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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 6  |  Issue : 2  |  Page : 51-53

Profile of fatal geriatric trauma at a Level 1 trauma centre of India


1 Department of Forensic Medicine, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
2 Department of Laboratory Medicine, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
3 Department of Forensic Medicine and Toxicology, Rama Medical College Hospital and Research Centre, Hapur, Uttar Pradesh, India
4 Department of Anesthesia and Critical Care, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
5 Department of Neurosurgery, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication10-Jan-2019

Correspondence Address:
Dr. Purva Mathur
Department of Laboratory Medicine, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpsic.jpsic_8_18

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  Abstract 


Background: Trauma in old age is a serious health issue and associated with high fatality. This study details the profile of fatal geriatric trauma at a Level 1 Indian trauma centre.
Methods: This is a retrospective study. A total of 779 geriatric patients were admitted to the Jai Prakash Narayan Apex Trauma Centre during 2-year period from January 2014 to December 2015. A retrospective analysis was done of all 194 fatal geriatric trauma patients who underwent autopsy at our centre during this 2-year period. The study has been taken ethical clearance from the institutional review board.
Setting: This study was conducted in a 165-bedded Level 1 trauma centre of India.
Participants: Hundred and ninety-four fatal geriatric trauma patients were included in the study.
Interventions: There were no interventions in this study.
Measurements: Data were represented in median (range: minimum–maximum) and frequency (%).
Results: The duration of admission of these 194 patients ranged from <1 to 91 days (median 3 days). The causes of trauma were road traffic accidents in 78 (40%), fall from height in 75 (39%), assault in 12 (6%), railway accident in 10 (5%) and unconsciousness in 10 (5%). The autopsy-proven primary cause of death was severe head injury in 89 (46%), septicaemia in 30 (15%), polytrauma in 11 (6%), orthotrauma in 12 (6%), haemorrhagic shock in 9 (5%), spinal injury in 8 (4%), musculoskeletal injury in 3 (2%) and fat embolism in 3 (2%).
Conclusion: In our study, while most of the early deaths were due to severe head injuries, late deaths were predominantly due to infections.

Keywords: Fatal, geriatric, infections, neurotrauma


How to cite this article:
Lalwani S, Mathur P, Kumar M, Sawhney C, Agrawal D, Katoch O. Profile of fatal geriatric trauma at a Level 1 trauma centre of India. J Patient Saf Infect Control 2018;6:51-3

How to cite this URL:
Lalwani S, Mathur P, Kumar M, Sawhney C, Agrawal D, Katoch O. Profile of fatal geriatric trauma at a Level 1 trauma centre of India. J Patient Saf Infect Control [serial online] 2018 [cited 2019 Nov 12];6:51-3. Available from: http://www.jpsiconline.com/text.asp?2018/6/2/51/249845




  Introduction Top


Globally, trauma is currently the fifth leading cause of death. The most lethal trauma is the traumatic brain injury, coined as the 'silent epidemic' by the Centres for Disease Control (CDC).[1] A neglected and understudied group in this silent epidemic is the geriatric population. With a rapidly growing elderly population in the world,[2] it is essential to understand the epidemiology and causes of mortality in this vulnerable trauma population.

This study was conducted at the Jai Prakash Narayan Apex (JPNA) Trauma Centre of the All India Institute of Medical Sciences, New Delhi, which is a 2500-bedded referral hospital of India. The trauma centre is a 165-bedded, multispecialty referral centre, with a neurotrauma and polytrauma Intensive Care Units, step-down facilities and wards.


  Methods Top


A total of 779 geriatric patients were admitted to the JPNA Trauma Centre during 2-year period from January 2014 to December 2015. A retrospective analysis was done of all 194 fatal geriatric trauma patients who underwent autopsy at our centre during this 2-year period. The parameters that were recorded included epidemiological features, type of trauma, duration of hospital stay, cause of death and microbiological data.


  Results Top


The duration of admission of these 194 patients ranged from <1 to 91 days (median 3 days). A total of 62 (32%) patients were admitted for <1 day. The total duration of admission of these 194 patients amounted to 2003 days. The age of the patients ranged from 65 to 97 years (median 65 years); there were 147 (76%) males and 47 (24%) females.

