Tag Archives: elderly

Best Of EAST #10: (F)utility Of ICP Monitoring In Geriatric Patients?

Patients with severe TBI are typically managed using staged protocols based on the Brain Trauma Foundation (BTF) guidelines for ICP monitoring. There have been a number of papers over the past six years that question the utility of ICP monitoring, at least using the procedures in the BTF guidelines.  Most of these studies do not specifically break out elderly patients.

The group at the Westchester Medical Center in NY used the TQIP database to review the impact of ICP monitoring for severe TBI in patients > 65 years old. They performed a four year database study on these patients with an isolated head injury (no other body regions with AIS > 2), initial GCS < 8, and a length of stay > 24 hours. The examined the presence or absence of an ICP monitor, AIS head score, GCS, and a number of outcome measures.

Here are the factoids:

  • A total of 4,433 patients met the above criteria, and 17% had an ICP monitor placed
  • After propensity matching for those with and without an ICP monitor, mortality was nearly identical in both groups at 49%
  • ICU length of stay, hospital length of stay, and ventilator days were significantly longer in the monitor group

The authors concluded that ICP monitoring in this elderly group of patients did not improve survival and increased length of time in the ICU, hospital, and on the ventilator. The recommend that the current guidelines be improved to recognize these facts.

Bottom line: This is a nice, simple study that sought to answer just a few nice, simple questions. The mortality results are convincingly equal between the groups with and without an ICP monitor. The lengths of stay and ventilator days are statistically significantly longer with p values < 0.001. However, the actual numbers are not provided. I have seen many studies where statistically different numbers are not clinically relevant.

There are a number of papers that have come to similar conclusion on other or broader groups of TBI patients. Although we have specific guidelines on who gets a monitor and what we do with the numbers, there is growing doubt that their use actually helps. Perhaps it is time for us to review the data and make appropriate revisions!

Here are my questions for the authors and presenter:

  • Tell us about your propensity score matching. This will help us understand how similar the patient groups really were, with the exception of their ICP monitors.
  • Please provide the actual numbers for your lengths of stay and ventilator days. We need to be sure these are clinically and/or financially significant.
  • Have the results of this work prompted you to rework your own practice guidelines for treatment of severe TBI? I’m always interested if the group feels strongly enough about their work that they would consider changing their practice based on it.



Adding A Hospitalist To The Trauma Service

Hospitals are increasingly relying on a hospitalist model to deliver care to inpatients on medical services. These medical generalists are usually trained in general internal medicine, family medicine, or pediatrics and provide general hospital-based care. Specialists, both medical and surgical, may be consulted when needed.

In most higher level trauma centers in the US (I and II), major trauma patients are admitted to a surgical service (Trauma), and other nonsurgical specialists are consulted based on the needs of the patients and the competencies of the surgeons managing the patients. As our population ages, more and more elderly patients are admitted for traumatic injury, with more and more complex medical comorbidities.

Is there a benefit to adding medical expertise to the trauma service? A few studies have now looked at this, and I will review them over the next few days. The Level I trauma center at Christiana Care in Wilmington, Delaware embedded a trauma hospitalist (THOSP) in the trauma service. They participated in the care of trauma patients with coronary artery disease, CHF, arrhythmias, chronic diseases of the lung or kidneys, stroke, diabetes, or those taking anticoagulants.

The THOSP was consulted on appropriate patients upon admission, or during admission if one of the conditions was discovered later. They attended morning and afternoon sign-outs, and weekly multidisciplinary rounds. A total of 566 patients with hospitalist involvement were matched to controls, and ultimately 469 patients were studied.

Here are the factoids:

  • Addition of the THOSP resulted in a 1 day increase in hospital length of stay
  • Trauma readmissions decreased significantly from 2.4% to 0.6%
  • The number of upgrades to ICU status doubled, but ICU LOS remained the same
  • Mortality decreased significantly from 2.9% to 0.4%
  • The incidence of renal failure decreased significantly
  • Non-significant decreases in cardiovascular events, DVT/PE and sepsis were also noted
  • There was no difference in the number of medical specialty consults placed (cardiology, endocrinology, neurology, nephrology)

Bottom line: This paper shows some positive impact, along with some puzzling mixed results. The decrease in mortality and many complications is very positive. Was the increase in ICU transfers due to a different care philosophy in medical vs surgical personnel? And the failure to decrease the number of specialty consults was very disappointing to me. I would expect that having additional medical expertise on the team should make a difference there.

