2017 Resarch Forum

SG: M-1 Applicant: Tigran Karamanukyan MD Principal Investigator: Ruby Skinner MD FACS FCCP FCCM

Application of a geriatric injury protocol demonstrates high survival rates in elderly trauma patients with high injury acuity Tigran Karamanukyan MD, Andrea Pakula MD MPH FACS, Aswitha Francis MS III, Maureen Martin MD FACS, Ruby Skinner MD FACS FCCP FCCM

INTRODUCTION : The use geriatric injury protocols (GIP) are common; however, there is limited data on their impact in patients with high injury severity (ISS). We previously reported that outcomes at our facility were influenced by extremes of age (>80yrs) and high injury severity (ISS>15), during the inception of our GIP. That early study revealed a mortality rates range (10-80%). That data prompted us to revise our GIP to reflect modern evidenced based guidelines with a focus on unique clinical pathways. PURPOSE : To determine the impact on survival in geriatric patients with high ISS by our revised GIP. METHOD: Ninety-eight patients (age >65) admitted to our Level II trauma center spanning a five year period with injury severity scores (ISS) >15 comprised the study cohort. Patients were managed with a GIP (evidenced based multidisciplinary care and focus on early progressive mobility and nutrition). A retrospective descriptive study was performed to evaluate the impact of this protocol on outcomes and disposition. RESULTS: During the study period, 10,474 trauma patients were admitted to our facility. The final study group was n=98, and was comprised of geriatric patients requiring admission with a high ISS of >15. The mean age was 75 + 7.7 yrs. The majority were blunt injuries, n=94. Pre-existing disease included: HTN/CAD (61%), DM (32%), CRI (10%), and anticoagulation (33%). The ISS was 25 + 9.2 and the geriatric trauma outcome score (GTOS) was 150 + 31. CNS injuries and long-bone fractures were predominant at 58% and 38% respectively. Those with ICU admissions (41%) had an APACHE II score of 16 + . The need for mechanical ventilation (38%), early transfusion (56%), and surgery (61%) were common. Complications were: Nosocomial infections (21%), hemodialysis (7%), new onset arrhythmias (19%), deep vein thrombosis (3%) and re-intubation (3%). Hospital LOS was 10 + 10+ days; ICU LOS was 8+7 days. The overall mortality rate was 17%, and the majority was due to CNS injury (70% of deaths). When patients managed with early withdrawal of care due to non-survivable CNS injuries or advanced directives were then excluded, the mortality was 6%. Extremes of age did not impact mortality- (>80yrs 21% versus 65-79 16%, P=0.5). Patients requiring immediate OR had a mortality of 21% versus non-immediate OR at 17%, P=0.4. The majority, (53%) were discharged to home. Remaining patients were discharged to rehab (22%) and skilled nursing facilities (24%). CONCLUSIONS: The application of our geriatric trauma protocol demonstrates favorable results in trauma patients with high injury acuity and co-morbidities. The majority of patients sustained operative intervention and survived. Despite high ISS and GTOS, mortality rates were significantly lower than predicted with the majority able to return home. Further prospective study is warranted to validate these findings.