The causes of trauma were road traffic accidents in 78 (40%), fall from height in 75 (39%), assault in 12 (6%), railway accident in 10 (5%) and falling unconsciousness in 10 (5%). The autopsy-proven primary cause of death was severe head injury in 89 (46%), septicaemia in 30 (15%), polytrauma in 11 (6%), orthotrauma in 12 (6%), haemorrhagic shock in 9 (5%), spinal injury in 8 (4%), musculoskeletal injury in 3 (2%) and fat embolism in 3 (2%).

No samples for microbiological culture were received from 119 patients. This included the 62 patients who had a stay of <1 day at the centre. From the remaining patients, a total of 977 ante-mortem samples were received for culture. Of the 977 samples, 385 (39%) were blood, 173 (18%) were tracheal aspirate, 130 (13%) were urine, 97 (10%) were bronchoalveolar lavage (BAL), 83 (9%) were pus/tissue/wound aspirate, 29 (3%) were central line tips, 40 (4%) were cerebrospinal fluid (CSF), 2 (0.20%) were intercostal drain fluid, 31 (3.2%) were peritoneal fluid and 7 (0.72%) were pleural fluid. Of these, 80 of 385 blood samples (21%), 47 of 173 tracheal aspirates (27%), 51 of 97 BAL aspirates (53%), 42 of 83 pus/tissue samples (51%), 12 of 130 urine samples (9%), 5 of 40 CSFs (13%), 12 of 31 peritoneal fluids (39%), 1 of 7 pleural fluids (14%) and 3 of 29 central line tips were culture positive (10%).

Of the 277 organisms recovered from these 253 culture-positive samples, Acinetobacter baumannii (98; 35%) was the most common isolate, followed by Pseudomonas aeruginosa (41; 15%),  Escherichia More Details coli (39; 14%), Klebsiella pneumoniae (29; 10%), Burkholderia cepacia (28; 10%), Candida spp. (10; 4%), Acinetobacter lwoffii (7; 3%), Staphylococcus aureus(7; 3%), Providencia spp.(5; 2%), Enterococcus faecalis (4;1%), Stenotrophomonas maltophilia (2; 0.7%), Staphylococcus haemolyticus (2; 0.7%), Pseudomonas putida (2; 0.7%), Enterobacter cloacae (1; 0.4%), Staphylococcus epidermidis (1; 0.4%) and  Salmonella More Details typhi (1; 0.4%).


  Discussion Top


In our study, most of the early deaths were due to severe head injuries, similar result has been reported in other studies,[3],[4],[5],[6],[7] and late deaths were predominantly due to infections; pneumonia and bloodstream infection (BSI) secondary to pneumonia being the most frequent among them. The data were obtained from the indigenous healthcare-associated infections surveillance system in which all infections are defined as per the CDC's criteria.[8],[9],[10] Most of the severely injured patients are put on life-saving devices such as central line, ventilators and urinary catheters. Trauma patients, especially the geriatric subgroup, are highly prone to pneumonia due to ventilation and aspiration. Prolonged central line and urinary catheter insertion also predispose these patients to BSIs and urinary tract infections (UTIs), respectively.[7],[11] We have observed more than 50% culture positivity in BAL samples (53%) and pus/tissue samples (51%) followed by that of tracheal aspirate (27%) and blood (21%). Gram-negative pathogens were most common isolates causing sepsis as observed from other studies in the literature.[5] Among the Gram-negative pathogens, A. baumannii (98%) was most common organism, while S. aureus (3%) was the most common among Gram-positive pathogens. Therefore, adopting measures such as preventive bundles for ventilator-associated pneumonia, BSIs and UTIs can significantly reduce the morbidity and mortality in this patient population. Studies conducted in different centres showed positive correlation of surveillance measure and decline in nosocomial infections. Data from these institutes including our centre suggest that the implementation of such bundles can reduce infection rates.[12],[13],[14],[15] However, due to the retrospective nature of this study, we could not assess the effects of hospital infection control measures which were taken for this geriatric population. As suggested by Chehade et al.,[16] introduction of 'Geriatric Emergency Departments' will facilitate increased involvement of geriatricians in trauma care and help in training other health disciplines in the basic principles of geriatric assessment and management.


