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Malnutrition is associated with increased morbidity and mortality after trauma. The Geriatric Nutritional Risk Index (GNRI) is a validated scoring system used to predict the risk of complications related to malnutrition in nontrauma patients. We hypothesized that GNRI is predictive of worse outcomes in geriatric trauma patients.This was a single-center retrospective study of trauma patients 65 years or older admitted in 2019. Geriatric Nutritional Risk Index was calculated based on admission albumin level and ratio of actual body weight to ideal body weight. Groups were defined as major risk (GNRI82), moderate risk (GNRI 82-91), low risk (GNRI 92-98), and no risk (GNRI98). The primary outcome was mortality. Secondary outcomes included ventilator days, intensive care unit length of stay (LOS), hospital LOS, discharge home, sepsis, pneumonia, and acute respiratory distress syndrome. Bivariate and multivariable logistic regression analyses were performed to determine the association between GNRI risk category and outcomes.A total of 513 patients were identified for analysis. Median age was 78 years (71-86 years); 24 patients (4.7%) were identified as major risk, 66 (12.9%) as moderate risk, 72 (14%) as low risk, and 351 (68.4%) as no risk. Injury Severity Scores and Charlson Comorbidity Indexes were similar between all groups. Patients in the no risk group had decreased rates of death, and after adjusting for Injury Severity Score, age, and Charlson Comorbidity Index, the no risk group had decreased odds of death (odds ratio, 0.13; 95% confidence interval, 0.04-0.41) compared with the major risk group. The no risk group also had fewer infectious complications including sepsis and pneumonia, and shorter hospital LOS and were more likely to be discharged home.Major GNRI risk is associated with increased mortality and infectious complications in geriatric trauma patients. Further studies should target interventional strategies for those at highest risk based on GNRI.Prognostic and Epidemiologic; Level III.

IntroductionDysphagia is associated with increased morbidity, mortality, and resource utilization in hospitalized patients, but studies on outcomes in geriatric trauma patients with dysphagia are limited. We hypothesized that geriatric trauma patients with dysphagia would have worse clinical outcomes compared with those without dysphagia.MethodsPatients with and without dysphagia were compared in a single-center retrospective cohort study of trauma patients aged ≥65 years admitted in 2019. The primary outcome was mortality. Secondary outcomes included intensive care unit (ICU) length of stay (LOS), hospital LOS, discharge destination, and unplanned ICU admission. Multivariable regression analyses and Bayesian analyses adjusted for age, Injury Severity Score, mechanism of injury, and gender were performed to determine the association between dysphagia and clinical outcomes.ResultsOf 1706 geriatric patients, 69 patients (4%) were diagnosed with dysphagia. Patients with dysphagia were older with a higher Injury Severity Score. Increased odds of mortality did not reach statistical significance (OR 1.6, 95% CI 0.6 to 3.4, p=0.30). Dysphagia was associated with increased odds of unplanned ICU admission (OR 4.6, 95% CI 2.0 to 9.6, p≤0.001) and non-home discharge (OR 5.2, 95% CI 2.4 to 13.9, p≤0.001), as well as increased ICU LOS (OR 4.9, 95% CI 3.1 to 8.1, p≤0.001), and hospital LOS (OR 2.1, 95% CI 1.7 to 2.6, p≤0.001). On Bayesian analysis, dysphagia was associated with an increased probability of longer hospital and ICU LOS, unplanned ICU admission, and non-home discharge.ConclusionsClinically apparent dysphagia is associated with poor outcomes, but it remains unclear if dysphagia represents a modifiable risk factor or a marker of underlying frailty, leading to poor outcomes. This study highlights the importance of screening protocols for dysphagia in geriatric trauma patients to possibly mitigate adverse outcomes.Level of evidenceLevel III.

