Is Early Appropriate Care of axial and femoral fractures appropriate in multiply-injured elderly trauma patients?
BACKGROUND
Previous work established resuscitation parameters that minimize complications with early fracture management. This Early Appropriate Care (EAC) protocol was applied to patients with advanced age to determine if they require unique parameters to mitigate complications.


METHODS
Between October 2010 and March 2013, 376 consecutive skeletally mature patients with unstable fractures of the pelvis, acetabulum, thoracolumbar spine, and/or proximal or diaphyseal femur fractures were treated at a level I trauma center and were prospectively studied. Patients aged ≤30 years (n = 114), 30 to 60 years (n = 184), and ≥60 years (n = 37) with Injury Severity Scores (ISS) ≥16 and unstable fractures of the pelvis, acetabulum, spine, and/or diaphyseal femur were treated within 36 h, provided they showed evidence of adequate resuscitation. ISS, Glasgow Coma Scale (GCS), and American Society of Anesthesiologists (ASA) classification were determined. Lactate, pH, and base excess (BE) were measured at 8-h intervals. Complications included pneumonia, pulmonary embolism (PE), acute renal failure, acute respiratory distress syndrome (ARDS), multiple organ failure (MOF), deep vein thrombosis, infection, sepsis, and death.


RESULTS
Patients ≤30 years old (y/o) were more likely to sustain gunshot wounds (p = 0.039), while those ≥60 y/o were more likely to fall from a height (p = 0.002). Complications occurred at similar rates for patients ≤30 y/o, 30 to 60 y/o, and ≥60 y/o. There were no differences in lactate, pH, or BE at the time of surgery. For patients ≤30 y/o, there were increased overall complications if pH was <7.30 (p = 0.042) or BE <-6.0 (p = 0.049); patients ≥60 y/o demonstrated more sepsis if BE was <-6.0 (p = 0.046).


CONCLUSIONS
EAC aims to definitively manage axial and femoral shaft fractures once patients have been adequately resuscitated to minimize complications. EAC is associated with comparable complication rates in young and elderly patients. Further study is warranted with a larger sample to further validate EAC in elderly patients.


METHODS
level II prospective, comparative study.
Department of Orthopaedic Surgery, Case Western Reserve University, The MetroHealth System, 2500 MetroHealth Drive, Cleveland, OH, 44109, USA.
M S
MS
Reich
Department of Orthopaedic Surgery, Case Western Reserve University, The MetroHealth System, 2500 MetroHealth Drive, Cleveland, OH, 44109, USA.
A J
AJ
Dolenc
Department of Orthopaedic Surgery, Case Western Reserve University, The MetroHealth System, 2500 MetroHealth Drive, Cleveland, OH, 44109, USA.
T A
TA
Moore
Department of Orthopaedic Surgery, Case Western Reserve University, The MetroHealth System, 2500 MetroHealth Drive, Cleveland, OH, 44109, USA. hvallier@metrohealth.org.
H A
HA
Vallier
Acidosis; Base excess; Early Appropriate Care; Elderly polytrauma; Fixation timing; Resuscitation
J Trauma. 1985 May;25(5):375-84
3999159
J Trauma. 2010 Oct;69(4):813-20
20938267
J Bone Joint Surg Br. 1999 Mar;81(2):356-61
10204951
J Trauma. 1998 Nov;45(5):873-7
9820695
Can J Surg. 2011 Aug;54(4):270-6
21651838
J Trauma Acute Care Surg. 2013 Feb;74(2):590-6
23354256
J Orthop Surg Res. 2015 Oct 01;10:155
26429572
J Bone Joint Surg Am. 2012 Dec 5;94(23 ):2195-204
23224390
J Trauma. 2008 Dec;65(6):1379-84
19077630
Crit Care Med. 2000 Jan;28(1):125-31
10667511
J Trauma. 1994 Oct;37(4):667-72
7932901
Spine (Phila Pa 1976). 2010 Oct 1;35(21 Suppl):S187-92
20881461
J Trauma. 2010 Sep;69(3):677-84
20838139
J Trauma. 1995 Aug;39(2):261-5
7674394
J Bone Joint Surg Am. 2006 May;88(5):997-1005
16651574
J Bone Joint Surg Am. 1989 Mar;71(3):336-40
2925704
J Bone Joint Surg Am. 2005 Mar;87(3):483-9
15741611
J Trauma. 2011 Jul;71(1):175-85
21336198
J Trauma. 1991 Jan;31(1):28-31
1986129
J Trauma. 1998 Oct;45(4):805-10
9783625
J Trauma. 1996 Nov;41(5):769-74
8913202
J Trauma. 1999 Apr;46(4):702-6
10217237
J Orthop Res. 2008 Nov;26(11):1478-84
18524013
J Trauma Acute Care Surg. 2014 Feb;76(2):366-73
24458043
J Trauma. 2000 Jan;48(1):8-14; discussion 14-5
10647559
J Trauma. 2002 Feb;52(2):242-6
11834982
Injury. 2000 Mar;31(2):81-4
10748809
J Trauma. 2009 Nov;67(5):1013-21
19901662
J Trauma. 2010 Dec;69(6):1527-35; discussion 1535-6
21150530
J Bone Joint Surg Br. 2008 Mar;90(3):393-9
18310768
J Trauma. 1974 Mar;14(3):187-96
4814394
J Trauma. 2009 Apr;66(4):1040-4
19359912
J Orthop Trauma. 2013 Oct;27(10):543-51
23760182
J Orthop Trauma. 2016 Jun;30(6):306-11
26741643
Spine (Phila Pa 1976). 1999 Aug 15;24(16):1646-54
10472098
J Trauma. 2002 Feb;52(2):299-307
11834992
Neurosurg Focus. 2014;37(1):E7
24981906
J Trauma. 1993 Nov;35(5):671-5; discussion 676-7
8230327
J Bone Joint Surg Am. 1995 Oct;77(10):1551-6
7593064
J Orthop Surg Res. 2015 Sep 24;10:153
26400732
Am Surg. 2011 Oct;77(10):1337-41
22127083
J Trauma. 1990 Feb;30(2):129-34; discussion 134-6
2304107
J Trauma. 2011 Apr;70(4):782-6
21610386
J Trauma. 2011 Feb;70(2):398-400
21307740
Scand J Trauma Resusc Emerg Med. 2013 Dec 21;21:91
24360246
J Trauma. 2002 Sep;53(3):452-61; discussion 461-2
12352480
Injury. 2009 Apr;40(4):362-7
19217104
Lancet. 1974 Jul 13;2(7872):81-4
4136544
Clin Orthop Relat Res. 1984 Jun;(186):45-56
6723159
J Trauma. 1989 Jul;29(7):981-1000; discussion 1000-2
2746708
Scand J Trauma Resusc Emerg Med. 2014 Aug 08;22:45
25248489