ABSTRACT
Background
Scalp lacerations without intracranial injury are generally considered anatomically minor traumas. However, elderly patients may experience unexpected clinical deterioration due to persistent bleeding after trivial injury. Such cases may represent clinically urgent conditions when physiological deterioration is taken into consideration. Evidence of the outcomes of isolated scalp lacerations in elderly patients remains limited.
Methods
A retrospective analysis of data from the Japan Trauma Data Bank (2019–2023) was conducted. Patients with isolated scalp lacerations, identified using Abbreviated Injury Scale codes, were included. Patients with intracranial injuries or injuries to other body regions were excluded. Patients were categorized into elderly (≥ 65 years) and non‐elderly (< 65 years) groups.
Results
Overall, 304 patients were included, of whom 181 (59.5%) were elderly. Elderly patients required red blood cell (RBC) transfusion within 24 h more frequently than non‐elderly patients (14.0% vs. 2.6%, p = 0.001). Furthermore, the rate of interhospital transfer after acute trauma management was significantly higher in elderly patients than in non‐elderly patients (13.1% vs. 3.4%, p = 0.004). Multivariable logistic regression analyses were performed to identify factors independently associated with RBC transfusion. These analyses demonstrated that age ≥ 65 years (OR 4.540, 95% CI 1.272–16.204) and systolic blood pressure < 90 mmHg on arrival (OR 6.124, 95% CI 2.182–17.186) were independently associated with RBC transfusion.
Conclusions
Advanced age is independently associated with RBC transfusion in patients with isolated scalp lacerations.
Keywords: geriatric trauma, isolated scalp laceration, outcome
Advanced age is an independent risk factor for red blood cell transfusion in patients with isolated scalp lacerations.
1. Introduction
Rapid population aging is a global issue, including in Japan, and the proportion of geriatric patients with trauma receiving emergency care is increasing [1]. Compared with younger individuals, older adults often have multiple comorbidities, reduced physiological reserves, and vulnerabilities such as frailty [2].
Scalp lacerations are among the most common soft tissue injuries encountered in emergency departments. Isolated scalp lacerations without associated intracranial injuries are generally considered anatomically minor traumas. If head computed tomography excludes skull fractures or intracranial lesions such as acute subdural hematoma, management typically consists of local wound care and suturing, followed by prompt discharge home [3]. However, in clinical practice, even elderly patients initially diagnosed with simple scalp lacerations may develop difficulty achieving hemostasis, resulting in massive bleeding, near‐hemorrhagic shock, or unplanned hospitalization and blood transfusion because of rebleeding or deterioration of their general condition [4]. Although these injuries are anatomically minor, they may represent clinically urgent conditions when physiological deterioration is taken into consideration.
The scalp has a unique anatomy, with dense fibrous tissue in its second layer preventing physiological vasoconstriction after injury and a rich blood supply [5, 6]. In geriatric patients, even minor scalp lacerations may result in persistent and substantial hemorrhage because of age‐related arteriosclerotic changes, tissue atrophy, and the use of anticoagulant medications [7].
Furthermore, trauma in older adults is multifactorial and associated with age‐related functional decline, including impaired gait and balance, visual impairment, cognitive decline, and polypharmacy [8]. Consequently, many elderly patients experience deterioration in activities of daily living after injury, and social factors may also make safe discharge to home difficult [9].
Although numerous epidemiological studies and clinical guidelines have been established for severe head injuries accompanied by intracranial lesions [8, 10, 11], limited evidence is available regarding isolated scalp lacerations without intracranial injury, particularly with respect to differences in outcomes between elderly and non‐elderly patients. We hypothesized that even in cases of isolated scalp lacerations without intracranial injury, elderly patients are more likely to experience clinical deterioration and unfavorable outcomes. Therefore, using a national database, we identified patients with isolated scalp lacerations without intracranial injury and compared clinical characteristics and outcomes between elderly and non‐elderly groups to investigate the impact of age on unfavorable outcomes.
2. Methods
We used the Japan Trauma Data Bank (JTDB) dataset from 2019 to 2023, provided by Japan Trauma Care and Research. Before study initiation, approval was obtained from the Institutional Clinical Research Ethics Committee of our hospital (management number: 15‐027‐5).
The JTDB is a national trauma database established to improve the quality of trauma care in Japan. As of 2022, approximately 300 major emergency medical institutions in Japan participate in the JTDB [12]. The database mainly includes patients with injuries of Abbreviated Injury Scale (AIS) Grade 3 or higher who are treated at tertiary emergency medical centers and other emergency care hospitals [13]; however, a substantial number of anatomically minor trauma cases are also registered.
Cases of scalp laceration were identified using the AIS (2008 version) codes (110602.1 or 110604.2). Patients with intracranial injuries, defined as injuries corresponding to AIS codes 120099.9 through 161013.5, and those with any additional injury codes involving body regions other than the head were excluded. Only patients with isolated scalp lacerations were included in this analysis. Patients < 16 years and those with cardiopulmonary arrest on arrival were excluded.
