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Advanced age is a well-recognized risk factor for adverse outcomes after trauma. A substantial body of literature, much of it cited within this article, demonstrates increased morbidity and mortality in geriatric trauma patients compared with their younger counterparts. Whether this outcome difference is because of the decreased physiologic reserve that accompanies aging, a higher incidence of preexisting medical conditions in the geriatric patient, or other factors yet to be identified remains unclear. It is clear, however, that good outcomes can be achieved in this patient population when appropriately aggressive trauma care is directed toward geriatric patients with survivable injuries. Implicit in the above statement is the need to identify, as soon as possible after injury, those patients who will benefit from aggressive resuscitation, timely injury management, and posttrauma rehabilitation. It is equally important, however, to limit these intensive and expensive treatment modalities to patients whose injuries are not only survivable but also compatible with an acceptable quality of life. Our purpose in developing this guideline was to provide the trauma practitioner with some evidence-based recommendations that could be used to guide decision-making in the care of the geriatric trauma patient. We began this process by first developing a series of questions, the answers to which we hoped could be supported by the existing scientific literature. The initial set of questions were as follows: 1. Is age itself a marker of increased morbidity/ mortality? If so, what age should be used? 2. Is age instead a surrogate for increased preexisting conditions (PECs)? If so, which premorbid conditions are particularly predictive of poor outcomes? 3. Should age itself be a criterion for triage from the field directly to a trauma center, regardless of Glasgow Coma Scale (GCS) score, Trauma Score (TS), and so forth? If so, what age should be used? 4. Do trauma centers have better outcomes with geriatric trauma than nontrauma centers? 5. Are there specific injuries, scores (e.g., Injury Severity Score [ISS], TS, GCS score), or PEC/age combinations in geriatric trauma patients that are so unlikely to be survivable that a nonaggressive approach from the outset could be justified? 6. What resuscitation end-points should be used for the geriatric trauma patient? 7. Should all geriatric trauma patients receive invasive hemodynamic monitoring? If so, what specific types of monitoring should be used? If not, which geriatric patients benefit from invasive monitoring? Unfortunately, after examining the available literature, it is clear that evidence-based responses to all of the questions raised above are not possible. As the evidentiary tables demonstrate, there are few, if any, prospective, randomized, controlled trials that definitively address any of the above issues. Second, there is a lack of uniformity as to a specific age criterion for geriatric trauma. As shown in the evidentiary tables, geriatric trauma is variously defined in the literature as age greater than or equal to 55, 60, 65, 70, 75, and even 80 years of age. There is even literature support for increased mortality from trauma beginning at age 45! Furthermore, because age is a continuous variable, and not a dichotomous one, adverse outcomes associated with geriatric trauma are likely to increase in a continuous fashion with age as opposed to a stepwise leap as a given patient reaches a specific age. Third, there is no concise definition of a geriatric trauma patient. In some studies, all patients over a given age are included, whereas in others, patients with penetrating injuries, burns, and minor injuries, such as slip-and-falls, are excluded. Some studies include all patients regardless of hemodynamic instability or injury severity, whereas others impose strict entrance criteria or exclude patients who do not survive for a predetermined period of time after admission. Such lack of uniformity regarding inclusion criteria makes it Submitted for publication October 3, 2001. Accepted for publication September 16, 2002. Copyright © 2003 by Lippincott Williams & Wilkins, Inc. From the Carolinas Medical Center (D.G.J.), Charlotte, North Carolina, Trauma Service, Bronson Hospital (B.R.P.), Kalamazoo, and Trauma Burn Center, University of Michigan Health System (W.W.), Ann Arbor, Michigan, New York Hospital–Cornell Medical Center (P.S.B.), New York, New York, Robert Wood Johnson Medical School (J.S.H.), New Brunswick, New Jersey, Mt. Sinai Hospital (M.R.H.), Chicago, Illinois, Morehouse School of Medicine (K.E.S.), Atlanta, Georgia, and R Adams Cowley Shock Trauma Center, University of Maryland Medical Center (T.M.S.), Baltimore, Maryland. Address for reprints: David G. Jacobs, MD, Carolinas Medical Center, P.O. Box 32861, Charlotte, NC 28232; email: djacobs@carolinas.org.

Purpose: The surgical resident experience with trauma has changed. Many residents are exposed to predominantly nonoperative patient care experiences while on trauma rotations. Data from a large multicenter study were analyzed to estimate surgical resident exposure to trauma laparotomy, diagnostic peritoneal lavage (DPL), and focused abdominal sonography for trauma (U/S). Methods: Centers completed a self-report questionnaire on their institutional demographics, admissions, and procedure for a 2-year period (1998-1999). Results: A total of 82 trauma centers that provide resident teaching were included. The included centers represent over 247,000 trauma admissions. The majority of trauma centers (65.9%) had > 80% blunt injury. Although all centers performed laparotomies, other results were more variable. For U/S, 24.2% performed none at all and 47.0% performed fewer than two U/S examinations per month. For DPLs, 3.8% performed none and 66.7% performed fewer than two per month. Assuming 1 night of 4 on call, the average surgical resident training at a trauma center performing > 80% blunt trauma has the potential to participate in only 15 trauma laparotomies, 6 diagnostic peritoneal lavages, and 45 ultrasound examinations per year. In addition, the resident will care for an average of 500 blunt trauma patients before performing a splenectomy or liver repair. Conclusion: Surgical resident experience on most trauma services is heavily weighted to nonoperative management, with a relatively low number of procedures, little experience with DPL, and highly variable experience with ultrasound. These data have serious implications for resident training and recruitment into the specialty.

Chest radiographs (CXRs) are frequently obtained in surgical intensive care unit (SICU) patients when a diagnosis of ventilator-associated pneumonia (VAP) is suspected. The purpose of this study was to determine if the interpretation of the CXR correlated with a diagnosis of VAP in SICU patients. Prospective evaluation of 20 SICU patients clinically suspected of VAP was performed from July 1997 through December 1998. All patients required mechanical ventilation for at least 48 hours, and antibiotic use was discontinued 24 hours before entry into the study. Bronchoscopy with protected specimen brush (PSB) sampling of secretions from the right and left lung was performed. A positive PSB was present if quantitative analysis yielded ≥104 colony-forming units/mL of bacteria. VAP was diagnosed if either the right or left PSB was positive and ruled-out if both the right and left PSB yielded 4 colony-forming units/mL. Twelve of 20 patients (60%) were diagnosed to have VAP by PSB criteria. Eight of 20 patients (40%) had CXRs interpreted as negative for infiltrates; four patients had VAP by PSB criteria. There were four patients with focal infiltrates; two patients had VAP. The remaining eight patients had radiographs interpreted as bilateral infiltrates (one) or pulmonary edema (seven); of these, six patients (75%) had VAP. The sensitivity of the CXR in determining the presence of VAP was 25 per cent, the specificity was 75 per cent, and the accuracy was 0.45. The CXR does not improve the clinician's ability to diagnose VAP: a normal CXR does not exclude the presence of VAP and the finding of a focal infiltrate does not confirm the diagnosis of VAP.