Was the THOSP really “embedded” if they were not involved in the regular daily rounds? In this case, they were present only for handoffs and for weekly multidisciplinary rounds. I believe that having them on the rounding team daily would be of huge benefit, allowing the surgeons and hospitalists to learn from each other. Plus, there should be a benefit to the residents in a Level I center, helping them broaden their ability to care for these complicated patients.

Reference: Embedding a trauma hospitalist in the trauma service reduces mortality and 30-day trauma-related readmissions. J Trauma 81(1):178-183, 2016.

Best Of AAST 2021: Identifying Risk For Elderly Falls

Over the past 20 years, falls have become the most common mechanism of injury at most trauma centers. In fact, many centers count twice as many falls as motor vehicle crashes! The problem with working in a trauma center is that we tend to see patients at risk for falls only after they have fallen.

The group at Butterworth Hospital attempted to determine if there was a way to identify patients at risk for falls earlier. They postulated that many of these patients may have experienced a fall within the past year, identifying them as at high risk for yet another. They retrospectively reviewed their trauma registry data for a three year period. Specifically, they wanted to identify how many of those had suffered earlier falls and what happened to them over time.

Here are the factoids:

  • A total of 597 patients were also admitted due to a fall during the year prior to their index admission
  • Only 2% had falls prevention teaching after the previous admission
  • About a third of patients fell again within a year after the index admission, and 20% were admitted again
  • The patients were assessed using the Hester-Davis score (see below), and patients who were identified by it as high risk were more likely to be readmitted or die
  • Overall mortality at 12 months was about 20%

The authors were surprised that so many of their falls patients had been previously admitted for a fall. They recognized that it presents a major prevention opportunity, and recommend these patients undergo some type of activity before and/or after discharge.

Note: The Hester Davis Fall Risk Scale (HDFRS) includes factors of age, date of last known fall, mobility, medications, mental status, toileting needs, volume/electrolyte status, communication/sensory, and behavior with the option to choose multiple options per risk category; a score of seven to ten indicates low fall risk, eleven to fourteen indicates moderate fall risk, and greater than fifteen indicates high fall risk.

Bottom line: This is a straightforward single-hospital registry study. Even though it reflects the experience of a single rural trauma center, the results are applicable to most others. It confirms that any fall in the elderly should be considered a sentinel event which has a good chance leading to death within a year. 

Here’s the way I see it:

“You fall, you die”

It is very important that every trauma center identify these patients when they arrive, and apply prevention efforts while in the hospital or hook them up with activities after discharge. And if you don’t have such a program included in your injury prevention activities, you should! It’s the most common mechanism seen by trauma centers, hands down!

I have only one suggestion for the presenter and authors:

  • The concept of being “at risk” was not clear to me. Did this mean that you looked back one year for each admission to see if there was an admission for a fall? Or did you just get the history of a fall from the previous admission? It looks like you identified an index admission, then looked back a year to see if the patient should be included in this study. Then you looked forward a year to see if there was yet another admission and/or death. Is this correct? Please clarify during your presentation at the meeting.

CONTINUUM OF CARE. AAST 2021, Oral abstract #18.

Detecting Rib Fractures In The Elderly

It’s well known that our elders do less well than younger folks after injury. The number of complications is higher, there tends to be more loss of independence during recovery, and mortality is increased. This is not only true of high energy trauma like car crashes, but also much lower energy events such as a fall from standing.

Rib fractures are common after falls in the elderly and contribute to significant morbidity if not treated adequately. Traditionally, they are identified through a combination of physical exam and chest x-ray. Unfortunately, only half of rib fractures are visible on x-ray. It falls to the physical exam to detect the rest.

