Uncertainty remains over best trauma interventions for older persons trauma
Date First Published:
July 7, 2022
Last Updated:
July 25, 2024
Report by:
Melinda (Dolly) Mcpherson, Advanced Clinical Practitioner (University hospital Southampton)
Three-Part Question:
In [older patients with major trauma] what [early clinical interventions] improve [patient outcomes]
Clinical Scenario:
You are expecting an 80 year old major trauma patient into the resuscitation room of the emergency department. You wonder what early interventions might improve her outcomes.
Search Strategy:
MEDLINE 1966-05/22, CINAHL 1982-05/22 Via EBSCOhost and AMED 1985-05/22, EMBASE 1974-05/22 via Ovid. In addition, the Cochrane database was searched
Search re-run July 2024 725 papers with 6 of relevance)
Search re-run July 2024 725 papers with 6 of relevance)
Search Details:
EBSCOhost
AB ( Frail OR “older person” OR Geriatric OR Frailty OR silver ) AND AB ( “major trauma” OR “silver trauma” OR Trauma OR polytrauma OR ISS15 ) AND AB ( Intervention OR treatment OR management OR procedure ) AND AB improve AND AB ( Outcome(s) OR Experience OR Mortality OR Morbidity OR survival )
OVID
(Frail or Old or 'older person' or Geriatric or Frailty or silver) and ('major trauma' or 'silver trauma' or Trauma or polytrauma) and (Intervention or treatment or management or procedure) and improve and (Outcome or Experience or Mortality or Morbidity or survival)).ab.
AB ( Frail OR “older person” OR Geriatric OR Frailty OR silver ) AND AB ( “major trauma” OR “silver trauma” OR Trauma OR polytrauma OR ISS15 ) AND AB ( Intervention OR treatment OR management OR procedure ) AND AB improve AND AB ( Outcome(s) OR Experience OR Mortality OR Morbidity OR survival )
OVID
(Frail or Old or 'older person' or Geriatric or Frailty or silver) and ('major trauma' or 'silver trauma' or Trauma or polytrauma) and (Intervention or treatment or management or procedure) and improve and (Outcome or Experience or Mortality or Morbidity or survival)).ab.
Outcome:
725 papers with 6 of relevance)
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Effect on outcome of early intensive management of geriatric trauma patients D. Demetriades, M. Karaiskakis, G. Velmahos, K. Alo, E. Newton, J. Murray, J.Asensio, H.Belzberg, T. Berne and W. Showmaker 2002 | 336 Patients > 70 years from the Los Angeles County trauma centre and trauma registry with ISS>15. Group 1 standard care, Group 2 trauma team activation and early intensive management |
Prospective cohort study | Ground level falls not included thus excluding a significant number of older persons trauma Single centre study and USA based Small cohort study |
||
| Association Between a Geriatric Trauma Resuscitation Protocol Using Venous Lactate Measurements and Early Trauma Surgeon Involvement and Mortality Risk David Bar-Or, Kristin M. Salottolo, Alessandro Orlando, Charles W. Mains, Pamela Bourg and Patrick J. Offner 2013 | Hemodynamically stable individuals with blunt trauma aged 65 and older admitted to the Level I trauma center. (protocol used= patients with raised lactate reviewed by trauma surgeon plus ATLS resuscitation) |
Prospective cohort study | Single centre, USA based Observational design Aetiology of hyperlactemia not differentiated within the study. |
||
| Increased trauma activation is not equally beneficial for all elderly trauma patients Bryan W. Carr, Peter M. Hammer, Lava Timsina, Grace Rozycki, David V. Feliciano and Jamie J. Coleman 2017 | 4,341 patients >70 years who attended the study hospital with trauma. High level trauma team activated for 696 patients | Retrospective review | Retrospective therefore causality cannot be inferred No measurement of comorbidities or frailty No measurement of interventions/treatments |
Author Commentary:
There is a paucity of evidence describing effective early interventions affecting mortality in the frail older trauma patient. The evidence that has been found describes early trauma team activation and aggressive monitoring and resuscitation resulting in improved outcomes but these studies are single centre, based in the USA and did not appreciate the low mechanism patients with hidden injuries.
Bottom Line:
While this topic required further research the studies found re-iterate that trauma team activation and aggressive management of identified major trauma improves patient outcomes irrespective of age.
References:
- D. Demetriades, M. Karaiskakis, G. Velmahos, K. Alo, E. Newton, J. Murray, J.Asensio, H.Belzberg, T. Berne and W. Showmaker. Effect on outcome of early intensive management of geriatric trauma patients
- David Bar-Or, Kristin M. Salottolo, Alessandro Orlando, Charles W. Mains, Pamela Bourg and Patrick J. Offner. Association Between a Geriatric Trauma Resuscitation Protocol Using Venous Lactate Measurements and Early Trauma Surgeon Involvement and Mortality Risk
- Bryan W. Carr, Peter M. Hammer, Lava Timsina, Grace Rozycki, David V. Feliciano and Jamie J. Coleman. Increased trauma activation is not equally beneficial for all elderly trauma patients
- Alouidor, R., Siu, M., Roh, S., Perez Coulter, A.M., Kamine, T.H., Kramer, K.Z., Winston, E.S., Ryb, G., Putnam, A.T. and Kelly, E.. Impact of Modified Geriatric Trauma Activation Criteria on patient outcomes at a level 1 trauma center.
- Park, C., Bharija, A., Mesias, M., Mitchell, A., Krishna, P., Storr-Street, N., Brown, A., Martin, M., Lu, A.C. and Staudenmayer, K.LPark, C., Bharija, A., Mesias, M., Mitchell, A., Krishna, P., Storr. Association between Implementation of a Geriatric Trauma Clinical Pathway and Changes in Rates of Delirium in Older Adults with Traumatic Injury.
- De Simone, B., Chouillard, E., Podda, M et al,. The 2023 WSES guidelines on the management of trauma in elderly and frail patients