Between 2013 and 2019, 667 patients aged 65 years and over were treated for cranio-maxillofacial surgery in our emergency department, of which 211 were patients with acute facial trauma during AC/APT. Of these, 15 did not meet the inclusion criteria due to refusal of general consent and were therefore excluded from the study. A total of 196 patients were eligible and were recruited for the statistical analysis (Figure 1).
3.1 Demographic characteristics: age and sex distribution
In our study, 56.6% (n=111) of patients were male, and 43.7% were female (n=85) (p<0.001) (Table 1), with a male-to-female ratio of 1.11/0.85. The most represented age group was 85-89 years, with 25 patients (25.5%), whereas 54.1% (n=106) were older than 80. The median age of the study population was 81 years (range, 65 to 96 years). Women were significantly older in this study than men (median 84, IQR 76-87 vs. median 79, IQR 74-86) (p=0.027). Further details are enclosed in Table 2. No statistical differences were found between the sexes for the following parameters: month, day of the week, triage group, route of admission, route of discharge, clinical symptoms, pre-existing comorbidities, reason for anticoagulation or AC/APT, type of AC/APT, and main trauma-related diagnosis.
Table 1. Demographics consisting of age and gender groups.
Age Group
|
Total
|
n= 196
|
65-69
|
24
|
[12.2]
|
70-74
|
33
|
[16.8]
|
75-79
|
33
|
[16.8]
|
80-84
|
37
|
[18.9]
|
85-89
|
50
|
[25.5]
|
90
|
19
|
[9.7]
|
Gender (n%)
|
Total
|
n= 196
|
Male
|
111
|
[56.6]
|
Female
|
85
|
[43.4]
|
3.2 Type of Referral
The most reported type of referral to the ED was through ambulance (n=85, 43.4%) or admission from another hospital (n=76, 38.8%). Self-admitted patients were only 19 out of 196 (9.7%). Other reported referral types were by family doctor, Swiss Air-Rescue, referrals from internal outpatient clinics at the University Hospital or repatriation.
3.3 Time and Day of Consultation
The daily time of consultation showed two peaks between 06:00 and 12:00 (n=70, 35.7%) and between 18:00 and 00:00 (n=77, 39.3%) without reaching statistical significance. The frequency of events from Monday to Saturday was comparable; however, much less on Sunday.
3.4 Triage
Concerning the Swiss Emergency Triage Scale [23, 24], the majority of patients (97; 49.5%) had urgent triage, followed by emergent (71; 36.2%) triage. Fifteen patients (7.7%) had such a severe injury that they were triaged as acute life-threatening.
3.5 Mechanisms of Injury
As for etiology, the most frequent cause of injury was falling (162 cases; 82.7%), followed by bike- (15 cases; 7.7%) and car accidents (5 cases; 2.6%). Other causes, such as motorcycle accidents, ski/snowboard falls, fighting, horse riding accidents, and gunshot suicide attempts were also documented. By stratifying according to gender, bike accidents were found to be significantly higher in male geriatric patients (male n = 14, 12.6% vs. female n = 1, 1.2%) with maxillofacial trauma (p=0.001). Moreover, road traffic accidents in total (bike-, motorcycle- and car accidents) were much higher in male patients (23 vs. 3). Interestingly, two male patients have documented cases of gunshot suicides. In contrast, no such cases have been observed among female patients.
3.6 Medical history of the patients
Regarding the medical history of patients, 137 of them (69.9%) suffered from a cardiovascular disease. Further single or multiple coexisting medical conditions include metabolic (n=22, 11.2%), lung (n=8, 4.1%), mental (n=8, 4.1%), and neurologic diseases (n=7, 3.6%). No statistical differences were observed between genders (p=0.13).
3.7 Indication for anticoagulation and type of it
Previous thromboembolic events (n=82, 42.3%) and atrial fibrillation (n=50, 25.5.%) were the most reported indications for intake of AC/APT. Mechanical heart valve and vascular replacement were only documented in 12 patients (6.1%). Use of ASS was significantly higher than other antiplatelet and anticoagulant medications (127 patients, 64.8%) (p<0.001), followed by clopidogrel (18 cases, 9.2 %). On the other hand, DOACs were the more frequently used anticoagulant medication (30 patients, 15.3.%), followed by VKAs (25 cases, 12.7%).
