Brian R. Plaisier

Practice management guidelines for geriatric trauma: the EAST Practice Management Guidelines Work Group.

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

Practice management guidelines for the optimal timing of long-bone fracture stabilization in polytrauma patients : The EAST practice management guidelines work group

I. STATEMENT OF THE PROBLEM The optimal timing for long-bone stabilization in polytrauma patients has been debated for the last two decades. Much of the relevant literature focused on long-bone fracture as a femoral fracture; however, a substantial portion of published studies include various fractures (tibia, humerus, spine, and/or pelvis). Reported benefits of early long-bone stabilization in polytrauma patients include increased patient mobilization by eliminating the need for traction and decreased pulmonary morbidity (fat emboli syndrome, pneumonia, adult respiratory distress syndrome [ARDS]), late septic sequelae, hospital care costs, mortality, hospital length of stay (LOS), intensive care unit (ICU) LOS, and ventilator days. Some authors suggest that early long-bone stabilization in polytrauma patients increases blood loss, fluid administration, and surgical stress, pulmonary morbidity, and mortality. However, others intimate that pulmonary morbidity (pulmonary shunt) is similar in those undergoing early or late stabilization (i.e., no worse, no better). There have been additional concerns regarding the timing of long-bone stabilization in patients with brain or chest injury. Problems with early fixation of long bones in patients with brain injury include secondary brain injury as a result of hypoxemia, hypotension, and/or complexity of controlling intracranial hypertension, increased mortality, and increased fluid administration, which might exacerbate cerebral edema. Other investigators suggest that early long-bone stabilization is not advised in patients with pulmonary contusion, multiple rib fractures, or hemopneumothorax, since there is increased pulmonary morbidity (ARDS, fat embolism syndrome), especially when intramedullary nailing and reaming are used. However, others indicate that chest injury patients with early intramedullary nailing have similar outcomes compared with later intramedullary nailing or other stabilization techniques (i.e., no worse or better). Other studies suggest that pulmonary contusion patients have similar pulmonary morbidity (PaO2/FIO2 and duration of mechanical ventilation) with early or late stabilization (i.e., no worse or better).

The development of self-awareness of deficits from 1 week to 1 year after traumatic brain injury: Preliminary findings

Primary objective: To examine the process of recovery of self-awareness with consideration for the variables of severity of injury and deficit factors. Research design: A longitudinal, descriptive design was used. Methods and procedures: Eighteen participants and their significant others were interviewed using the Awareness Questionnaire at 1 week, 1 month, 4 months and 1 year post-injury. Main outcomes and results: Participants differed in self-awareness according to severity of injury, deficit factors and time post-injury. Overall, participants with mild TBI demonstrated better self-awareness. There was a significant interaction effect between severity of injury and time post-injury. Reduced self-awareness of cognitive deficits was noted for the participants with moderate and severe TBI. Conclusions: Time post-injury, severity of injury and deficit factors are confounding variables in the study of self-awareness.

Patterns and Antecedents of the Development of Self-Awareness following Traumatic Brain Injury: The Importance of Occupation

The purpose of this study was to explore the pattern of the development of self-awareness following traumatic brain injury (TBI). Further, the antecedents to change in self-awareness and the use of compensatory strategies were examined. A longitudinal descriptive method was used with 18 adult participants and their significant others. Each pair was interviewed at 1 week, 1 month, 4 months and 1 year post-injury, using the Awareness Questionnaire, the Patient Assessment of Own Functioning Inventory and the Personal Evaluation of Community Integration. Comparative analyses were conducted between the participants and their significant others, as well as among the different levels of severity of brain injury. The participants with mild TBI showed better self-awareness than the participants with moderate/severe TBI. By 1 year post-injury, however, the level of self-awareness for the participants with mild TBI was not significantly different from that for the participants with moderate/severe TBI. The pattern of the development of self-awareness was different between the two groups. The participants with mild TBI initially overestimated deficits, but demonstrated good self-awareness throughout. The participants with moderate/severe TBI significantly underestimated deficits, but demonstrated a gradual increase in self-awareness. The reported antecedents to self-awareness were similar. Both groups primarily used a comparison of their ability to perform familiar occupations after the injury as a means for developing self-awareness. Severity of injury and time post-injury are both significant variables in the pattern of recovery of self-awareness following TBI. Occupational therapists should consider the use of familiar occupations to assist in the recovery process.

Behavioral aspects of trauma in children and youth.

Trauma is prevalent in the lives of children. It derives from many sources, and, depending on its characteristics, can produce transient or enduring and devastating consequences. Early trauma, if left untreated, can set the stage for chronic deficits in the behavioral repertoires of affected children, and thus shape personality development. Additionally, when trauma is repetitive and chronic, the developing brain may be affected in ways that impede otherwise effective intervention. Yet diagnosing traumatic stress in children requires a departure from exclusively adult-like considerations and attention must be devoted to the ongoing developmental processes. Trauma-associated clinical features in children are sharply distinct from those that are associated with adult traumatization and must be taken into account from screening and diagnosis through treatment and outcome evaluation. We suggest that a learning foundation for symptom development will best assist the identification and selection of efficacious treatments. Pediatricians should make use of validated screening procedures that effectively identify affected children to facilitate timely referral and ongoing monitoring of treatment outcomes for their patients. A representative list of such instruments can be found in Table 1. With respect to hospital-based trauma work, we suggest the following recommendations: Professionals must be alert to the presence of acute stress symptoms in any child or parent after all injury incidents. These symptoms may occur in any injured child regardless of age, gender, injury severity, mechanism of injury, or length of time since injury. Certain mechanisms of injury, (ie, pedestrian versus motor vehicle collision), place the parent at higher risk for symptomatology. All family members, including parents and siblings, must be considered at risk for acute and long-term functional abnormalities. It is important to educate patients and family members that acute stress symptoms are common after an injury incident and are likely to resolve as the patients injuries heal. Yet despite this, before discharge from the hospital, parents must be taught to evaluate their traumatized childs behavior, as well as their own, for any evidence of posttraumatic stress disorder. Health care providers must anticipate potential strain upon family relationships and financial resources. Parents posttraumatic stress symptoms may result in deterioration of their own ability to support their injured child. And finally, reassessment of patient and family members should occur within the first days, at 1 to 2 weeks, 6 months, and 1 year following injury to ensure proper recovery and optimization of psychosocial function.