and Speechley, 1989; Van Vaerenbergh and Broos, 1990). Falls result in fractures or serious injuries in 10-17.5 per cent of such cases, with 2 per cent of falls resulting in fatality (DeMaria et al., 1987b; Martin and Teberian, 1990). An overall mortality rate of 17 per cent in elderly multiple trauma victims is acceptably low. Oreskovich et al. (1984) noted a mortality rate of 15 per cent (mean ISS 19) and DeMaria et al. (1987a) a mortality rate of 21 per cent (mean ISS25). Each kind of emergency surgery in the aged involves major risks; an isolated hip fracture, for instance, is enough to cause a 20 per cent mortality within 6 months (Broos et al., 1989). In a previous study we have shown that

Table V. Pre-existing diseases in 126 elderly trauma victims

Disease

Survivors (N= 105)

Cardiopulmonary Osteoarticular Neuropsychiatric Renal Diabetes

47 31 36 13 11

P> 0.05

(45%) (30%) (34%) (12%) (10%)

Non-survivors (N=21) 11 4 9 9 4

(52%) (19%) (43%) (43%) (I 9%)

Broos et al.: Multiple trauma in elderly patients

despite a lower ES, the mortality in elderly multiple trauma patients is significantly higher than in young trauma victims (Broos et al., 1988). This difference may be due to the much higher haemodynamic and cardiopulmonary reserve in younger patients and a decreased ability of elderly patients to tolerate hypovolaemia and shock (Shorr et al., 1989). Once injured, the elderly patient is less able to mount an appropriate metabolic response. Ageing leads to a reduction in lean body mass and the catabolic response to trauma imposes a significantly greater burden upon the older individual, who frequently does not have sufficient nutrient reserves (Martin and Teberian, 1990). DeMaria (1987a) noted a mortality rate of 46 per cent in patients of 80 years or older which was four times greater than for patients aged 65 to 79 years. Nevertheless, there was no difference between the mean age of the survivors and the non-survivors in our study. The results in our patients showed, once again, the weakness of the ISS for predicting survival in the elderly. This failure of the traditional trauma scoring technique can be explained by the fact that the ES is based primarily on anatomical, rather than physiological grounds (Oreskovich et al., 1984; DeMaria et al., 1987a). Also the impact of pre-existing diseases on survival was not statistically significant. On the other hand, once again, the predicting value of the GCS was proved (Geisler and Saleman, 1987). Non-survivors had a nine times higher incidence of serious brain damage. These figures confirm the findings of DeMaria et al. (1987a). Our studies also showed that the need for early intubation, followed by long-term assisted ventilation was predictive of survival. Ten patients died of ARDS and MSOF after long-term intubation. Frequently, head injured patients require longterm intubation and there is, therefore, a causal link between these two variables. Nevertheless, as already proved by DeMaria et al. (1987a), ARDS and the need for prolonged ventilatory assistance are not an indication for withdrawing support. Also in our survivors group, II patients (9 per cent) required endotracheal intubation for 5 days or longer. In this group, seven patients developed concomitant pneumonia and ARDS. When trauma care systems become more complex and the survival rate increases, the next question that arises is whether the quality of life after injury can also be improved. In 1984, Oreskovich et al. were rather pessimistic, as only 12 per cent of their surviving elderly trauma patients were able to recover their previous level of independence. These results were in contrast to the findings of DeMaria et al. (1987a). In this study, nearly 90 per cent of the surviving elderly trauma patients returned home. Also, the fact that about 78 per cent of our survivors were able to return home within 6 months is encouraging. The difference between these results can be explained by the fact that in Oreskovich’s study 80 per cent of the patients suffered limb trauma (by far the most frequently injured body region) compared with 40 per cent in the study of DeMaria et al. (1987a) and 65 per cent in our patients. In the study of De Maria et al. (1987a), as well as in our study, patients with isolated orthopaedic injury were not included. It is generally accepted that patients with an isolated hip fracture, for instance, present more severe underlying disease, making the prognosis for functional recovery after trauma dramatically different (DeMaria et al., 1987a; Broos et al., 1989). Our previous study on isolated hip fractures in the elderly showed a home-going rate of only 60 per cent (Broos et al., 1989). Our results also confirm the previous finding of Plum and Posner (1980) as to the predictive value of the GCS

367

concerning recovery of brain function. AI1 seven surviving patients with severe head injury (GCS between 3 and 8) had to be permanently institutionalized because of the sequelae of brain damage.

Conclusions A typical multiply-injured elderly patient is a pedestrian hit by a car or a motorcycle. Nevertheless, a simple fall at home was the cause of the accident in nearly one victim in four. In the elderly, the ISS and pre-existing diseases are not predictive of survival. On the other hand, the GCS is of important prognostic value to survival as well as to functional recovery. Frequently, the presence of serious brain injury and the necessity for early intubation followed by long-term assisted ventilation are signs of a fatal outcome. Nevertheless, ‘the mortality rate is not especially higher than in other important emergency procedures. Prompt identification of injuries and sources of haemorrhage is critical in the elderly patient who will proceed more quickly to shock and who has much less cardiovascular reserve. The high cost of aggressive trauma care in the elderly is justified as nearly 80 per cent of the survivors are able to return home within 6 months after injury.

References Bai.imer F., Stedtfeld H. W., Dimitriadis K. et al. (1991) Polytraumen motorisierter StraBenverkehrsteilnehmer - zur Koinzidenz mit Jugend-und Seniorenalter. Vkrsichmngmedizin 43, 41.

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Injury: InternationalJournalof the Care of the Injured(1993) Vol. M/NO. 6

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Tinetti M. and Speechley M. (1989) Prevention of falls among the elderly. N. Engl. J Med. 320, 1055. Trunkey D. D., Siegel J., Baker S. P. et al. (1983) Panel: current status of trauma severity indices. 1. Traurrm 23, 185. Van Vaerenbergh J. and Broos P. (1990) Positive Romberg-test and the prediction of falling in the elderly. ~I$&. Gerontol. Geriafr. 21, 71. Zollinger H. K. (1982) Unfallursachen und Unfalltool im Alter. Z. Unfallmed. Berufskr. 74, 207.

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