OBJECTIVE Evaluate the effect of age on opioid consumption after traumatic injury. SUMMARY BACKGROUND DATA Older trauma patients receive fewer opioids due to decreased metabolism and increased complications, but adequacy of pain control is unknown. We hypothesized that older trauma patients require fewer opioids to achieve adequate pain control. METHODS A secondary analysis of the multimodal analgesia strategies for trauma Trial evaluating the effectiveness of 2 multimodal pain regimens in 1561 trauma patients aged 16 to 96 was performed. Older patients (≥55 years) were compared to younger patients. Median daily oral morphine milligram equivalents (MME) consumption, average numeric rating scale pain scores, complications, and death were assessed. Multivariable analyses were performed. RESULTS Older patients (n = 562) had a median age of 68 years (interquartile range 61-78) compared to 33 (24-43) in younger patients. Older patients had lower injury severity scores (13 [9-20] vs 14 [9-22], P = 0.004), lower average pain scores (numeric rating scale 3 [1-4] vs 4 [2-5], P < 0.001), and consumed fewer MME/day (22 [10-45] vs 52 [28-78], P < 0.001). The multimodal analgesia strategies for trauma multi-modal pain regimen was effective at reducing opioid consumption at all ages. Additionally, on multivariable analysis including pain score adjustment, each decade age increase after 55 years was associated with a 23% reduction in MME/day consumed. CONCLUSIONS Older trauma patients required fewer opioids than younger patients with similar characteristics and pain scores. Opioid dosing for post-traumatic pain should consider age. A 20 to 25% dose reduction per decade after age 55 may reduce opioid exposure without altering pain control.

Objective The objective of this study was to compare adverse pregnancy outcomes between fetuses with estimated fetal weight (EFW) 10% in women with preterm preeclampsia (PE) with severe features. Materials and Methods All women with preterm PE with severe features and nonanomalous singletons with EFW were identified at a tertiary center. Women with oligohydramnios or absent/reversed umbilical Doppler velocimetry were excluded. Using multivariable analysis, we compared the composite maternal and neonatal morbidities (CMM and CNM) between those with appropriate for gestational age (AGA) fetal growth, defined as EFW at 10 to 90th versus those with fetal growth restriction (FGR), defined as EFW Results In this study, 165 patients were included; 112 had EFW at 10th to 90th percentile, and 53 had FGR. Of the 53 with FGR, 33 (62%) had EFW at 5 to 9% for GA and 20 (38%) had EFW Conclusion Women with preterm PE with severe features and FGR, when compared with those with AGA, have significantly higher risk of CMM and CNM.

Introduction Delayed intracranial hemorrhage (ICH) after negative initial head cat scan (CT) is a recognized complication after blunt trauma. Due to theoretical increased risk in patients on direct oral anticoagulants (DOACs) and inability to monitor degree of anticoagulation, there is a lack of consensus regarding need for observation or repeat imaging. We hypothesized that patients on DOACs would have low risk of delayed ICH after blunt head trauma. Methods In June 2020, an electronic literature search of MEDLINE (Ovid), Embase (Elsevier), and Cochrane Library was performed by a medical librarian. Included studies reported outcomes on adult trauma patients taking anticoagulants that were observed after initial normal head CT. A meta-analysis was performed using random effects model. Results Our electronic search returned 5719 papers with 12 meeting final inclusion/exclusion criteria. Overall, 5289 patients were studied including 1263 (23.9%) on DOAC and 1788 (33.8%) on warfarin. Sixty-nine patients suffered delayed ICH, 25 on DOAC and 44 on warfarin. The pooled weighted percentage for delayed ICH on DOAC was 2.43% (95% CI, 1.31 – 3.88%) compared to 2.31% (95% CI, 1.26 – 3.66%) on warfarin. The overall crude risk of death from delayed ICH while on DOAC or Warfarin was 0.36% (11/3051). Conclusions The risk of delayed ICH following low energy blunt head trauma for patients on DOACs is low, and risk of clinically significant bleeding is even lower. The practice of routinely observing or systematically reimaging patients on DOACs after low energy blunt head trauma with initially negative head CT may not be warranted.