Location of Injury and Other Factors Associated With Increased Survival Among Severely Injured Geriatric Trauma Patients

Abstract

Background

Patients with a Trauma Injury Severity Score (TRISS) < .5 are termed “unexpected survivors.” There is scarce information published on this subset of geriatric patients whose survival is an anomaly.

Methods

This is a retrospective case-control study examining all geriatric patients (age ≥65) not expected to survive (TRISS<.5) in the Pennsylvania Trauma Outcome Study (PTOS) database from 2013 to 2017. Primary outcome was survival to discharge. We selected 10 clinically important variables for logistic regression analysis as possible factors that may improve survival.

Results

1336 patients were included, 395 (29.6%) were unexpected survivors. Factors that improved survival odds are the following: Place of injury: street/highway (AOR:0.51; 95% CI: .36-.73, P < .001) and residential institution (AOR:0.46; 95% CI: .21-.98, P = .043); and presence of Benzodiazepines (AOR:0.49; 95% CI: .31-.77, P = .002) or ethanol (AOR:0.57; 95% CI: .34-.97, P = .040). Factors that decreased survival odds are the following: Hypotension (AOR: 8.59; 95% CI: 4.33-17.01, P < .001) and hypothermia (AOR: 1.58; 95% CI: 1.10-2.28, P = .014). Gender, race/ethnicity, blood transfusion in first 24 hours, shift of presentation to Emergency Department, place of injury (farm, industrial, recreational, or public building), use of Tetrahydrocannabinol, amphetamines or opioids, and level of trauma activation did not impact survival.

Discussion

Location of injury (street/highway and residential institution) and ethanol or benzodiazepine use led to a significant increased survival in severely injured geriatric patients. Hypotension and hypothermia led to decreased survival. Future studies should determine possible reasons these factors lead to survival (and identify additional factors) to focus efforts in these areas to improve outcomes in geriatric trauma.

Keywords

trauma geriatrics unexpected survival

Get full access to this article

View all access options for this article.

References

United States Census Bureau . Older People Projected to Outnumber Children for First Time in U.S. History. https://www.census.gov/newsroom/press-releases/2018/cb18-41-population-projections.html. Accessed June 1, 2020.

Bonne

Schuerer

. Trauma in the older adult: epidemiology and evolving geriatric trauma principles. Clin Geriatr Med. 2013;29(1):137-150. doi:10.1016/j.cger.2012.10.008.

Singh

Gupta

Garg

Gupta

. Evaluation of trauma and prediction of outcome using TRISS method. J Emergencies, Trauma, Shock. 2011;4(4):446-449. doi:10.4103/0974-2700.86626.

Millham

LaMorte

. Factors associated with mortality in trauma: Re-evaluation of the TRISS method using the National Trauma Data Bank. J Trauma. 2004;56(5):1090-1096. doi:10.1097/01.TA.0000119689.81910.06.

Gillott

Copes

Langan

Najarian

Wiseman

Sacco

. Triss Unexpected Survivors-a Statistical Phenomenon or a Clinical Reality? J Trauma Inj Infect Crit Care. 1992;33(5):743-748. doi:10.1097/00005373-199211000-00025.

Norris

Woods

Harbrecht

Fabian

Rhodes

Morris

, et al.

TRISS unexpected survivors: an outdated standard?

J Trauma. 2002;52(2):229-234. doi:10.1097/00005373-200202000-00005.

de Munter

Polinder

Nieboer

Lansink

KWW

Steyerberg

de Jongh

MAC

. Performance of the modified TRISS for evaluating trauma care in subpopulations: a cohort study. Injury. 2018;49(9):1648-1653. doi:10.1016/j.injury.2018.03.036.

Barea-Mendoza

Chico-Fernández

Sánchez-Casado

Molina-Díaz

Quintana-Díaz

Jiménez-Moragas

, et al. Predicting survival in geriatric trauma patients: a comparison between the TRISS methodology and the Geriatric Trauma Outcome Score. Cir Esp. 2018;96(6):357-362. doi:10.1016/j.ciresp.2018.02.014.

Yousefzadeh-Chabok

Hosseinpour

Kouchakinejad-Eramsadati

Ranjbar

Malekpouri

Razzaghi

, et al. Comparison of revised trauma score, injury severity score and trauma and injury severity score for mortality prediction in elderly trauma patients. Ulus Travma Acil Cerrahi Derg. 2016;22(6):536-540. doi:10.5505/tjtes.2016.93288.

10.

Javali

Krishnamoorthy, Patil

Srinivasarangan

Suraj , Sriharsha . Comparison of injury severity score, new injury severity score, revised trauma score and trauma and injury severity score for mortality prediction in elderly trauma patients. Indian J Crit Care Med. 2019;23(2):73-77. doi:10.5005/jp-journals-10071-23120.

11.

Sammy

Lecky

Sutton

Leaviss

O'Cathain

. Factors affecting mortality in older trauma patients-A systematic review and meta-analysis. Injury. 2016;47(6):1170-1183. doi:10.1016/j.injury.2016.02.027.

12.

Karmy-Jones

Copes

Champion

, et al. Results of a multi-institutional outcome assessment: results of a structured peer review of TRISS-designated unexpected outcomes. J Trauma. 1992;32(2):196-203.

13.

Demetriades

Chan

Velmahos

, et al. TRISS methodology in trauma: the need for alternatives. Br J Surg. 1998;85(3):379-384. doi:10.1046/j.1365-2168.1998.00610.x.

14.

Jiang

Zheng

Zhang

. The incidence of geriatric trauma is increasing and comparison of different scoring tools for the prediction of in-hospital mortality in geriatric trauma patients. World J Emerg Surg. 2020;15(1):59. doi:10.1186/s13017-020-00340-1.

15.

Byrne

Mann

Dai

, et al. Association between emergency medical service response time and motor vehicle crash mortality in the United States. JAMA Surg. 2019;154(4):286-293. doi:10.1001/jamasurg.2018.5097.

16.

Ashburn

Hendley

Angi

, et al. Prehospital trauma scene and transport times for pediatric and adult patients. West J Emerg Med. 2020;21(2):455-462. doi:10.5811/westjem.2019.11.44597. Published 2020.

17.

Harmsen

Giannakopoulos

Moerbeek

Jansma

Bonjer

Bloemers

. The influence of prehospital time on trauma patients outcome: a systematic review. Injury. 2015;46(4):602-609. doi:10.1016/j.injury.2015.01.008.

18.

Cheng

Inaba

Johnson

, et al. The impact of pre-injury controlled substance use on clinical outcomes after trauma. J Trauma Acute Care Surg. 2016;81(5):913-920. doi:10.1097/TA.0000000000001229.

19.

Leonard

Buckley

Curtis

. Impact of alcohol on outcomes in hospitalized major trauma patients: a literature review. J Trauma Nurs. 2016;23(2):103-114. doi:10.1097/JTN.0000000000000194.

20.

Hsieh

LoFu

HCLCH

, et al. Does alcohol intoxication protect patients from severe injury and reduce hospital mortality? The association of alcohol consumption with the severity of injury and survival in trauma patients. Am Surg. 2013;79(12):1289-1294. doi:10.1177/000313481307901222.