3.8 Localization and type of injury
The most frequently injured anatomical region was the orbit with 122 patients (62.2%), followed by zygomatic bone (n=64, 32.7%), nose septum (n=45, 23%), sinus maxillaris (n=38, 19.4%) and, calvaria (n=28, 14.3%). Injury of the orbital part of the frontal bone was significantly more affected in men (n=21, 18.9%, p<0.001). Moreover, frontal bone injuries at the sinus frontalis level and calvaria injuries were also significantly higher in men (p=0.018 and p=0.011, respectively).
Concomitant extracranial injuries include injuries of the upper extremities (62 cases, 31.6%), lower extremities (21 cases, 10.7%), thorax (27 cases, 13.8), and abdomen (4 cases, 2%). Thorax was significantly more affected in men (p=0.001).
The most reported primary injuries were orbital fracture (n= 46, 23,5%) along with fracture of the zygomatic bone (n=38, 19,4%) and fracture of the midface (Le Fort I, II, III) (n=35, 17,9%) followed by zygomatic bone fracture (n=38, 19.4%), and mandible fracture (n=20, 10.2%) (Table 2).
Concomitant secondary diagnoses include extremity fractures (n=51, 21.6%), chest trauma (n=19, 9.7%), spinal column fracture (n=5, 2.6%), and abdominal trauma (n=3, 1.5%).
Regarding bleeding complications (Figure 2), 14 patients suffered an intracerebral haemorrhage (n=14, 7.1%), whereas retrobulbar bleeding was observed in 20 patients (10.2%). Epistaxis was noted in 23 cases (11.7%) and oral bleeding in 10 (5.1%). To better comprehend the nature of maxillofacial trauma in geriatric patients under AC/APT, we also recorded subgroups related to the affected region of the face. In 120 patients (61.2%), haematomas involved the middle third of face, followed by the lower third of face (n=14, 7.2%). Haematoma of the upper third of face was observed in 9 patients (4.6%). Haematomas in general and especially haematomas in the lower third of the face were significantly more frequent in women (p=0.028 and p=0.028, respectively) (Figure 2).
Table 2. Main diagnoses and associated haemorrhagic complications.
Main diagnosis
|
Total
(n, %)
|
Haematoma/Bleeding
(n, %)
|
No fracture/ soft tissue defect
|
7, 3.6
|
11, 6.3
|
Orbital cavity fracture
|
46, 23.5
|
44, 25.3
|
Central middle face fracture
(Le Fort I, II , III)
|
35, 17.9
|
38, 21.8
|
Zygomatic bone fracture
|
38, 19.4
|
32, 18.4
|
Mandible fracture
|
20, 10.2
|
12, 6.9
|
Skull base fracture
|
22, 11.2
|
18, 10.3
|
Nasal bone fracture
|
10, 5.1
|
10, 5.7
|
Tooth injury/dental trauma
|
6, 3.1
|
2, 1.1
|
Calvaria fracture
|
12, 6.1
|
7, 4.0
|
3.9 Clinical Symptoms
The most frequently reported symptoms were sensibility alterations (n=26, 13.3%), clinically observed bleeding (n=22, 11.2%), neurologic disturbances as unconsciousness (n=21; 10.7%), and amnesia (n=10; 5.1%), nausea, and vomiting (n=2; 1%). Sensibility alterations were significantly higher in women (n=16, 18.8% vs. n=10, 9.0%, p=0.045). The main reported symptoms are depicted in Figure 3.
