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doi:10.1016/j.jss.2010.10.007
six to eight times more likely to die (OR 6.24 and 8.27,
P < 0.001).
Conclusion. Elderly patients have higher rates of
fractures and intracranial injuries with an extremely
worse mortality after pedestrian trauma. 2011 Elsevier
Background. Walking is the primary mode of transportation for people aged 65 y and over; hence pedestrian injuries are a substantial source of morbidity
and mortality among elderly patients in the United
States. This study is aimed at evaluating the pattern
of injury in the elderly pedestrians and how it differs
from younger patients.
Methods. Retrospective analysis of the National
Trauma Data Bank (20022006) was performed, with inclusion criteria defined as pedestrian injuries based on
ICD-9 codes, excluding age < 15 y. The following age
categories in years were created: 1524 (reference
group), 2534, 3544, 4554, 5564, 6574, 7584, and
8589. The injury prevalence was compared, and multivariate regression for mortality was conducted adjusting for demographic and injury characteristics.
Results. A total of 79,307 patients were analyzed. Superficial injuries were the most common at 29.1%, with
lower extremity fractures and intracranial injuries following at 25.1% and 21.4% respectively. The very elderly (7584 and 8589) had significantly higher rates
of fractures of the pelvis(16.2% and 16.8% versus 8.1%
in the youngest group), upper (19.3% and 18.4% versus
9.8%), lower extremities (31.1% and 31.9% versus
22.5%) and intracranial injuries (25.5% and 28.7% versus 22.4%), but sustained lower rates of hepatic (2.3%
and 1.7% versus 3.0%) injuries, with no difference
seen in pancreatic, splenic, and genitourinary injuries.
On multivariate analysis, very elderly patients were
INTRODUCTION
1
Presented at the 5th Annual Academic Surgical Congress
meeting, February 35, 2010 in San Antonio, Texas.
2
To whom correspondence and reprint requests should be addressed at Department of Surgery, Howard University Hospital,
2041 Georgia Ave., N.W., Washington, D.C. 20060. E-mail: ssiram@
howard.edu.
0022-4804/$36.00
2011 Elsevier Inc. All rights reserved.
14
15
RESULTS
TABLE 1
Study Population Demographic and Injury Severity
Characteristic
N
Gender
Male
Female
Age [mean (SD)]*
1524
2534
3544
4554
5564
6574
7584
8589
Race
White
African American
Hispanic
Asian or Pacific Islander
American Indian/Alaska
Other
Insurance (n 66295)
Private insurance
Government insured
Self pay/none
Other
Injury severity score [median (IQR)]**
<9
9 and <15
15 and <25
25
Shock
Length of stay [median (IQR)]**
Death
*
79,307
51,904
27,235
34.2 (22.1)
12,578
9313
11,611
10,619
6391
4018
3497
760
65.6
34.4
21.4
15.8
19.8
18.1
10.9
6.8
6.0
1.3
36,055
18,149
13,222
2096
526
4435
48.4
24.4
17.8
2.8
0.7
6.0
18,931
14,469
15,610
17,285
9 (417)
31,030
21,581
10,612
11,434
5806
3 (17)
5,508
28.6
21.8
23.6
26.1
41.6
28.9
14.2
15.3
7.7
7.0
SD standard deviation.
IQR interquartile range.