For each eligible patient, the following data were extracted and retrospectively analyzed: demographic characteristics, injury mechanism and circumstances, vital signs on arrival, in‐hospital clinical course, outcomes (including length of hospital stay, in‐hospital mortality, and discharge disposition), emergency interventions (including blood transfusion within 24 h after admission, endotracheal intubation, vasopressor use, and administration of tranexamic acid), and in‐hospital complications (central nervous system, cardiovascular, respiratory, infectious, and other complications). Interhospital transfer was defined as transfer to another hospital for continuation of care after completion of acute trauma care and did not include early transfer immediately after initial treatment.
Patients aged ≥ 65 years were defined as elderly, consistent with previous literature [1, 2], and were categorized into elderly (≥ 65 years) and non‐elderly (< 65 years) groups. An initial comparison was performed between these two groups.
In the univariate analyses, binary variables were presented as counts and percentages and compared using the chi‐square test or Fisher's exact test, as appropriate. Continuous variables are expressed as medians with interquartile ranges. Variables with a normal distribution were compared using Student's t‐test, whereas non‐normally distributed variables were compared using the Mann–Whitney U test.
The primary outcome of this study was red blood cell (RBC) transfusion within 24 h after admission. For multivariate analyses, regression models were constructed using variables that showed statistical significance in the univariate analyses and were considered potentially associated with the outcome based on previous studies. Before modeling, collinearity among covariates was assessed to confirm the absence of multicollinearity. Logistic regression analyses were performed using the enter method. All statistical analyses were two‐sided, and a p < 0.05 was considered statistically significant.
3. Results
Overall, 304 patients were included: 181 (59.5%) aged ≥ 65 years (elderly group) and 123 (40.5%) aged < 65 years (non‐elderly group) (Figure 1). Patient characteristics are shown in Table 1. Female sex (51.1% vs. 23.8%, p < 0.001), unintentional injury (97.2% vs. 87.7%, p = 0.002), and ground‐level falls (66.7% vs. 28.7%, p < 0.001) were more common in the elderly group, whereas assault‐ and traffic‐related injuries were more frequent in the non‐elderly group.
FIGURE 1.
Inclusion and exclusion criteria. Excluding: Intracranial injuries (codes: 120099.9–161013.5), injury codes for other body regions (2–9, AIS2008), age < 16 years, and CPA on arrival.
TABLE 1.
Patients' demographics.
| ALL (n = 304) | Elderly (n = 181) | Non‐elderly (n = 123) | p | |
|---|---|---|---|---|
| Age | 71 (53.0–82.0) | 81 (73.0–85.0) | 46 (30.0–56.0) | < 0.001 |
| Sex | < 0.001 | |||
| Male | 181 (59.9%) | 88 (48.9%) | 93 (76.2%) | |
| Female | 121 (40.1%) | 92 (51.1%) | 29 (23.8%) | |
| Mechanism | ||||
| Blunt | 294 (96.7%) | 176 (97.2%) | 118 (95.9%) | 0.533 |
| Penetrating | 11 (3.6%) | 6 (3.3%) | 5 (4.1%) | 0.762 |
| Unintentional | 282 (93.4%) | 175 (97.2%) | 107 (87.7%) | 0.002 |
| Assault | 9 (3.0%) | 2 (1.1%) | 7 (5.7%) | 0.034 |
| Self‐inflicted | 3 (1.0%) | 0 | 3 (2.5%) | 0.065 |
| GLF | 155 (51.3%) | 120 (66.7%) | 35 (28.7%) | < 0.001 |
| Fall from stairs | 48 (15.9%) | 23 (12.8%) | 25 (20.5%) | 0.079 |
| Fall from height | 13 (4.3%) | 4 (2.2%) | 9 (7.4%) | 0.042 |
| Traffic accident | 50 (16.4%) | 13 (7.2%) | 37 (30.1%) | < 0.001 |
| Car accident | 25 (8.2%) | 5 (2.8%) | 20 (16.3%) | < 0.001 |
| Bicycle accident | 18 (5.9%) | 4 (2.2%) | 14 (11.4%) | 0.002 |
| Pedestrian | 5 (1.6%) | 3 (1.7%) | 2 (1.6%) | 1.000 |
| Motorbike accident | 2 (0.7%) | 1 (0.6%) | 1 (0.8%) | 1.000 |
| Alcohol use | 62 (21.2%) | 24 (13.6%) | 38 (32.8%) | < 0.001 |
| Drug use | 3 (1.1%) | 0 | 3 (2.6%) | 0.068 |
| Comorbidity | ||||
| CVD | 20 (6.6%) | 19 (10.5%) | 1 (0.8%) | 0.001 |
| Hemiplegia/paraplegia | 3 (1.0%) | 3 (1.7%) | 0 | 0.275 |
| Dementia | 31 (10.2%) | 30 (16.6%) | 1 (0.8%) | < 0.001 |
| Heart failure | 5 (1.6%) | 4 (2.2%) | 1 (0.8%) | 0.652 |
| Chronic pulmonary disease | 8 (2.6%) | 7 (3.9%) | 1 (0.8%) | 0.149 |
| Diabetes | 32 (10.5%) | 26 (14.4%) | 6 (4.9%) | 0.008 |
| Malignant neoplasm | 12 (3.9%) | 10 (5.5%) | 2 (1.6%) | 0.132 |
| Anticoagulant use | 32 (10.5%) | 31 (17.1%) | 1 (0.8%) | < 0.001 |
Note: Proportion of participants with available data: sex: 302/304 (99.3%), alcohol use: 293/304 (96.4%), and drug use: 280/304 (92.1%).