  Conclusion Top


RTA still accounts for the majority of elderly trauma in India, in contrast to falls, which predominate in the Western world.[1],[2],[16] This requires a system change and public awareness in developing countries, with emphasis on wearing helmets and seat belts.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Thompson HJ, McCormick WC, Kagan SH. Traumatic brain injury in older adults: Epidemiology, outcomes, and future implications. J Am Geriatr Soc 2006;54:1590-5.  Back to cited text no. 1
    
2.
Thompson HJ, Weir S, Rivara FP, Wang J, Sullivan SD, Salkever D, et al. Utilization and costs of health care after geriatric traumatic brain injury. J Neurotrauma 2012;29:1864-71.  Back to cited text no. 2
    
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Mock CN, Jurkovich GJ, Nii-Amon-Kotei D, Arreola-Risa C, Maier RV. Trauma mortality patterns in three nations at different economic levels: Implications for global trauma system development. J Trauma 1998;44:804-12.  Back to cited text no. 3
    
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Menon A, Pai VK, Rajeev A. Pattern of fatal head injuries due to vehicular accidents in Mangalore. J Forensic Leg Med 2008;15:75-7.  Back to cited text no. 4
    
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Lalwani S, Rajkumari N, Bindra A, Mathur P. Profile of fatal patients admitted to a neuro trauma critical care unit. Eur J Trauma Emerg Surg 2015;41:65-7.  Back to cited text no. 5
    
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Chandra J, Dogra TD, Dikshit PC. Pattern of cranio-intracranial injuries in fatal vehicular accidents in Delhi, 1966–76. Med Sci Law 1979;19:186-94.  Back to cited text no. 6
    
7.
Lalwani S, Singh V, Trikha V, Sharma V, Kumar S, Bagla R, et al. Mortality profile of patients with traumatic spinal injuries at a level I trauma care centre in India. Indian J Med Res 2014;140:40-5.  Back to cited text no. 7
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8.
Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control 2008;36:309-32.  Back to cited text no. 8
    
9.
CDC. National Healthcare Safety Network, Device Associated Infections Module. Protocols and Instructions; 2010. Available from: http://www.cdc.gov/nhsn/psc_da.html; http://www.cdc.gov/nhsn/library.html. [Last accessed on 2018 Sep 11].  Back to cited text no. 9
    
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Spalding MC, Cripps MW, Minshall CT. Ventilator-associated pneumonia: New definitions. Crit Care Clin 2017;33:277-92.  Back to cited text no. 10
    
11.
Reber PU, Schmied B, Seiler CA, Baer HU, Patel AG, Büchler MW, et al. Missed diaphragmatic injuries and their long-term sequelae. J Trauma 1998;44:183-8.  Back to cited text no. 11
    
12.
Kumar A, Biswal M, Dhaliwal N, Mahesh R, Appannanavar SB, Gautam V, et al. Point prevalence surveys of healthcare-associated infections and use of indwelling devices and antimicrobials over three years in a tertiary care hospital in India. J Hosp Infect 2014;86:272-4.  Back to cited text no. 12
    
13.
Jaggi N, Rodrigues C, Rosenthal VD, Todi SK, Shah S, Saini N, et al. Impact of an international nosocomial infection control consortium multidimensional approach on central line-associated bloodstream infection rates in adult Intensive Care Units in eight cities in India. Int J Infect Dis 2013;17:e1218-24.  Back to cited text no. 13
    
14.
Mehta Y, Jaggi N, Rosenthal VD, Rodrigues C, Todi SK, Saini N, et al. Effectiveness of a multidimensional approach for prevention of ventilator-associated pneumonia in 21 adult Intensive-Care Units from 10 cities in India: Findings of the international nosocomial infection control consortium (INICC). Epidemiol Infect 2013;141:2483-91.  Back to cited text no. 14
    
15.
Mathur P, Tak V, Gunjiyal J, Nair SA, Lalwani S, Kumar S, et al. Device-associated infections at a level-1 trauma centre of a developing nation: Impact of automated surveillance, training and feedbacks. Indian J Med Microbiol 2015;33:51-62.  Back to cited text no. 15
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16.
Chehade M, Gill TK, Visvanathan R. Low energy trauma in older persons: Where to next? Open Orthop J 2015;9:361-6.  Back to cited text no. 16
    




 

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