A Multi-Institutional Analysis of Damage Control Laparotomy in Elderly Trauma Patients: Do Geriatric Trauma Protocols Matter?

Abstract

Background

Trauma centers are receiving increasing numbers of older trauma patients. There is a lack of literature on the outcomes for elderly trauma patients who undergo damage control laparotomy (DCL). We hypothesized that trauma centers with geriatric protocols would have better outcomes in elderly patients after DCL.

Methods

A retrospective chart review of consecutive adult trauma patients with DCL at 8 level 1 trauma centers was conducted from 2012 to 2018. Patients aged 40 or older were included. Age ≥ 55 years was defined as elderly. Demographics, injury information, clinical outcomes, including mortality, and complications were recorded. Univariate and multivariate analyses were performed.

Results

A total of 379 patients with DCLs were identified with an average age of 54.8 ± 0.4 years with 39.3% (n = 149/379) of patients aged ≥ 55. Geriatric protocols or a consulting geriatric service was present at 37.5% (n = 3/8) of institutions. Age ≥ 55 was a significant risk factor for in-hospital mortality (OR 2, 95% CI 1.0-4.0, P = .04). Institutions without dedicated geriatric trauma protocols/services had higher overall in-hospital mortality on both univariate (57.9% vs 34.3%, P = .02) and multivariate analyses (OR 2.1, 95% CI 1.3-3.4, P < .001).

Conclusions

Surgical management of older trauma patients remains a challenge. Geriatric protocols or dedicated services were found to be associated with improved outcomes. Future efforts should focus on standardizing the availability of these resources at trauma centers.

Keywords

trauma damage control geriatrics

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References

Bonne

Schuerer

DJE

. 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

http://www.ncbi.nlm.nih.gov/pubmed/23177604

Bolger

JC.

Zaidi

Fuentes-Bonachera

et al. Emergency surgery in octogenarians: outcomes and factors affecting mortality in the General Hospital setting. Geriatr Gerontol Int. 2018;18(8):1211-1214.doi:10.1111/ggi.13456

http://www.ncbi.nlm.nih.gov/pubmed/29897164

Arhinful

Jenkins

Schiller

HJ.

Cullinane

DC.

Smoot

DL.

Zielinski

. Outcomes of damage control laparotomy with open abdomen management in the octogenarian population. J Trauma. 2011;70(3):616-621.doi:10.1097/TA.0b013e31820d19ed

http://www.ncbi.nlm.nih.gov/pubmed/21610351

Fallon

WF.

Rader

Zyzanski

et al. Geriatric outcomes are improved by a geriatric trauma consultation service. J Trauma. 2006;61(5):1040-1046.doi:10.1097/01.ta.0000238652.48008.59

http://www.ncbi.nlm.nih.gov/pubmed/17099506

Tillou

Kelley-Quon

Burruss

et al. Long-term postinjury functional recovery: outcomes of geriatric consultation. JAMA Surg. 2014;149(1):83-89.doi:10.1001/jamasurg.2013.4244

http://www.ncbi.nlm.nih.gov/pubmed/24284836

Wong

CL.

AlAtia

McFarlan

Lee

HY.

Valiaveettil

Haas

. Sustainability of a proactive geriatric trauma consultation service. Can J Surg. 2016;59(6):7216 doi:10.1503/cjs.007216

http://www.ncbi.nlm.nih.gov/pubmed/27669403

Calland

JF.

Ingraham

AM.

Martin

et al. Evaluation and management of geriatric trauma: an eastern association for the surgery of trauma practice management guideline. J Trauma Acute Care Surg. 2012;73(5 Suppl 4):S345-350.doi:10.1097/TA.0b013e318270191f

http://www.ncbi.nlm.nih.gov/pubmed/23114492

The Committee on Trauma . Transfer to Definitive Care. In: Advanced Trauma Life Support. 10th ed. American College of Surgeons; 2018:240-254.

Bridges

LC.

Waibel

BH.

Newell

. Permissive hypotension: potentially harmful in the elderly? A national trauma data bank analysis. Am Surg. 2015;81(8):770-777.doi:10.1177/000313481508100814

http://www.ncbi.nlm.nih.gov/pubmed/26215238

10.

