Trauma Team Activation for Geriatric Trauma at a Level II Trauma Center: Are the Elderly Under-triaged?

Abstract Geriatric patients often sustain life-threatening injuries from minor trauma. A growing body of research suggests that these patients are often under-triaged in the emergency setting.The purpose of this research was to evaluate whether or not geriatric trauma patients are under-triaged at a community based level II trauma center. 1434 trauma patients over the age of 65 presenting from 2010-2015 were retrospectively reviewed from the Cabell Huntington Hospital trauma registry and analyzed for age, gender, arrival type, ED response, Glasgow Coma Scale (GCS), Injury Severity Score (ISS), injury cause, ICD-9 diagnosis codes, and mortality. Under-triage and over-triage rates were determined using the Cribari method (under-triage = ISS ≥ 16 without full trauma team activation [TTA]; Over-triage = ISS ≤ 15 with full TTA). The under-triage rate was 9.5% (132/1393) with the majority of under-triaged patients having head trauma (n=423). There were 371 head trauma patients with a recorded GCS and analysis shows those with a GCS ≥ 13 had a 1.2% mortality risk (n=326; ISS 10.2), but that risk drastically increases to 60% with GSC ≤ 12 (n=45; ISS 21.5). Of the 45 patients with GSC ≤ 12, only 4% had priority 1 TTA using the current protocol (2/45). The American College of Surgeons-Committee of Trauma (ACS-COT) recommends an acceptable under-triage rate of \u3c 5%. In order to improve geriatric care and reduce under-triage rates, we recommend that an age-based criteria be added to our TTA protocol at our community based Level II trauma center: priority 1 TTA for all patients 65 years or older sustaining head trauma with a GCS ≤ 12 or suspicion of intracranial hemorrhage

Trauma Team Activation for Geriatric Trauma at a Level II Trauma Center: Are the Elderly Under-triaged?

Geriatric patients often sustain life-threatening injuries from minor trauma. A growing body of research suggests that these patients are often under-triaged in the emergency setting.The purpose of this research was to evaluate whether or not geriatric trauma patients are under-triaged at a community based level II trauma center. 1434 trauma patients over the age of 65 presenting from 2010-2015 were retrospectively reviewed from the Cabell Huntington Hospital trauma registry and analyzed for age, gender, arrival type, ED response, Glasgow Coma Scale (GCS), Injury Severity Score (ISS), injury cause, ICD-9 diagnosis codes, and mortality. Under-triage and over-triage rates were determined using the Cribari method (under-triage = ISS ≥ 16 without full trauma team activation [TTA]; Over-triage = ISS ≤ 15 with full TTA). The under-triage rate was 9.5% (132/1393) with the majority of under-triaged patients having head trauma (n=423). There were 371 head trauma patients with a recorded GCS and analysis shows those with a GCS ≥ 13 had a 1.2% mortality risk (n=326; ISS 10.2), but that risk drastically increases to 60% with GSC ≤ 12 (n=45; ISS 21.5). Of the 45 patients with GSC ≤ 12, only 4% had priority 1 TTA using the current protocol (2/45). The American College of Surgeons-Committee of Trauma (ACS-COT) recommends an acceptable under-triage rate of < 5%. In order to improve geriatric care and reduce under-triage rates, we recommend that an age-based criteria be added to our TTA protocol at our community based Level II trauma center: priority 1 TTA for all patients 65 years or older sustaining head trauma with a GCS ≤ 12 or suspicion of intracranial hemorrhage

Current concepts in the treatment of gross patellofemoral instability

Patellofemoral instability is a painful and commonly recurring condition, which often must be managed surgically. Diagnosis can be aided by the use of a variety of physical exam signs, such as the Q angle, Beighton hypermobility score, glide test, J sign, patellar tilt test, and apprehension test. Imaging modalities including x-ray, CT, and MRI guide both diagnosis and management by revealing trochlear dysplasia, bony malalignment, and ligamentous injury that contribute to instability. Following an initial patellar dislocation, nonoperative management with bracing and physical therapy is an acceptable option, despite limited evidence that operative management may improve functional outcome and reduce recurrent dislocations. For recurrent dislocations, operative management is indicated, and the appropriate procedure depends on the patient’s anatomy and the cause of instability. Reconstruction of the medial patellofemoral ligament (MPFL) restores the primary soft tissue restraint to lateral patellar dislocations, and can be performed using a variety of techniques. In patients whose instability is related to bony malalignment, a tibial tubercle osteotomy is commonly performed to realign the extensor mechanism and establish proper patellar tracking. In patients with trochlear dysplasia, a trochleoplasty may be performed to create a sufficient groove for the patella to traverse. Often these procedures must be combined to address all causes of instability. The reported outcomes following all three of these procedures are generally very good, with the majority of patients experiencing functional improvements and a low rate of recurrent instability, although more large randomized controlled trials are needed to determine which techniques are most effective. The purpose of this clinical commentary is to provide an overview of the current methods employed by orthopedic surgeons to diagnose and manage patellar instability. Level of Evidence:

