Article, Traumatology

Bleeding sites in elderly trauma patients who required massive transfusion: a comparison with younger patients

a b s t r a c t

Introduction: Among elderly patients with severe trauma, the sites of Massive hemorrhage and their clinical char- acteristics are not well understood. Therefore, we investigated the sites of massive hemorrhage in patients with severe trauma, and compared the results for younger and elderly patients.

Methods: A cohort of Severe trauma patients (Injury Severity Score >=16) admitted from March 2007 to December 2014 was reviewed retrospectively. The inclusion criterion was Massive bleeding, which was defined as bleeding that required the transfusion of >= 10 red cell concentrate units within 24 hours of admission, or as cases of early death that occurred despite continuous blood transfusion and before the patient could receive >=10 red cell con- centrate units within the first 24 hours after their admission.

Results: Eighty-four patients met our inclusion criterion. The younger group (b 65 years old) included 40 patients (48%), whereas the older group (>=65 years old) included 44 patients (52%). The percentage of nondiagnosable cases at the Primary survey (massive bleeding due to multisite damage caused by a bone fracture or contusion, Retroperitoneal hematoma without a pelvic ring fracture and with stable pelvic ring fracture) was 14% in the younger group and 40% in the older group (odds ratio, 3.92; 95% confidence interval, 1.37-11.27, P = .017).

Conclusions: Even if no abnormalities are observed at the primary survey of elderly patients with severe trauma, physicians should consider the possibility of massive bleeding.

(C) 2015

  1. Introduction

In recent years, the Life expectancy and elderly population in most developed countries has increased [1]. In Japan, 32.3% of the population was N 60 years old in 2010, and this number is projected to reach 42.7% by 2050 [2]. Unfortunately, the percentage of trauma fatalities among elderly persons has also been increasing, and 48.3% of all fatalities oc- curred among elderly Trauma victims (>= 65 years old) between 2008 and 2012 in Japan [3]. Therefore, increasing numbers of elderly patients with severe trauma are being admitted to emergency departments.

Interestingly, elderly patients are reported to have higher trauma- related mortality rates compared to younger patients, due to their phys- iological differences and decline in Baseline functions [4-7]. Therefore, Aggressive early resuscitation and careful monitoring may be warranted for a large number of elderly patients with severe trauma. In these cases, the cause of massive bleeding is typically either major internal hemor- rhage (hemothorax, Abdominal hemorrhage, or retroperitoneal hema- toma with unstable pelvic ring fracture) or active external bleeding. In

* Corresponding author. Tel.: +81 88 837 3000; fax: +81 88 837 6766.

E-mail address: [email protected] (T. Ohmori).

addition, most cases of massive bleeding can be diagnosed during the primary survey, using chest and Pelvic radiography or focused assess- ment with sonography for trauma (FAST) [8]. However, we often en- counter elderly patients with severe trauma who have massive bleeding from unexpected sites. In these cases, the diagnosis and treat- ment of the bleeding may be delayed, as it is often difficult to identify the Abnormal vital signs at the primary survey [6,9].

Among elderly patients with severe trauma, the sites of massive hemorrhage and their clinical characteristics are not well understood. Therefore, we retrospectively investigated the sites of massive hemor- rhage in patients with severe trauma, and compared the results for younger and elderly patients. In addition, we examined the cases of non-diagnosable massive bleeding among elderly patients with severe trauma to determine their relevant clinical characteristics.

  1. Methods
    1. Setting

The Kochi Health Sciences Center (Kochi, Japan) is a 649-bed acute care hospital, with an annual volume of N 3000 trauma patients (most

http://dx.doi.org/10.1016/j.ajem.2015.09.047

0735-6757/(C) 2015

cases are related to Blunt mechanisms). Elderly trauma patients (>= 65 years old) comprise approximately 61% of the total admissions. This hospital also contains 20 intensive care beds, and approximately 200 trauma patients are admitted to the intensive care unit each year. The emergency medical transportation system is mainly via ground trans- portation, although air transportation (helicopter) is also available. Since 2007, a prospective trauma registry (of patients with an Injury Se- verity Score [ISS] of >=9) has been maintained, and approximately 32% of these trauma cases are transported via helicopter. All trauma patients transported by ground or air transportation are assessed by an emer- gency medicine physician or trauma surgeon.

