Search

Spinal fractures are the third most common traumatic injury in older people, of which cervical spine injuries make up around 15%. They are predominantly seen in people living with frailty who fall from standing height. Spinal fractures in this patient group are associated with substantial morbidity and mortality (over 40% at 1 year). For many older people who survive, their injuries will be life changing. Practice between EDs varies significantly, with no universally accepted guidelines on either assessment, investigation or management specific to older people experiencing trauma. This expert practice review examines the current evidence and emergency management options in this patient group through clinical scenarios, with the aim of providing a more unified approach to management. [ABSTRACT FROM AUTHOR]

Background: Frailty is known to affect how people admitted with traumatic injuries recover during their inpatient stay and shortly after discharge. However, few studies have examined the effect of frailty on long‐term mortality when adjusted for significant factors including age. We aimed to determine the effect of frailty on 1‐year morality in older adults admitted with traumatic injuries. Methods: We undertook an observational study at the Severn Major Trauma Network's major trauma centre based in South West England. Patients ≥65 years old admitted between November 2018 and September 2019 with traumatic injuries were included. Isolated hip fractures and inpatient injuries were excluded. A geriatrician assessed all patients for frailty using the Clinical Frailty Scale. Follow‐up occurred at 1 year. A multivariable Cox proportional baseline hazards model assessed the effect of frailty on time‐to‐mortality. The adjusted model included age, sex, multimorbidity, surgery, most injured site, injury severity, postinjury complications, and geriatrician review. Results: Five hundred and eighty‐five patients were included. Median age was 81 years old (IQR 74–88), and median injury severity score was 13 (IQR 9–25). At 1 year 147 (25.1%) patients had died. Living with frailty was associated with mortality. The risk of dying increased with frailty severity. Compared to CFS 1–3: CFS 4 aHR = 1.73 (95% CI 0.89–3.36, p = 0.11); CFS 5 aHR = 3.82 (95% CI 2.11–6.93, p < 0.001); CFS 6 aHR = 4·05 (95% CI 2.21–7.45, p < 0.001); CFS 7–8 aHR = 6.57 (95% CI 3.43–12.59, p < 0.001). Conclusion: This study is the first to demonstrate a consistent effect of frailty, at all levels of severity and independent of age, on older peoples' survival 1 year after traumatic injury. These data support performing an admission frailty assessment to aid long‐term management decisions and provide opportunity to modify frailty to improve outcomes. [ABSTRACT FROM AUTHOR]

Background Frailty assessment using the Clinical Frailty Scale (CFS) has been mandated for older people admitted to English major trauma centres (MTC) since April 2019. Little evidence is available as to CFS-associated outcomes in the trauma population. Objective To investigate post-injury outcomes stratified by the CFS. Methods A single centre prospective observational cohort study was undertaken. CFS was prospectively assigned to patients ≥ 65 years old admitted to the MTC over a 5-month period. Primary outcome was 30-day post-injury mortality. Secondary outcomes were length of hospital stay, complications and discharge level of care. Results In 300 patients median age was 82; 146 (47%) were frail (CFS 5–9) and 28 (9.3%) severely frail (CFS 7–9). Frail patients had lower injury severity scores (median 9 vs 16) but greater 30-day mortality (CFS 5–6 odds ratio (OR) 5.68; P  < 0.01; CFS 7–9 OR 10.38; P  < 0.01). Frailty was associated with delirium (29.5% vs 17.5%; P  = 0.02), but not complication rate (50.7% vs 41.6%; P  = 0.20) or length of hospital stay (13 vs 11 days; P  = 0.35). Mild to moderate frailty was associated with increased care level at discharge (OR 2.31; P  < 0.01). Conclusions Frailty is an independent predictor of 30-day mortality, inpatient delirium and increased care level at discharge in older people experiencing trauma. CFS can therefore be used to identify those at risk of poor outcome who may benefit from comprehensive geriatric review, validating its inclusion in the 2019 best practice tariff for major trauma. [ABSTRACT FROM AUTHOR]