Incision Length in Small Incision Total Knee Arthroplasty: How Long of an Incision Is Needed?

This prospective review studied incision length with a small incision TKA technique and compared measured incision lengths to various anatomic and clinical parameters. We prospectively reviewed 357 cases of primary total knee arthroplasty using a small paramedial incision and utilizing small incision instrumentation. By using linear regression analysis, we found that incision length was generally related to the width of the distal cut femur and the width of the proximal cut tibia. Incision length was not related to height, weight, BMI, or femoral implant width. Clinically based upon our data, a reasonable starting incision for small incision TKA (as measured in knee extension) is a length that is 1.6 times the measured width of the distal femur. The surgeon should always extend the incision if he/she encounters difficulty in exposure and/or placement of instrumentation

Luteal-Phase Accentuation of Acoustic Startle Response in Women with Premenstrual Dysphoric Disorder

Alterations in central nervous system response to menstrual cycle-related fluctuations in neuroactive steroids are thought to underlie the emergence of negative affect in the luteal phase of the menstrual cycle in women with premenstrual dysphoric disorder (PMDD). Such changes in the neuroendocrine milieu may lead to heightened arousal and response to stress in women with PMDD. Using the acoustic startle paradigm, we sought to determine whether women with PMDD have an accentuated physiologic response to a mildly aversive stimulus during the luteal compared to follicular phase. Further, we also examined the impact of visual affective stimuli on acoustic startle response (ASR) magnitude. During the follicular and luteal phases of the menstrual cycle, acoustic stimuli (103 dB) were delivered to 15 women with PMDD and 14 healthy menstruating women of similar age. After obtaining baseline ASR, the procedure was repeated when subjects viewed pleasant, neutral and unpleasant pictures. There was a significant group by menstrual cycle phase interaction for baseline ASR magnitude, which can be attributed to the heightened startle magnitude in women with PMDD compared to healthy women during the luteal relative to the follicular phase. The direction and degree to which picture viewing modulated the startle magnitude did not vary by group or menstrual cycle phase. These data suggest that menstrual cycle phase has a powerful modulatory effect on physiologic reactivity in women with PMDD but not in healthy women. Physiologic response to affective stimuli appears to be intact in women with PMDD across the menstrual cycle

Demographic, Clinical, and Psychosocial Predictors of the Reliability of Mothers' Clinical Judgments

The purpose of this study was to investigate to what extent selected adverse demographic, clinical, and psychosocial data measured at the 2-week well child visit could predict poorer reliability of mothers' judgments during acute illness episodes over the next 32 months. The study was a randomized trial of the Acute Illness Observation Scales (AIOS); 369 mothers participated, 183 in the intervention group using the Acute Illness Observation Scales and 186 in the control group using a three-point global assessment scale. There were 704 acute illnesses judged simultaneously and independently by mothers and pediatricians. Standard Pearson r correlations were performed between the independent variables, taken singly and in all possible combinations, and the dependent variable, reliability of mothers' judgments as measured by weighted kappa (kw). Group assignment was entered as an independent variable. Analyses were performed separately for all first, second, and third acute illness visits to control for any "practice effect" (analysis 1). To control for consistency of observers, the first, second, and third visits of mothers with three visits were also analyzed (analysis 2). Depending on the visit number, adverse demographic, clinical, and psychosocial characteristics did correlate with poorer reliability independent of group assignment. The correlations ranged from small (analysis 1, first visit, multiple variable r2 = 4%) to large (analysis 2, second visit, multiple variable r2 = 29%). Controlling for both visit number and consistency of observers vs visit number alone (analysis 2 vs analysis 1) increased multivariate correlations to kW. The results support the untoward impact that adverse demographic, clinical, and psychosocial factors have on mothers' clinical judgment. These data may assist pediatricians in identifying parents who might benefit from more intensive teaching and support about acute illness episodes in their children.</jats:p