The management of these patients is carried out in accordance with Advanced Trauma Life Support guidelines [8]. First, the bleeding sites are diagnosed at the primary survey via chest and pelvic radiography and FAST. Second, the bleeding sites are diagnosed via whole body com- puted tomography (CT) with contrast fluid if the patient’s hemodynamic parameters are stable. Our institution almost always performs whole body CT with contrast fluid for high-energy injury cases. However, pa- tients are moved directly to the operating room or angiography room for hemostasis without CT if they are hemodynamically unstable and have diagnosable massive bleeding at the primary survey. If the patient has non-diagnosable massive bleeding at the primary survey, we per- form CT despite their hemodynamically instability. Furthermore, trauma patients with major blood loss are managed when a patient has exhibit- ed a poor response to initial fluid resuscitation or has suspected Active hemorrhage. In these cases, Group O red cell concentrate (RCC) and group AB fresh frozen plasma are used until the patient’s blood type can be determined. Once the patient’s blood type is determined, transfusion is performed with a 1:1:1 target ratio for RCC:FFP:platelet concentrate (PC). We also attempt to maintain the patient’s hemoglobin concentrations at 7.0 to 9.0 g/dL [10].

Study design and data collection

We retrospectively reviewed the trauma registry at our institution for all severe trauma patients (ISS >= 16) who were admitted between March 2007 and December 2014. The inclusion criterion was massive bleeding, which was defined as bleeding that required the transfusion of >= 10 RCC units within 24 hours of admission [11-13], or as cases of early death that occurred despite continuous blood transfusion and be- fore the patient could receive >= 10 RCC units within the first 24 hours after their admission. However, cases with >= 10 transfused RCC units that were due to intraoperative bleeding (such as craniotomy and inter- nal fracture fixation that was not for Hemostatic resuscitation) were not defined as having massive bleeding, and were excluded. We also ex- cluded cases of isolated head injury and cases that were pronounced dead on arrival, as it is difficult to identify the bleeding sites in these pa- tients, given their catastrophic injuries.

The included patients were subsequently divided into younger (b 65 years old) and older (>= 65 years old) groups, based upon their age at pre- sentation. As we wished to compare the sites of massive bleeding be- tween the younger and older groups, patients were also divided into cases that were diagnosable (group A) and non-diagnosable (group B) at the primary survey. Group A included cases of facial trauma, cardi- ac injury, hemothorax, abdominal hemorrhage, unstable pelvic ring fracture, and open fracture of an extremity. Group B included cases of retroperitoneal hematoma without a pelvic ring fracture, retroperitone- al hematoma with stable pelvic ring fracture, and multi-site damage that was caused by bone fracture or contusion. Multi-site damage that was caused by bone fracture or contusion was defined as massive, multi-site, non-cavity bleeding with the documented absence of single-site massive bleeding. We identified the relevant injuries and patient characteristics at the time of admission using the hospital’s electronic patient database or the patient’s charts. All bleeding sites were retrospectively identified using the original chest and pelvic

radiography, FAST, and CT findings. The patient’s vital signs were re- corded on arrival.

In the older group, we also compared the following characteristics between Groups A and B: age, sex, mechanism of injury, systolic blood pressure, heart rate, Shock Index, Revised Trauma Score , ISS, prob- ability of survival, pre-injury anticoagulant use, coagulopathy on arrival, transfusion (RCC, FFP, or PC), emergency procedure used to stop the hemorrhage (thoracotomy, laparotomy, transcatheter arterial emboli– zation, or fracture fixation), and clinical outcomes (all-cause mortality and mortality due to hemorrhage). Shock was defined as an shock index >= 1 [14,15], coagulopathy was defined as an international normal- ized ratio of N 1.2 [16], and survival or death was assessed during a 28-day follow-up period.

Statistical analysis

All continuous data were presented as median (interquartile range), and categorical data were presented as number (percentages). Inter- group differences for continuous variables were evaluated using the Mann-Whitney U test, and differences for categorical variables were evaluated using the ?2 test or Fisher’s exact test, as appropriate. Inter- group differences in risk were compared using odds ratios (ORs) and 95% confidence intervals (CIs). A 2-tailed P b .05 was considered to indi- cate a statistically significant difference. All statistical analyses were per- formed using SPSS version 19 (SPSS Inc, Chicago, IL).