A group at Beth Israel Hospital in Boston explored the utility of using chest CT in an attempt to determine if this would result in more appropriate and cost-efficient care in the elderly. They performed a retrospective study of 3 years of their own data on patients aged 65 or more presenting after a mechanical fall and receiving a rib fracture diagnosis. Imaging was ordered at the discretion of the physician. A total of 330 patients were elderly, fell, and had both chest x-ray and chest CT obtained. This was a very elderly group, with a mean age of 84 years!

Here are the factoids:

  • Rib fractures were seen on chest x-ray in 40 patients (12%) and on CT in an additional 56 ; 234 patients had no fractures on either
  • When fractures were seen on both studies, CT identified a median of 2 more fractures than chest x-ray
  • Patients with fractures not seen on chest x-ray were admitted significantly more often than those without fractures (91% vs 78%)
  • Mortality, admission to ICU, ICU length of stay, and hospital length of stay were not different if fractures were seen only on CT
  • CT scan identified new issues or clarified diagnoses suggested by chest x-ray in 14 cases, including one malignancy
  • Rib detail images were obtained in 13 patients and proved to be better than chest x-ray, but not quite as good as CT scan

Conclusion: use of CT for rib fracture diagnosis resulted in a few more admissions, but no change in hospital resource utilization, complications, or mortality.

Bottom line: Hmm…, read the paper closely. The authors conclude that more patients with CT-only identified rib fractures are admitted. But compared to what? Unfortunately, patients without rib fractures on CT. What about comparing to patients who had fractures seen on chest x-ray too? If that number is the same, then of what additional use is CT? Identifying a few incidentalomas?

Given that there is no change in the usual outcome measures listed here, it doesn’t seem like there is any additional benefit to adding CT. And I can see a lot of downsides: cost, radiation, and possible exposure to IV contrast. In my mind, there is still nothing that beats a good physical exam and a chest x-ray. Skip the CT scan. And don’t even think about ordering rib detail images! That’s so 1990s. And even if no rib fractures are seen on imaging, physical exam is the prime determinant for admitting your patient for aggressive pain management and pulmonary toilet.

Reference: Chest CT imaging utility for radiographically occult rib fractures in elderly fall-injured patients. J Trauma 86(5):838-843, 2019.

Syncope Workup in Trauma Patients – Updated With CPG

Syncope accounts for 1-2% of all ED visits, and is a factor in some patients with blunt trauma, especially the elderly. If syncope is suspected, a “syncope workup” is frequently ordered. Just what this consists of is poorly defined. Even less understood is how useful the syncope workup really is.

Researchers at Yale retrospectively looked at their experience doing syncope workups in trauma patients. They were interested in seeing what was typically ordered, if it was clinically useful, and if it impacted length of stay.

A total of 14% of trauma patients had syncope as a possible contributor to their injury. The investigators found that the following tests were typically ordered in these patients:

  • Carotid ultrasound (96%)
  • 2D Echo (96%)
  • Cardiac enzymes (81%)
  • Cardiology consult (23%)
  • Neurology consult (11%)
  • EEG (7%)
  • MRI (6%)

Most of this testing was normal. About 3% of cardiac enzymes were abnormal, as were 5% of carotid imaging and 4% of echocardiograms.

Important! Of the patients who underwent an intervention after workup, 69% could have been identified based on history, physical exam, or EKG and did not depend on any of the other diagnostic tests.

Is it possible to determine a subset of this population that may show a higher yield for this screening? Surgeons at Temple University in Philadelphia found that there was little utility in using carotid duplex studies. They did note that patients with a history of heart disease were more likely to have an abnormal EKG, and that an abnormal EKG predicted an abnormal echo. Overall, only patients with a history of significant cardiac comorbidity, older age, and higher ISS had findings requiring intervention.

Bottom line: Don’t just reflexively order a syncope workup when there is a question of this problem. Think about it first, because the majority of these studies are nonproductive. They are not needed routinely in trauma patients with “syncope” as a contributing factor.  Obtain a good cardiac history, and if indicated, order an EKG and go from there. See the practice guideline proposed by the Temple group below. And be sure to include the patients primary doctor in the loop!


  1. Routine or protocol evaluation of trauma patients with suspected syncope is unnecessary. J Trauma 70(2):428-432, 2011.
  2. Syncope workup: Greater yield in select trauma population. Intl J Surg, accepted for publication June 27, 2017.