**
16
TABLE 2
Demographic and Injury Characteristics by Age Categories
Gender (%)
Male
Race (%)
White
African American
Hispanic
Asian or Pacific Islander
American Indian/Alaska
Other
Insurance (%)
Private insurance
Government insured
Self pay/none
Other
Injury severity Score (%)
<9
914
1524
25
Median (IQR)*
Shock
Death
LOS [Median (IQR)]*
1524 (%)
2534 (%)
3544 (%)
4554 (%)
5564 (%)
6574 (%)
7584 (%)
8589 (%)
61.5
69.4
69.6
68.8
63.7
55.7
51.7
47.9
49.5
23.8
18.0
2.1
0.8
5.9
45.2
22.5
23.2
2.3
0.9
5.8
47.3
27.6
17.2
2.01
1.12
4.9
51.5
27.3
13.2
2.3
0.7
5.0
56.2
20.3
13.9
3.9
0.5
5.3
60.9
13.3
13.1
6.5
0.4
5.9
68.9
8.6
11.2
6.5
0.3
4.6
73.9
6.6
7.9
7.4
0.0
4.2
31.9
15.5
26.8
25.8
25.4
12.8
35.0
26.8
25.5
15.1
32.4
27.1
27.6
16.9
28.6
26.9
31.3
18.6
23.1
27.0
22.2
44.4
9.5
24.0
20.5
45.1
9.2
25.3
24.8
41.9
7.5
25.8
39.7
29.2
14.9
16.3
9 (518)
7.9
6.5
4 (19)
36.4
30.5
15.8
17.3
10 (519)
9.3
8.4
4 (211)
32.6
30.2
18.3
18.9
10 (521)
10.1
10.3
5 (211)
30.7
30.2
18.0
21.1
10 (422)
9.6
12.3
5 (210)
28.7
31.8
16.4
23.1
12 (622)
10.3
17.0
5 (210)
28.0
31.5
17.5
23.1
10 (622)
10.5
19.2
5 (211)
46.2
27.7
12.7
13.5
9 (416)
5.2
4.5
3 (16)
43.3
27.8
13.8
15.1
9 (417)
6.6
5.5
3 (18)
TABLE 3
Injury Pattern by Body Regions
Injury type by region
External injuries (Total %)
Superficial injury
Contusion of head/neck/
trunk/extremity
Open wound of lower extremity
Open wound of upper extremity
Open wound of head/neck/trunk
Extremities (total %)
Fracture of upper extremity
Fracture of lower extremity
Sprain of lower extremity
Head and neck (total %)
Intracranial injury
Fracture of skull
Chest (total %)
Heart and lung injury
Pneumothorax/hemothorax
Fracture of ribs, sternum,
larynx, trachea,
Abdomen, pelvis (total %)
Hepatic injury
Splenic injury
Genitourinary injury
Retroperitoneal, peritoneal and
extra-hepatic biliary injury
Gastrointestinal tract injury
Pancreatic injury
Pelvic fracture
ICD9 Codes
Percentage
910919
920924
73.9
29.1
17.5
890894
880884
870879
861
860
807
4.3
3.9
19.1
39.0
11.6
25.1
2.3
31.9
21.4
10.5
20.1
6.0
5.2
8.9
864
865
866867
868
19.7
3.0
2.5
2.3
1.6
863
863
808
0.9
0.2
9.2
810819
820828
843845
850854
800802
9.8%), lower extremities (31.1% and 31.9% versus 22.5%). and intracranial injuries (25.5% and
28.7% versus 22.4%), but sustained lower rates of hepatic (2.3% and 1.7% versus 3.0%, P < 0.001) injuries,
with no difference in the rates of pancreatic, splenic
and genitourinary injuries (see Table 4).
On multivariate regression controlling for demographics and injury severity characteristics, older patients significantly had increasing odds of mortality
after pedestrian trauma (Fig. 1). The 2534 y age
group was not statistically different from the reference group (OR 1.08, CI 0.901.30) in contrast to
the other age categories with significantly worse
mortality with increasing age compared to the reference group (Fig. 1). Statistically, overlapping confidence interval in the younger four age groups
comparison (2564 y) suggests the likelihood of no
difference amongst the group. However, the three
age categories > 65 y showed a significant difference
compared with the younger age groups (non-overlapping confidence interval), and when compared within
groups (Fig. 1). Elderly patients 6574, 7584, and
8589 years were approximately four, six, and eight
times more likely to die after pedestrian injury compared with those 1524 y, and the difference in mortality seen within subsets of patients > 65 y was also
statistically significant.