  1. Results
    1. Patient composition

Among the 1283 cases of severe trauma (ISS >= 16) that were admit- ted during the study period, 84 patients met our inclusion criterion. The younger group included 40 patients (48%), whereas the older group in- cluded 44 patients (52%) (Fig. 1). When the younger groups and older group were compared, no significant differences were observed, other than the mechanism of injury and initial heart rate (Table 1).

Comparison of the massive bleeding sites according to age

In the younger group, abdominal hemorrhage was the most com- mon site (11 cases, 27%), followed by bleeding due to open fracture of an extremity (9 cases, 22%), and unstable pelvic ring fracture (7 cases,

Exclusions

Isolated head injury (N=415) Dead on arrive (N=67)

Admitted between March 2007 and December 2014 Severe trauma patients (ISS ?16)

N = 1283

Patients with massive bleeding

N = 84

N = 801

Younger patients (age < 65 years)

N = 40 (48%)

Older patients (age ? 65 years)

N = 44 (52%)

Fig. 1. Patients’ disposition. Patients with massive bleeding: cases requiring >=10 units of red cell concentrate within 24 hours of admission, or cases of early death due to massive bleeding.

Table 1

Comparison of younger and older patients who received massive transfusions

the primary survey. In the older group, 18 (40%) non-diagnosable cases (group B) were observed at the primary survey. The percentage

Younger group (n = 40)

Older group P

(n = 44)

of non-diagnosable cases at the primary survey was significantly higher in the older group, compared to that in the younger group (OR, 3.92;

Age (y) 41 (27-55) 80 (75-83) b.001

Male sex, n (%) 29 (73) 25 (57) .18

Mechanism of injury, n (%) b.05

Traffic accident

27 (68)

32 (73)

Fall

6 (15)

12 (27)

Occupational accident

6 (15)

0 (0)

Other

1 (2)

0 (0)

initial systolic blood pressure (mm Hg)

88 (72-123)

109 (81-126)

.45

Initial heart rate, (beats/min)

108 (86-133)

94 (79-114)

b.05

Shock index >= 1, n (%)

20 (50)

17 (39)

.35

RTS

6.6 (5.2-7.6)

6.8 (6.0-7.6)

.51

ISS

35 (22-43)

37 (27-48)

.46

Transfusion,

RCC

20 (12-29)

16 (12-20)

.12

FFP

20 (12-37)

19 (11-21)

.07

PC

10 (0-20)

10 (0-16)

.79

Death, n (%)

10 (25)

12 (27)

.76

Death caused by bleeding, n (%)

8 (20)

10 (23)

.72

Values are given as median (interquartile range) or number (%).

17%), Furthermore, 6 (14%) non-diagnosable cases (Group B) were observed in the younger group (Fig. 2).

In the older group, unstable pelvic ring fracture was the most com- mon site of massive bleeding (10 cases, 23%), followed by bleeding due to multi-site damage caused by bone fracture or contusion (9 cases, 20%), bleeding due to open fracture of an extremity (6 cases, 14%), and abdominal hemorrhage and retroperitoneal hematoma with- out a pelvic ring fracture (each: 5 cases, 11%). As widening of the medi- astinum was not observed on the chest radiography findings from the mediastinal hematoma case, it was difficult to make the diagnosis at

95% CI, 1.37-11.27; P = .017) (Fig. 3).

Comparison of the massive bleeding sites among the elderly patients

In the older group, group A included 26 patients (60%) and group B included 18 patients (40%). The percentage of shock patients was low in both groups, and although it tended to be lower in group B, this differ- ence was not significant. Although the time from arrival to transfusion initiation was not significantly different between the groups, group B had a longer time to initiation of treatment. Regarding the procedures to control the bleeding, thoracotomy was performed in the case of me- diastinum hematoma in group B. In addition, laparotomy was per- formed for 4 cases in group B, although it revealed abdominal hemorrhage that was oozing out from a retroperitoneal hematoma into the abdominal cavity. Regarding the causes of death due to bleeding in group A, unstable pelvic ring fractures were observed in 4 cases, whereas hemothorax and facial injury were observed in 1 case (each). For Group B, retroperitoneal hematoma without a pelvic ring fracture was observed in 3 cases, and multi-site damage caused by bone fracture or contusion was observed in 1 case (Table 2).

