ORIGINAL ARTICLE Normal Presenting Vital Signs Are Unreliable in Geriatric Blunt Trauma Victims Daithi S. Heffernan, MD, AFRCSI, Rajan K. Thakkar, MD, Sean F. Monaghan, MD, Radhika Ravindran, BS, Charles A. Adams, Jr., MD, FACS, Matthew S. Kozloff, MD, Shea C. Gregg, MD, Michael D. Connolly, MD, Jason T. Machan, PhD, and William G. Cioffi, MD, FACS Background: Normal vital signs are typically associated with improved outcomes in trauma patients. Whether this association is true for geriatric patients is unclear. Methods: A Level 1 trauma center retrospective chart review of vital signs on presentation (heart rate [HR] and blood pressure) in young (aged 17–35 years) and geriatric (aged 65 years or older) blunt trauma victims from September 2003 to September 2008 was preformed. Generalized nonlinear using piecewise regression for the linear portion of standard logistic models was used to model risk of mortality as a function of HR and blood pressure. Independent models were selected for elderly and young trauma patients based on blood pressure and HR. Models of the same complexity were then fit within each gender and age. Results: There were 2,194 geriatric and 2,081 young patients. Two hundred fifty-one (11.4%) geriatric and 49 (2.4%) young patients died. At all points of “normality,” the mortality of the geriatric patients was higher than the young group. Mortality increases considerably in the elderly patients for HRs 90 beats per minute (bpm), an association not seen until HR of 130 bpm in the young group. Mortality significantly increases with systolic blood pres- sure (SBP) 110 mm Hg in the geriatric patients but not until a SBP of 95 mm Hg in the young patients. HR and mortality association was most variable in the male geriatric patients. Conclusions: Vital signs on presentation are less predictive of mortality in geriatric blunt trauma victims. Geriatric blunt trauma patients warrant in- creased vigilance despite normal vital signs on presentation. New trauma triage set points of HR 90 or SBP 110 mm Hg should be considered in the geriatric blunt trauma patients. Key Words: Geriatric trauma, Blunt, Vital signs. (J Trauma. 2010;69: 813– 820) T he first published trauma triage tools used physiologic parameters for the assessment of the trauma victim. 1 “Vital signs” or physiologic criteria such as heart rate (HR), blood pressure, respiratory rate, level of consciousness, and temperature are easy to obtain but are limited in their ability to quantify the physiologic insult after injury. It is widely accepted that larger the deviation from normal, greater the physiologic insult from the trauma and that this degree of deviation from the normal is correlated with the probability of dying. These data are limited in its ability to prognosticate physiologic insult and outcomes in the elderly because it is almost exclusively drawn from young, previously healthy individuals. Elderly patients typically have multiple underly- ing comorbidities, often pertaining to the cardiovascular sys- tem. Although hypotension in a younger patient is easily recognized when systolic blood pressure (SBP) drops 100 mm Hg, it may be present at much higher pressures in the elderly. Thus, in an elderly patient, a SBP of 110 mm Hg may represent hypotension in a patient whose SBP is 150 mm Hg. As the population of the United States ages, it is critical to understand the pathophysiology of the geriatric trauma patient, especially in how they differ from younger trauma victims. We define geriatric as any patient aged 65 years or older, an age where significant declines in functional status are manifested. 2 Elderly trauma patients (aged 65 years or older) have been shown to have increased morbidity and mortality after trauma, when compared with younger patients. 3 To better understand the difference between young and elderly patients, we selected a group as disparate in age as possible and compared those aged 18 years to 35 years with those aged 65 years or older. Although it is often stated that elderly patients suffer greater magnitudes of injury from similar amounts of force, we think other factors may be at play in the differences between young and elderly trauma victims. It is our hypothesis that part of the increased morbidity and mortality in the elderly may be attributable to a false sense of security from “normal” vital signs on presentation, leading to delays in work-ups, resuscitation, or appropriate triage. In addition, the geriatric trauma patient’s inability to tolerate even minor deviations from normal may be magnified if what is considered normal is itself invalid. To better understand and define critical physiology for this vulnerable population, we examined the effect of derangements in vital signs on presentation in a geriatric population on survival. PATIENTS AND METHODS This is a retrospective review of prospectively collected data from the trauma registry at a single, American College of Submitted for publication February 23, 2010. Accepted for publication July 27, 2010. Copyright © 2010 by Lippincott Williams & Wilkins From the Division of Trauma and Surgical Critical Care (D.S.H., R.K.T., S.F.M., R.R., C.A.A., M.S.K., S.C.G., M.D.C., W.G.C.), Department of Surgery and Division of Biostatistics (J.T.M.), Department of Orthopedics and Surgery, Warren Alpert School of Medicine, Rhode Island Hospital, Providence, Rhode Island. Presented at the 68th Annual Meeting of the American Association for the Surgery of Trauma, October 1–3, 2009, Pittsburgh, Pennsylvania. Address for reprints: Daithi Heffernan, MD, AFRCSI, Division of Trauma and Surgical Critical Care, Department of Surgery, 435 APC Building, 593 Eddy Street, Rhode Island Hospital, Providence, RI 02903; email: dheffernan@Brown.edu. DOI: 10.1097/TA.0b013e3181f41af8 The Journal of TRAUMA ® Injury, Infection, and Critical Care • Volume 69, Number 4, October 2010 813