Geriatric Blunt Multiple Trauma: Improved Survival with Early Invasive Monitoring

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Abstract

Geriatric trauma survival rates are reported to approach 85%, but no series to our knowledge has included a predominance of multiply injured patients. In 1985, we treated 60 patients more than 65 years of age who sustained blunt multiple trauma, excluding burns and minor falls. A pedestrian-motor vehicle mechanism, initial BP < 150 mm Hg, acidosis, multiple fractures, and head injuries all predicted mortality.

To investigate this, in 1986, we began invasive monitoring in all patients with any of these risk factors and modified this in 1987 to emergent monitoring, postponing all but the most critical diagnostic studies. All patients included were hemodynamically stable after initial evaluation. Attempts were made to optimize all patients with volume, inotropes, and afterload reduction as needed. There was no difference between 1986 and 1987 in patient age, injury severity, or per cent of patients requiring operation.

In 1986, mean time from ED admission to monitoring was 5.5 hours. Eight of 15 patients had an initial cardiac output (CO) < 3.5 L/M and/or mixed venous saturation (MV02) < 50%. All developed progressive pump failure despite therapy and died within 24 hours. The other seven had an initial CO between 3.4–5.5 L/M, but five had an MV02 < 50%. All augmented their CO with therapy over 6–12 hours to a mean CO of 6.8 L/M and resolved their MV02, but six died from MOF. Survival was 7%.

In 1987–88, we reduced time to monitoring to 2.2 hours by limiting diagnostic tests. Thirteen of 30 patients treated had an initial CO < 3.5 L/M. Three died of progressive pump failure, three from MOF, but seven augmented CO to a mean of 6.3 L/M and survived. Eight had an initial CO > 3.5 L/M but < 5.2 L/M. All augmented CO to a mean of 6.8 L/M. Four survived, three died from head injuries, and one had an unexplained late cardiac arrest. Nine patients had initial cardiac outputs greater than 5.8 L/min. Six survived, two died from head injuries, and one had an unexplained late cardiac arrest. Survival was 53%.

ED evaluation of multiply injured geriatric patients may be misleading as those seemingly stable may have dangerously low CO. Untreated, this hypoperfusion state will proceed to cardiogenic shock and may produce MOF if treated late. Emergent invasive monitoring identifies occult shock early, limits hypoperfusion, and will help prevent MOF and improve survival.

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