  1. Discussion

In this study, the percentage of cases with massive bleeding that was non-diagnosable at the primary survey was 14% among the younger pa- tients and 40% among the older patients; this difference was statistically significant (P b .05). Among these cases, massive bleeding due to multi- site damage that was caused by a bone fracture or contusion or

Cardiac injury

(5%)

Hemothorax (10%)

Facial trauma (5%)

Multi-site damage caused by bone fracture or contusion (7%)

Retroperitoneal hematoma without a pelvic ring fracture (7%)

Non-diagnosable cases at the primary survey (14%)

Abdominal hemorrhage (27%)

Younger group (<65 years old)

Unstable pelvic ring fracture (17%)

Open fracture of an extremity (22%)

Hemothorax (5%)

Facial trauma

(7%)

Abdominal hemorrhage (11%)

Older group (?65 years old)

Open fracture of an extremity (14%)

Multi-site damage caused by bone fracture or contusion (20%)

Retroperitoneal hematoma without a pelvic ring fracture (11%)

Non-diagnosable cases at the primary survey (40%)

Unstable pelvic ring fracture (23%)

Stable pelvic ring fracture (7%)

Mediastinal hematoma (2%)

Fig. 2. Site of the massive bleeding in the younger and older groups.

100

80

Percentage of patients (%)

60

40

20

0

Younger group Older group

diagnosable cases might decrease. In addition, retroperitoneal hemato- ma without a pelvic ring fracture was the most common cause of death in the non-diagnosable cases. Therefore, special attention is critical to improving patient survival in these cases.

In elderly trauma patients, the causes for non-diagnosable cases of massive bleeding at the primary survey are as follows:

86%

Group A Group B

60%

n = 34

40%

n = 26

14%

n = 6

n = 18

  • The patients’ blood vessels and connective tissues are weak, and hematoma forms easily; therefore, it is difficult to create the tamponade effect.
  • Pre-injury anticoagulant and antiplatelet medication use may in-

fluence bleeding [18,19].

  • It is difficult to achieve hemostasis, due to elderly trauma patients’ relatively quick progression to a hypocoagulable state [20].

Furthermore, it is difficult to detect the physiological signs of mas- sive bleeding in these patients, and it is possible to only determine its

Fig. 3. Comparison of the sites of massive bleeding in the younger and older groups. Group A was defined as diagnosable cases at the primary survey, whereas group B was defined as non-diagnosable cases. Older patients had a significantly higher risk of non-diagnosable bleeding, compared to the younger patients (OR, 3.92; 95% CI, 1.37-11.27; P = .017).

retroperitoneal hematoma without a pelvic ring fracture was common. Thus, a large number of cases with non-cavitary hemorrhage were ob- served among our elderly trauma patients. However, it has been report- ed that the mortality rate is not significantly different between cases of cavitary and non-cavitary hemorrhage [17], although that study was not conducted among elderly patients. In particular, bleeding due to multi- site damage that was caused by bone fracture or contusion (which is dif- ficult to diagnose via computed tomography) was observed in 20% of the older patients.

The prevalence of shock in these non-diagnosable cases was only 33%. This result indicates that it is difficult to recognize abnormal vital signs early in the diagnosis of elderly patients, making it difficult to di- agnosis any massive hemorrhage, and delaying the decision to provide a blood transfusion. The prevalence of mortality in the diagnosable and non-diagnosable cases was similar, although if the time to transfu- sion was shorter, it is possible that the mortality rate among the non-

Table 2

Comparison of cases with diagnosable and non-diagnosable bleeding at the primary sur- vey among elderly patients

severity at a point when it is too late to administer effective treatment. Therefore, Hemorrhage control is the most common cause of prevent- able trauma-related death [21,22], and this finding has been confirmed in elderly trauma patients [23]. Furthermore, bleeding due to multi-site damage that is caused by bone fracture or contusion is often difficult to diagnose via computed tomography. Thus, even if no abnormalities are observed at the primary survey of elderly patients with severe trauma, massive bleeding should be considered, and more resources should be directed towards early diagnosis and invasive hemodynamic and cardi- ac monitoring, in order to identify occult shock [7].