Aim To determine if frailty is associated with poor outcome following in-hospital cardiac arrest; to find if there is a "frailty threshold" beyond which cardiopulmonary resuscitation (CPR) becomes futile. Methods Retrospective review of patients aged over 60 years who received CPR between May 2017 and December 2018, in a tertiary referral hospital, which does not provide primary coronary revascularisation. Clinical Frailty Scale (CFS) and Charlson Comorbidity Index were retrospectively assigned. Results Data for 90 patients were analysed, the median age was 77 (IQR 70-83); 71% were male; 44% were frail (CFS > 4). Frailty was predictive of in-hospital mortality independent of age, comorbidity and cardiac arrest rhythm (OR 2.789 95% CI 1.145–6.795). No frail patients (CFS > 4) survived to hospital discharge, regardless of cardiac arrest rhythm, whilst 13 (26%) of the non-frail (CFS ≤ 4) patients survived to hospital discharge. Of the 13 survivors (Age 72; range 61–86), 12 were alive at 1 year and had a good neurological outcome, the outcome for the remaining patient was unknown. Conclusion Frail patients are unlikely to survive to hospital discharge following in-hospital cardiac arrest, these results may facilitate clinical decision making regarding whether CPR may be considered futile. The Clinical Frailty Scale is a simple bedside assessment that can provide invaluable information when considering treatment escalation plans, as it becomes more widespread, larger scale observations using prospective assessments of frailty may become feasible. [ABSTRACT FROM AUTHOR]

Adults aged ≥60 years now represent the majority of patients presenting with major trauma. Falls are the most common cause of injury, accounting for nearly three-quarters of all traumas in this population. Trauma to the thorax represents the second most common site of injury in this population, and is often associated with other serious injuries. Mortality rates are 2–5 times higher in older adults compared to their younger counterparts, often despite equivalent injury severity scores. Risk scoring systems have been developed to identify rib fracture patients at high risk of deterioration. Overall mortality from rib fractures is high, at approximately 10% for all ages. Mortality and morbidity from rib fractures primarily derive from pain-induced hypoventilation, pneumonia and respiratory failure. The main goal of care is therefore to provide sufficient analgesia to allow respiratory rehabilitation and prevent pulmonary complications. The provision of analgesia has evolved to incorporate novel regional anaesthesia techniques into conventional multimodal analgesia. Analgesia algorithms may aid early aggressive management and escalation of pain control. The current role for surgical fixation of rib fractures remains unclear for older adults who have been underrepresented in the research literature. Older adults with rib fractures often have multi-morbidity and frailty which complicate their injuries. Trauma services are evolving, and increasingly geriatricians will be embedded into trauma services to deliver comprehensive geriatric assessment. This review aims to provide an evidence-based overview of the management of rib fractures for the physician treating older patients who have sustained trauma. [ABSTRACT FROM AUTHOR]

Trauma in the elderly (>65 years) is an increasingly common presentation to the ED. A fall from standing height is the most common mechanism after which such patients present, and rib fracture is the most common non-spinal fracture. Thoracic injury in patients aged over 65 is associated with significant morbidity and mortality. There are currently no universally applied guidelines for assessment, investigation and management of such patients. In this expert practice review, we discuss the evidence base and options for clinical management in this vulnerable patient group. [ABSTRACT FROM AUTHOR]

Spinal fractures are the third most common traumatic injury in older people, of which cervical spine injuries make up around 15%. They are predominantly seen in people living with frailty who fall from standing height. Spinal fractures in this patient group are associated with substantial morbidity and mortality (over 40% at 1 year). For many older people who survive, their injuries will be life changing. Practice between EDs varies significantly, with no universally accepted guidelines on either assessment, investigation or management specific to older people experiencing trauma. This expert practice review examines the current evidence and emergency management options in this patient group through clinical scenarios, with the aim of providing a more unified approach to management., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Trauma in the elderly (>65 years) is an increasingly common presentation to the ED. A fall from standing height is the most common mechanism after which such patients present, and rib fracture is the most common non-spinal fracture. Thoracic injury in patients aged over 65 is associated with significant morbidity and mortality. There are currently no universally applied guidelines for assessment, investigation and management of such patients. In this expert practice review, we discuss the evidence base and options for clinical management in this vulnerable patient group., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)