'Normal' vital signs belie occult hypoperfusion in geriatric trauma patients.

Base deficit (BD) and lactic acid (LA) are accepted markers of hypoperfusion and predictors of outcome in the trauma patient and we aim to assess the value of these markers in the triage of the elderly with "normal" vital signs. Patients older than age 65 who presented between 1997 and 2004 but who did not have isolated head injuries were included. Three patient groups were established: normal, occult hypoperfusion (OH), and shock. Outcome measures included mortality, hospital length of stay, intensive care unit length of stay, and discharge disposition. One hundred six patients were included in the analysis and had similar Injury Severity Scores. Mean systolic blood pressure was similar in the normal and OH groups. Forty-two per cent of patients had abnormal BD or LA in the emergency room indicating OH. These patients were more likely to have a longer intensive care unit length of stay (8.6 days vs. 3 days; P = 0.01) and were also more likely to be discharged to a nursing facility (P = 0.03). The trend was toward increased mortality in the OH group. OH is a common finding in elderly trauma patients. Outcomes in these patients are different and more like those presenting in shock.

Bile leak in open cholecystectomy: related to gangrenous cholecystitis?

BACKGROUND: Open cholecystectomy is still required for treatment of gallbladder disease when inflammation has changed the usual anatomic landmarks and make laparoscopic cholecystectomy unsafe or technically impossible. METHODS: In this study, we reviewed all the records of patients who underwent open or laparoscopic-converted-to-open cholecystectomy between January 2000 and August 2006. RESULTS: A total of 3367 patients underwent cholecystectomies. Three hundred five patients underwent laparoscopic-converted-to-open, and 123 patients underwent open cholecystectomy. The incidence of bile leaks in the open cholecystectomy group was 2.6% (11/428). Twenty-four percent had gangrenous cholecystitis (102/428). Eight (8/11) of the bile leaks were associated with gangrene. All bile leaks presented within the first five days after surgery with an average of 2.9 days. All patients had bilious output through aJP drain. All leaks resolved over 10 days. Three resolved spontaneously, andeightresolved after ERCP stent. CONCLUSIONS: The incidence of bile leaks in the open cholecystectomy group was high (2.6%) in our study, compared to other series published. When gangrenous cholecystitis was present, the incidence of bile leaks was 24%. The placement of a JP drain was essential for the identification of the bile leak.

Patterns of injury in geriatric falls.

Falls are the most common cause of trauma in the elderly. Data regarding patterns of injury following geriatric falls are scant. We conducted a retrospective review of falls in patients aged 65 years and older seen at a trauma center over a nine year period. Two thousand eighty three patients met the inclusion criteria. Hip fracture proved to be the dominant injury (55%), 98% of which were isolated. Five hundred seven (21%) were non-hip fractures. Two hundred thirty eight patients (10%) sustained traumatic intracranial hemorrhage. Chest injury was the next most common injury type (6.7%) with rib fractures comprising 86% of this subgroup. A pattern of association between intracranial hemorrhage and cervical spine fractures was identified. Intra-abdominal injuries are rare.

Vital capacity as a predictor of outcome in elderly patients with rib fractures.

BACKGROUND: This study tests the relationships between early bedside vital capacity (VC) measurement and morbidity, mortality, and resource consumption in geriatric blunt chest trauma patients with rib fractures. METHODS: This was a retrospective study examining all patients > or = 65 years old with rib fractures who had a VC measured within 48 hours of their emergency department evaluation. Outcome variables included pulmonary complications, death from pulmonary complications, hospital length of stay (LOS), intensive care unit length of stay (ICU LOS), and discharge disposition. RESULTS: Thirty-eight patients met the study criteria. The mean age was 80.2 (+/-7.4) years, the mean number of rib fractures was 3.6 (+/-1.6), and the mean ISS was 6.9 (+/-4.7). VC and the percentage of the predicted vital capacity (pVC) were both inversely correlated with LOS (p = 0.0076 and p = 0.0172, respectively). Linear regression analysis suggested that patients with a VC < 1.4 L or < 55% of their pVC had a LOS > 3 days. Mean VC was 36% higher in patients who were discharged home versus those discharged to an extended care facility (ECF; p = 0.025). There was a trend toward significance when comparing VC to ICU LOS (p = 0.079), but none in predicting pulmonary complications (p = 0.3299). No correlations between VC and mortality can be drawn given the single death in the cohort. CONCLUSIONS: Bedside VC is a simple measurement which could predict LOS in elderly patients with rib fractures and may identify those patients requiring ECF upon discharge. Further prospective study may highlight the utility of emergency room VC in determining the disposition of these patients.