The major limitation of the present study is that it was a retrospec- tive review of a clinical database, rather than a prospective observation- al study. In addition, the sample size was small, and larger-scale studies are needed to confirm our results. Furthermore, the time to transfusion initiation after arrival and transfusion amount may differ, depending on the expertise of the staff who are involved in primary care at that time. Moreover, it is possible that some older patients received a larger trans- fusion to increase their Hemoglobin levels. Therefore, it is possible that the number of cases with massive bleeding or death may change, de- pending on the attending medical staff. In addition, we were unable to account for the effects of iatrogenic coagulopathies due to fluid resusci- tation [24,25] or preexisting disease. Finally, the definition of “elderly” in this study was individuals who were >= 65 years old, although there is no consensus regarding this definition in the literature.

Diagnosable (n = 26)

Non-diagnosable P

(n = 18)

  1. Conclusions

Age, y 78 (74-83) 81 (77-85) .32

Mechanism of injury, n (%) .45

Traffic accident 20 (77) 12 (67)

Fall 6 (23) 6 (33)

Systolic blood pressure, mmHg 106 (80-119) 110 (92-132) .63

Heart rate, beats/min

98 (81-117)

83 (76-110)

.35

physicians should consider the possibility of massive bleeding due to

Shock index (>= 1), n (%)

12 (46)

6 (33)

.40

multi-site damage that was caused by a bone fracture, contusion, or ret-

In this study, elderly patients were significantly more likely to have non-diagnosable massive bleeding during the primary survey, com- pared to the younger patients. Therefore, even if no abnormalities are observed at the primary survey of elderly patients with severe trauma,

ic ring fracture.

RTS

6.9 (6.0-7.8)

6.5 (6.0-7.6)

.59 roperitoneal hematoma without a pelv

ISS

35 (23-45)

42 (30-50)

.20

Ps b 0.5, n (%)

12 (46)

10 (56)

.54

Coagulopathy on arrival (INR >= 1.2), n (%)

6 (23)

6 (33)

.45 References

Pre-injury anticoagulation treatment, n (%)

5 (19)

4 (22)

.89

Time to start transfusion after arrival, min

57 (13-87)

104 (63-147)

.05 [1] Christensen K, Doblhammer G, Rau R, Vaupel

Transfusion, U

RCC

16 (12-22)

17 (11-20)

ahead. Lancet 2009;374:1196-208.

.45 [2] United Nations Department of Economic

World Population Prospects/The 2015 Rev

FFP

19 (12-20)

19 (11-22)

.99 August 8, 2015].

PC

Procedure for Bleeding control, n (%)

10 (0-14)

10 (3-18)

.76 [3] Japan Trauma Data Bank Report 2014 (2 traumabank/dataroom/data/JTDB2014e.pdf.

JW. Ageing populations: the challenges

and Social Affairs/Population Division/ ision. http://esa.un.org/wpp/. [Accessed

009-2013). http://www.jtcr-jatec.org/

Thoracotomy

2 (8)

1 (6)

.74

[4] Aschkenasy MT, Rothenhaus TC. Trauma and falls in the elderly. Emerg Med Clin

Laparotomy

5 (19)

4 (22)

.89

North Am 2006;24:413-32.

TAE

6 (23)

8 (44)

.13

[5] Callaway DW, Wolf R. geriatric trauma. Emerg Med Clin North Am 2007;25:837-60.

Fracture stabilization

13 (50)

6 (33)

.27

[6] Heffernan DS, Thakkar RK, Monaghan SF, Ravindran R, Adams Jr CA, Kozloff MS, et al.

Death, n (%)

7 (27)

5 (28)

.95

Normal presenting vital signs are unreliable in geriatric blunt trauma victims. J Trau-

Death caused by bleeding, n (%)

6 (23)

4 (22)

.76

ma 2010;69:813-20.

[7] Giannoudis PV, Harwood PJ, Court-Brown C, Pape HC. Severe and multiple trauma in

Ps, Probability of survival; INR, international normalized ratio; TAE, transcatheter arterial embolization.

Values are given as median (interquartile range) or number (%).

older patients; incidence and mortality. Injury 2009;40:362-7.

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