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Background: In the elderly, trauma has been associated with increased, long-term, all-cause mortality. Functional limitations secondary to injury may be responsible for the reduced survival rate. The objective of this study was to test this hypothesis using data from the Longitudinal Study of Aging (LSOA)., Methods: The LSOA is an extension of the 1984 National Health Interview Survey, which focused on 7,527 persons who were 70 years and older in 1984. Using data from the LSOA, a cohort of elderly patients hospitalized for injury in 1985 (N = 102) was identified from Medicare hospital discharge data. An uninjured cohort (N = 408) was also identified using the LSOA and matched by age (within 1 year) and sex. Deaths in both cohorts were identified using the National Death Index. Hazard ratios (HRs) for mortality within 6 years subsequent to injury, adjusted for demographic, health status, and functional characteristics, were calculated., Results: The injured cohort had a significantly reduced rate of survival compared with the uninjured cohort (HR = 1.5; 95% confidence interval [CI] 1.1-2.2), and this relationship persisted after adjusting for demographic and health characteristics (HR = 1.4; 95% CI 1.0-2.0). After additional adjustment for measures of functional decline, the association diminished (HR = 1.2; 95% CI 0.8-1.7). Functional decline remained a strong, independent factor for the risk of mortality., Conclusion: Trauma in the elderly has both an acute and long-term influence on mortality; the latter seems to be mediated through a decline in function resulting from the injury. This study suggests that strategies to return the elderly patient to preinjury functional status are of paramount importance. Future research should explore the impact of these interventions on long-term survival.

Background: On April 8, 1998, an F5 tornado touched down in two counties of Alabama producing a wide path of destruction. The presence of a regional trauma system in this area presents an opportunity to evaluate the effectiveness of the system in responding to the victims of this natural disaster., Methods: Emergency room logs and the regional trauma system database were searched for all patients treated for injuries sustained from the tornado, and medical records were reviewed for demographic information, mode of transportation to hospital, injuries, treatment, and outcome. Fatalities were identified by means of the coroner's office., Results: A total of 224 patients were evaluated at nine area hospitals, of whom 63 (28%) required admission. There were 32 deaths: 30 persons were dead at the scene, and 2 patients subsequently died at Level I trauma centers. Among patients with nonfatal injuries, 39% were managed at Level I facilities, 46% at Level III facilities, and 15% at nontrauma facilities. Forty patients (55%) seen at Level I facilities required admission compared with 15 patients (17%) at Level III facilities and 8 patients (29%) at nontrauma facilities; Level I facilities also had the highest Injury Severity Score. Of patients requiring admission, 83% were transported by emergency medical services; these patients also had the highest Injury Severity Score., Conclusion: The regional trauma system facilitated appropriate and efficient triage to system hospitals, routing the most severely injured patients to the Level I centers without overwhelming them with the more numerous, less severely injured patients.

Inferior vena cava (IVC) injuries are potentially devastating insults that continue to be associated with high mortality despite advances in prehospital and in-hospital critical care. Between 1987 and 1996, 37 patients (32 males and 5 females; average age, 30 years) were identified from the trauma registry as having sustained IVC trauma. Overall mortality was 51 per cent (n = 19), with 13 intraoperative deaths and five patients dying within the first 48 hours. Blunt IVC injuries (n = 8) had a higher associated mortality than penetrating wounds (63% versus 48%). Of the 29 patients with penetrating IVC trauma, the wounding agent influenced mortality (shotgun-100% versus gunshot-43% versus stab-0%). Anatomical location of injury was also predictive of death [suprahepatic (n = 3)-100% versus retrohepatic (n = 9)-78% versus suprarenal (n = 6)-33% versus juxtarenal (n = 2)-50% versus infrarenal (n = 15)-33%]. A direct relationship existed between outcome and the number of associated injuries: nonsurvivors averaged four and survivors averaged three. Eighty per cent of patients sustaining four or more associated injuries died, by contrast to a 33 per cent mortality in those suffering less than four injuries. Physiological factors were also predictive of outcome. Patients in shock (systolic blood pressure < 80) on arrival had a higher mortality than those who were hemodynamically stable (76% versus 30%). Preoperative lactate levels were of prognostic value for death (> or = 4.0-59% versus < 4.0-0%), as was base deficit (< 4-22%, > or = 4, and < 10-36%, > or = 10-73%). Interestingly, neither time from injury to hospital arrival (47.4 minutes versus 33.0 minutes) nor time in the emergency department before surgery (45.6 minutes versus 42.6 minutes) differed between survivors and fatalities. Mortality remained high in the 34 patients who had operative control of their IVC injuries [lateral repair (n = 27)-44% versus ligation (n = 6)-66% versus Gortex graft (n = 1)-0%]. As wounding agent, anatomical location, associated injuries, and physiological status seem to most directly impact mortality, future efforts must focus both on establishing prevention programs directed at reducing the incidence of this injury, as well as on advancing the management of those who do survive to hospitalization, if we are to improve on the outcome of these devastating injuries.