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Predictors of mortality among older major trauma patients

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Abstract

Background

Older trauma patients have a higher mortality yet are more likely to be under-triaged compared to younger patients. Studies have suggested that current trauma team activation criteria are suboptimal for older patients.

Objectives

The objective was to describe trauma care delivered, patient outcomes, and to identify variables independently associated with mortality.

Methods

We performed a health records review from 2014 to 2020 of older (age ≥ 65 years) trauma patients presenting to a level one trauma centre with any of the following: injury severity score (ISS) > 12, and all trauma team activations or admission to the trauma ward. The primary outcome was 30-day all-cause mortality. Secondary outcomes included injury mechanism and trauma care delivered. Multivariable logistic regression was used to identify factors independently associated with 30-day all-cause mortality. Multiple imputation was used to deal with missing data.

Results

We enrolled 1,380 patients (mean age 80 years, mean ISS 18); 26.8% had multimorbidity (≥ 2 chronic conditions) and 65.9% met criteria for polypharmacy (≥ 5 medications). The most common mechanism was fall from standing height (61.1%). Thirty-day all-cause mortality occurred in 239 (17.3%) patients. A Glasgow coma scale (GCS) < 15 (odds ratio [OR] = 5.55; 95% CI 3.73–8.24), ISS > 15 (OR = 3.75, 95% CI 2.35–6.01), age ≥ 85 years (OR = 2.04, 95% CI 1.29–3.22), anticoagulation with a direct oral anticoagulant (DOAC) or warfarin (OR = 1.59, 95% CI 1.08–2.35) and multimorbidity (OR = 1.53, 95% CI 1.06–2.22) were significantly associated with increased risk 30-day mortality (C-statistic = 0.82, 95% CI 0.79–0.85). Dementia (OR = 0.61, 95% CI 0.40–0.95) and time to CT scan > 60 min (OR = 0.50, 95% CI 0.34–0.74) were associated with decreased mortality risk.

Conclusion

We identified five factors associated with increased 30-day mortality in older trauma patients: GCS < 15, ISS > 15, age ≥ 85 years, anticoagulation, and multimorbidity. These factors should be considered when developing modified trauma team activation criteria for older adults.

Abstrait

Contexte

Les patients traumatisés âgés ont une mortalité plus élevée, mais sont plus susceptibles d’être sous-triés que les patients plus jeunes. Des études ont suggéré que les critères actuels d’activation des équipes de traumatologie sont sous-optimaux pour les patients âgés.

Objectifs

L’objectif était de décrire les soins traumatologiques dispensés, les résultats pour les patients et d’identifier les variables associées indépendamment à la mortalité.

Méthodes

De 2014 à 2020, nous avons effectué un examen des dossiers médicaux de patients de plus de 65 ans qui ont subi un traumatisme et qui se sont présentés à un centre de traumatologie de niveau 1 avec l’un ou l’autre des éléments suivants: le score de gravité de la blessure (SSI) > 12, et toutes les activations de l’équipe de traumatologie ou l’admission au service de traumatologie. Le critère de jugement principal était la mortalité toutes causes confondues de 30 jours. Les critères de jugement secondaires comprenaient le mécanisme de blessure et les soins prodigués en cas de traumatisme. La régression logistique multivariée a été utilisée pour identifier les facteurs indépendamment associés à la mortalité toutes causes confondues sur 30 jours. L’imputation multiple a été utilisée pour traiter les données manquantes.

Résultats

Nous avons recruté 1380 patients (âge moyen 80 ans, SSI moyenne 18); 26.8% avaient une multimorbidité (2 maladies chroniques) et 65.9% répondaient aux critères de polypharmacie (5 médicaments). Le mécanisme le plus courant était la chute de la hauteur debout (61.1%). Une mortalité toutes causes confondues sur 30 jours est survenue chez 239 (17.3%) patients. Une échelle de coma de Glasgow (GCS) < 15 (rapport de cotes [OR] = 5.55; 95% CI 3.73–8.24), ISS > 15 (OR = 3.75, 95% CI 2.35–6.01), âge 85 ans (OR = 2.04, 95% CI 1.29–3.22), anticoagulation avec un anticoagulant oral direct (DOAC) ou la warfarine (RC = 1.59, IC à 95%, de 1,08 à 2.35) et la multimorbidité (RC = 1.53, IC à 95%, de 1.06 à 2.22) étaient significativement associées à un risque accru de mortalité à 30 jours (C-statistic = 0.82, IC à 95%, de 0.79 à 0.85). Démence (RC = 0.61, IC à 95%, 0.40 à 0.95) le temps de TDM > 60 min (OR = 0.50, IC à 95%, 0.34 à 0.74) était associé à une diminution du risque de mortalité.

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Data availability

The data that support the findings of this study are available upon request from the authors.

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Acknowledgements

We would like to acknowledge Yuxin Zhang for assistance with statistical analysis. This work was presented as a plenary presentation at the 2022 Canadian Association of Emergency Physicians Annual Conference in Quebec City, Quebec.

Funding

This work was supported by a grant from the Department of Emergency Medicine, University of Ottawa.

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Authors and Affiliations

Authors

Contributions

KY, DE, JL, ME, AB and SF developed the study idea and design. MT and MJN oversaw data analysis. RN, RR and KY conducted data abstraction. KY wrote the initial version of the manuscript, and all study authors reviewed the manuscript and provided suggested revisions. KY takes responsibility for the submitted manuscript and study.

Corresponding author

Correspondence to Krishan Yadav.

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None.

Additional information

Communicated by Peter A. Cameron.

Supplementary Information

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Supplementary file1 (DOCX 26 KB)

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Yadav, K., Lampron, J., Nadj, R. et al. Predictors of mortality among older major trauma patients. Can J Emerg Med 25, 865–872 (2023). https://doi.org/10.1007/s43678-023-00597-w

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