3.9 Hospitalization, treatment of bleeding complications, and mortality
Hospitalization was required in 60.2% (n=118) of the patients; 61.2% (n=52) were female, and 59.5% (n=66) were male, with an average length of hospital stay of 5 days. No patient required emergency (<6 hours) surgical treatment regarding maxillofacial trauma related bleeding complications. Of all hospitalized patients, haematomas of the middle third of the face were operated on most frequently in absolute terms (n=46, Table 3). Conversely, oral bleeding had the highest probability of requiring surgical intervention among hospitalized patients, with a rate of 70% (Table 3). Five patients died during their hospitalization (2.6%), and five others died within 30 days after admission in the ED (30-day mortality 5.1%).
Table 3. Operative management of bleeding complications regarding anatomic location.
Hematoma
|
Surgical care *
(n, %)
|
Haematoma upper third of face
|
2, 22
|
Haematoma middle third of face
|
46, 38
|
Haematoma lower third of face
|
4, 28
|
Epistaxis
|
5, 22
|
Oral bleeding
|
7, 70
|
Bleeding requiring emergency treatment (<6 h, heavy bleeding)
|
0, 0
|
3.10 Patient injury severity score
The median ISS was 6 with an IQR of 5 to 12. There were significantly notable disparities observed between males and females (p=0.002). Specifically, males exhibited a median ISS of 9 (IQR 5-14), whereas females displayed a median ISS of 5 (IQR 5-9).
3.12 Hospitalization time and mortality
Hospitalization was required for 60.2% (n=118) of the patients; of them, 61.2% (n = 52) were female and 59.5% (n = 66) were male. The average length of hospital stay was five days.
Five of the patients died in the hospital (2.6%), and five other patients died within 30 days after admission in the ED (30-day mortality 5.1%).
3.13 Total costs
Costs of up to 10,000 Swiss francs were incurred by 48.5% of patients (n=95). Total costs per patient were illustrated in Figure 4.
Median hospital costs of all 196 patients amounted to 1162 CHF per patient (IQR 487 – 2002 CHF). No statistically significant differences (p=0.774) in median costs per patient were observed between males and females [females 1218 (IQR 537-1962) CHF vs 1039 (IQR 438-2007) CHF in males].
3.14 Association of clinical outcomes and ISS
Multivariable analysis was carried out to determine the contributing factors (gender, age and ISS) for 30-day mortality, in-hospital mortality, hospitalization duration and costs. Multivariable analysis has shown a positive association between: in-hospital mortality (OR 1.24; [95% confidence interval [CI]: 1.09,1.42; p<0.001]) and ISS; 30–day mortality (OR 1.24; [95% CI: 1.09,1.42; p=0.001]) and ISS, as well between hospitalization duration and ISS (OR 0.28; [95% CI: 0.18, 0.37; p<0.001]) (Table 4).
Table 4. Multivariable analysis to determine the contributing factors (gender, age, ISS) for 30-day mortality and in-hospital mortality.
|
Adjusted odds ratio
|
(95% CI)
|
p-value
|
30-days mortality
|
|
|
|
Sex
|
3.81
|
(0.67; 21.52)
|
0.130
|
Age
|
1.12
|
(0.99; 1.28)
|
0.077
|
ISS
|
1.35
|
(1.16; 1.56)
|
<0.001
|
In-hospital mortality
|
|
|
|
Sex
|
1.34
|
(0.15; 11.76)
|
0.792
|
Age
|
1.14
|
(0.95; 1.35)
|
0.151
|
ISS
|
1.24
|
(1.09; 1.42)
|
0.001
|
Hospitalization duration
|
|
|
|
Sex
|
1.00
|
(-0.16; 2.15)
|
0.090
|
Age
|
0.02
|
(-0.05; 0.09)
|
0.590
|
ISS
|
0.28
|
(0.18; 0.37)
|
<0.001
|
Costs (CHF)
|
|
|
|
Sex
|
147.46
|
(-1356.30; 1651.22)
|
0.847
|
Age
|
39.38
|
(-54.09; 132.84)
|
0.407
|
ISS
|
-29.53
|
(-155.41; 96.35)
|
0.644
|
A total of 196 observations were included in the final model.
AUROC (30-days mortality) = 0.927.
AUROC (in-hospital mortality) = 0.945.