Joseph

Zangbar

Pandit

et al. Mortality after trauma laparotomy in geriatric patients. J Surg Res. 2014;190(2):662-666.doi:10.1016/j.jss.2014.01.029

http://www.ncbi.nlm.nih.gov/pubmed/24582068

11.

Harbrecht

BG.

Peitzman

AB.

Rivera

et al. Contribution of age and gender to outcome of blunt splenic injury in adults: multicenter study of the eastern association for the surgery of trauma. J Trauma. 2001;51(5):887-895.doi:10.1097/00005373-200111000-00010

11706335

12.

Myers

JG.

Dent

DL.

Stewart

et al. Blunt splenic injuries: dedicated trauma surgeons can achieve a high rate of nonoperative success in patients of all ages. J Trauma. 2000;48(5):801-806.doi:10.1097/00005373-200005000-00002

10823522

13.

Kwok

AC.

Semel

ME.

Lipsitz

et al. The intensity and variation of surgical care at the end of life: a retrospective cohort study. Lancet. 2011;378(9800):1408-1413.doi:10.1016/S0140-6736(11)61268-3

http://www.ncbi.nlm.nih.gov/pubmed/21982520

14.

Callaway

DW.

Wolfe

. Geriatric trauma. Emerg Med Clin North Am. 2007;25(3):837-860.doi:10.1016/j.emc.2007.06.005

http://www.ncbi.nlm.nih.gov/pubmed/17826220

15.

Jani

Rajkumar

. Ageing and vascular ageing. Postgrad Med J. 2006;82(968):357-362.doi:10.1136/pgmj.2005.036053

http://www.ncbi.nlm.nih.gov/pubmed/16754702

16.

Mador

Nascimento

Hollands

Rizoli

. Blood transfusion and coagulopathy in geriatric trauma patients. Scand J Trauma Resusc Emerg Med. 2017;25(1):33 doi:10.1186/s13049-017-0374-0

http://www.ncbi.nlm.nih.gov/pubmed/28356162

17.

Grossman

Scaff

DW.

Miller

Reed

Hoey

Anderson

. Functional outcomes in octogenarian trauma. J Trauma. 2003;55(1):26-32.doi:10.1097/01.TA.0000072109.52351.0D

http://www.ncbi.nlm.nih.gov/pubmed/12855877

18.

Reske-Nielsen

Medzon

. Geriatric trauma. Emerg Med Clin North Am. 2016;34(3):483-500.doi:10.1016/j.emc.2016.04.004

http://www.ncbi.nlm.nih.gov/pubmed/27475011

19.

Brooks

SE.

Peetz

. Evidence-based care of geriatric trauma patients. Surg Clin North Am. 2017;97(5):1157-1174.doi:10.1016/j.suc.2017.06.006

http://www.ncbi.nlm.nih.gov/pubmed/28958363

20.

Jacobs

DG.

Plaisier

BR.

Barie

et al. Practice management guidelines for geriatric trauma: the East practice management guidelines work group. J Trauma. 2003;54(2):391-416.doi:10.1097/01.TA.0000042015.54022.BE

http://www.ncbi.nlm.nih.gov/pubmed/12579072

21.

Goodmanson

NW.

Rosengart

MR.

Barnato

AE.

Sperry

JL.

Peitzman

AB.

Marshall

. Defining geriatric trauma: when does age make a difference? Surgery. 2012;152(4):668-675.doi:10.1016/j.surg.2012.08.017

http://www.ncbi.nlm.nih.gov/pubmed/23021136

22.

Lustenberger

Inaba

Schnüriger

et al. Gunshot injuries in the elderly: patterns and outcomes. A national trauma databank analysis. World J Surg. 2011;35(3):528-534.doi:10.1007/s00268-010-0920-7

http://www.ncbi.nlm.nih.gov/pubmed/21203760

23.

Kuhne

CA.

Ruchholtz

Kaiser

GM.

Nast-Kolb

. Working group on multiple trauma of the German Society of T. Mortality in severely injured elderly trauma patients-when does age become a risk factor? World J Surg. 2005;29(11):1476-1482.

24.

Finelli

FC.

Jonsson

Champion

HR.

Morelli

Fouty

. A case control study for major trauma in geriatric patients. J Trauma. 1989;29(5):541-548.doi:10.1097/00005373-198905000-00001

http://www.ncbi.nlm.nih.gov/pubmed/2724372