A.J. Ordoobadi1,2, C. Wu2, M. Castillo-Angeles3, A. Salim3, M. Jarman1,2, S. Nitzschke3 1Brigham And Women’s Hospital, Center For Surgery And Public Health, Boston, MA, USA 2Brigham And Women’s Hospital, Department Of Surgery, Boston, MA, USA 3Brigham And Women’s Hospital, Division Of Trauma, Burn, And Surgical Critical Care, Boston, MA, USA
Introduction: Trauma centers are increasingly caring for critically injured older adults, and a subset of these patients require surgery for hemorrhage control. Prolonged time to surgery for hemorrhage control is associated with increased mortality. We hypothesized that older adults requiring hemorrhage control surgery have a longer time to surgery than younger adults.
Methods: We performed a retrospective analysis of the Trauma Quality Improvement Program from 2017-2019 for adult patients who were taken directly from the emergency department to the operating room for hemorrhage control surgery. We excluded patients who were functionally dependent or who had an advanced directive limiting care. The primary outcome was time to surgery, defined as the duration between hospital arrival and to time of surgery. Multivariable linear regression was used to determine the difference in time to surgery between younger adults (age 18-64) and older adults (age 65 and older), while controlling for potential confounders.
Results: We identified 32,496 adult patients who underwent surgery for hemorrhage control, including 3,071 (9.4%) older adults. On unadjusted analysis, older adults had a longer time to surgery than younger adults (106 min vs. 81 min, p<0.001). Injury severity score (ISS) was similar between the two groups (24.3 vs. 24.5, p=0.457), but older adults were less likely to be injured by a penetrating mechanism (18% vs. 53%, p<0.001). Shock index >1 was less likely in older adults (36% vs. 48%, p<0.001). Medical comorbidities were more common among older adults. On multivariable linear regression, controlling for patient demographics, injury mechanism, ISS, trauma center level, interfacility transfer, and type of surgery, time to surgery was 11.4 minutes longer for older adults (95% CI 7.5-15.3 min, p<0.001). Adding shock index >1 as a dichotomous variable to the model decreased this time difference to 10.5 min (95% CI 6.5-14.5 min, p<0.001), and adding medical comorbidities further decreased the time difference to 6.3 minutes (95% CI 2.0-10.6 min, p=0.004).
Conclusion: Older adults have a longer time to surgery for hemorrhage control than younger adults. This difference is partially mediated by physiologic differences that impact the presentation of shock among older adults and by a higher burden of medical comorbidities in older adults. Trauma centers should work to streamline decisions regarding surgical intervention among older adults in hemorrhagic shock.