17
TABLE 4
Comparison of Injuries by Body Regions Among the Different Age Categories
1524
2534
3544
4554
5564
6574
7584
8589
31.3
17.2
26.2
16.6
24.5
16.2
23.9
15.8
22.5
17.6
24.6
20.7
24.0
22.5
22.8
22.1
<0.001
<0.001
4.4
4.4
19.1
4.7
3.9
19.3
4.7
3.9
19.9
3.9
3.9
19.5
3.9
3.9
20.8
4.2
5.0
21.6
5.1
7.5
24.1
5.9
9.9
25.7
<0.001
<0.001
<0.001
9.8
22.5
3.3
10.9
23.0
3.0
11.5
26.4
2.7
12.9
27.4
2.4
15.1
29.1
2.3
16.2
29.0
2.3
19.3
31.1
2.0
18.4
31.9
2.2
<0.001
<0.001
<0.001
22.4
10.2
19.6
9.9
20.0
9.6
20.2
10.2
23.0
11.2
25.3
11.7
25.5
12.4
28.7
11.6
<0.001
<0.001
5.8
4.2
4.6
5.4
4.6
7.1
5.6
5.9
10.8
5.7
6.1
13.0
5.7
6.9
14.8
5.5
7.1
16.0
6.6
7.1
17.9
6.3
5.1
16.6
0.315
<0.001
<0.001
3.0
2.7
2.3
1.4
3.2
2.3
2.8
1.4
3.0
2.4
2.8
1.7
3.0
2.4
2.4
1.8
2.6
2.6
2.4
2.0
2.4
2.2
2.4
2.0
2.3
2.1
2.9
2.0
1.7
1.3
2.4
2.5
0.01
0.083
0.161
0.004
0.8
0.2
8.1
0.9
0.2
8.5
1.2
0.2
9.2
1.1
0.2
9.8
1.2
0.4
11.9
1.3
0.3
15.3
1.2
0.2
16.2
1.1
0.4
16.8
0.027
0.257
<0.001
DISCUSSION
in elderly patients. The increased prevalence of intracranial injuries, and pneumothorax/hemothorax could
be associated with the higher rates of skull and rib fractures, respectively. The prevalence of skull fracture
would appear to overcome any theoretic benefit, one
12.00
Odds of Death
External injuries
Superficial injury
Contusion of head/neck/trunk/
extremities
Open wound of lower extremity
Open wound of upper extremity
Open wound of head/neck/trunk
Extremities
Fracture of upper extremity
Fracture of lower extremity
Sprain of lower extremity
Head and neck
Intracranial injury
Fracture of skull
Chest
Heart and lung injury
Pneumothorax/hemothorax
Fracture of ribs, sternum, larynx,
and trachea
Abdomen and pelvis
Hepatic injury
Splenic injury
Genitourinary injury
Retroperitoneal, peritoneal and
extra-hepatic biliary injury
Gastrointestinal tract injury
Pancreatic injury
Pelvic fracture
10.00
8.00
6.00
4.00
2.00
0.00
Upper CI
1.30
1.48
2.07
2.79
4.46
7.60
11.36
Lower CI
0.90
1.05
1.48
1.95
3.02
5.13
6.02
1.25
1.75
2.33
3.67
6.24
8.27
Age Categories
FIG. 1. Adjusted odds of mortality by age categories after pedestrian trauma.
18
strongly correlated with age and may not both fit in the
model.
In conclusion, this study clearly demonstrates that elderly injuries after pedestrian injury differ by injury
patterns and are associated with a significantly worse
mortality. We also showed that age 65 y still remains
an appropriate cutoff for the definition of the elderly
as it statistically represents the age when the mortality
becomes significantly different from the younger subsets. Finally, we outlined the importance of appreciating the subtle differences that exist even amongst the
elderly cohort, with older citizens experiencing a doubling in odds of mortality with increasing decades of
age. Therefore, management of elderly patients in the
emergency department after pedestrian trauma needs
to be individualized, and this can serve as a guide in policy creation for those in charge of elderly care as a whole.
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