Should Age Be a Factor to Change From a Level II to a Level I
Vanessa K. Shifflette, MD, Manuel Lorenzo, MD, Alicia J. Mangram, MD, Michael S. Truitt, MD,
Joseph D. Amos, MD, and Ernest L. Dunn, MD
Background: Elderly trauma patients have a higher incidence of medical
comorbidities when compared with their younger cohorts. Currently, the
minimally accepted criteria established by the Committee on Trauma for the
highest level of trauma activation (Level I) does not include age as a factor.
Should patients older than 60 years with multiple injuries and/or a significant
mechanism of injury be considered as part of the criteria for Level I
activation? Would these patients benefit from a higher level of activation?
Methods: The National Trauma Data Bank was queried for the period of
January 1, 1999, to December 31, 2008, for all trauma patients and associated
injury severity score (ISS). The data abstracted were based on age and ISS.
Results: The National Trauma Data Bank contained 802,211 trauma pa-
tients. Seventy-nine percent were younger than 60 years, and 21% were older
than 60 years. Our analysis shows that in all levels of injury, patients older
than 60 years have an increased risk for morbidity and mortality. We found
a threefold increase in morbidity and a fivefold increase in mortality among
the older (age ?60 years) population with a minor ISS. Elderly patients with
a major ISS demonstrated a twofold increase in morbidity and a fourfold
increase in mortality.
Conclusion: Patients with an ISS between 0 and 15 are often triaged to Level
II activation. Our data would suggest that patients older than 60 years should
be a criterion for the highest level of trauma activation.
Key Words: Age, Elderly, Trauma activation.
(J Trauma. 2010;69: 88–92)
up to 47 years. At the end of the 20th century, the average life
expectancy had significantly increased to 77 years: 74 years
for men and 79 years for women.1Projected estimates in the
United States for the 85-year-old subgroup are 6.1 million by
the year 2010, increasing to 9.6 million by 2030.2As a
consequence of this increase in longevity, every trauma
center is seeing a rise in their elderly trauma population. The
elderly trauma patient presents a challenging clinical prob-
lem. As the human body ages, significant anatomic and
physiologic changes occur.3–5Medical comorbidities in ad-
he US Census Bureau stated that a child born at the
beginning of the 20th century was expected to live only
dition to these changes augment this patient population sus-
ceptibility to specific mechanisms of injuries. Elderly trauma
victims are less likely to undergo rapid trauma evaluation and
have significantly worse outcomes compared with the
younger patients.6The purpose of this study is to show that
the elderly trauma patients, with similar injury severity scores
(ISSs), do worse than their younger cohorts. Aggressive and
prompt medical and surgical cares are imperative for the
survival of the patients comprising this age group. Therefore,
the age of a trauma patient should become a criterion for the
highest level of activation.
The National Trauma Data Bank (NTDB) was queried
for the period of January 1, 1999, to December 31, 2008, for
all trauma patients and associated ISS. The data abstracted
included age and ISS. The categories were divided into all
trauma patients aged 60 years or younger and those aged
older than 60 years. Patients younger than 13 years were
excluded. The ISS category was further divided into minor
(0–9), major (10–15), severe (16–24), and critical (?24).
Within these populations, the percentage of morbidity and
mortality associated with each age group was evaluated.
Pearson correlation coefficients were obtained. A p value
?0.05 was considered statistically significant.
For the 10-year period under review, the NTDB contained
802,211 trauma patients. The younger patient population with
ages 13 years to 60 years made up 79% (635,232 individuals),
whereas the older population with age ?60 years accounted for
21% (166,979 individuals). The minor ISS (0–9) category
showed a 1.5% versus 5% morbidity (p ? 0.001) among the
younger versus older trauma patients, along with a 0.6% versus
3.3% mortality (p ? 0.001), respectively. The major ISS (10–
15) category showed a 4.8% versus 10.4% morbidity (p ?
0.001) and 1.4% versus 5.9% mortality (p ? 0.001) among the
younger versus older trauma patients, respectively. The severe
The critical ISS (?24) category showed a 27.3% versus 28%
morbidity (p ? 0.0495) and 27.9% versus 41.3% mortality (p ?
0.001; Table 1; Figs. 1 and 2), respectively. The percent distri-
bution within each ISS category was found to be similar among
each age group (Table 2).
Submitted for publication November 1, 2009.
Accepted for publication April 12, 2010.
Copyright © 2010 by Lippincott Williams & Wilkins
From the Department of General Surgery, Methodist Health System, Dallas, Texas.
Presented at the 68th Annual Meeting of the American Association for the Surgery
of Trauma, October 1–3, 2009, Pittsburgh, Pennsylvania.
Address for reprints: Vanessa K. Shifflette, MD, Department of General Surgery,
Methodist Health System, 1441 North Beckley Avenue, GME—5th floor,
Dallas, TX 75203; email: firstname.lastname@example.org.
The Journal of TRAUMA®Injury, Infection, and Critical Care • Volume 69, Number 1, July 2010