Abbreviations: CVD, cerebrovascular disease; GLF, ground level fall.
Alcohol consumption before the injury was more common in the non‐elderly group. Anticoagulant use was significantly higher in the elderly group (17.1% vs. 0.8%, p < 0.001). Cerebrovascular disease, dementia, and diabetes mellitus were also more prevalent in elderly patients.
The vital signs and emergency interventions are summarized in Table 2. The elderly group had lower diastolic blood pressure (80 vs. 85.5 mmHg, p = 0.022), wider pulse pressure (54 vs. 46 mmHg, p = 0.001), and lower body temperature on arrival (36.3°C vs. 36.6°C, p < 0.001). Hypothermia (< 36.0°C) was more frequent in elderly patients (23.0% vs. 9.4%, p = 0.004). The incidence of shock (systolic blood pressure [SBP] < 90 mmHg), endotracheal intubation, and tranexamic acid administration did not differ significantly between the groups. Time from injury to hospital arrival and time from emergency call to hospital arrival are also shown in Table 2. The time from injury to hospital arrival was significantly longer in the elderly group than in the younger group (59 vs. 48 min, p = 0.002).
TABLE 2.
Vital signs on arrival, labs data, and procedures.
| ALL (n = 304) | Elderly (n = 181) | Non‐elderly (n = 123) | p | |
|---|---|---|---|---|
| Time | ||||
| Injury—arrival (min) | 52 (41.0–77.0) | 59 (44.0–90.0) | 48 (37.0–62.0) | 0.002 |
| Call—arrival (min) | 42 (33.0–52.0) | 43 (33.0–54.0) | 40 (33.0–49.0) | 0.234 |
| SBP (mmHg) | 133 (113.75–157.0) | 136.0 (113.0–161.0) | 131 (115.0–149.0) | 0.208 |
| SBP < 90 mmHg | 23 (7.7%) | 17 (9.5%) | 6 (5.0%) | 0.188 |
| DBP (mmHg) | 81 (68.0–97.0) | 80 (64.0–94.0) | 85.5 (74.0–99.0) | 0.022 |
| Pulse pressure (mmHg) | 50 (37.0–67.0) | 54 (37.0–74.5) | 46 (37.0–55.0) | 0.001 |
| Pulse (/min) | 84 (73.0–96.0) | 83 (73.0–95.0) | 84 (74.0–100.0) | 0.487 |
| Tachycardia (≥ 120/min) | 21 (7.1%) | 12 (6.7%) | 9 (7.6%) | 0.820 |
| Respiratory rate (/min) | 19 (16.0–21.0) | 20 (17.0–22.0) | 18 (16.0–20.0) | 0.068 |
| Tachypnea (≥ 30/min) | 15 (5.4%) | 12 (7.3%) | 3 (2.7%) | 0.111 |
| Body temperature (°C) | 36.5 (36.1–36.8) | 36.3 (36.0–36.7) | 36.6 (36.3–36.9) | < 0.001 |
| < 36.0°C | 50 (17.9%) | 40 (23.0%) | 10 (9.4%) | 0.004 |
| < 35.0°C | 9 (3.2%) | 8 (4.6%) | 1 (0.9%) | 0.160 |
| GCS | 15 (14.0–15.0) | 15.0 (14.0–15.0) | 15.0 (14.0–15.0) | 0.439 |
| < 9 | 14 (4.9%) | 4 (2.3%) | 10 (8.6%) | 0.023 |
| Serum lactate (mmol/L) | 2.0 (1.4–3.4) | 2.0 (1.42–3.20) | 2.0 (1.24–3.43) | 0.983 |
| Intubation in ER | 4 (1.3%) | 1 (0.6%) | 3 (2.4%) | 0.307 |
| Vasopressor use in ER | 2 (0.7%) | 1 (0.6%) | 1 (0.8%) | 1.000 |
| TXA administration | 19 (7.7%) | 14 (7.7%) | 5 (4.1%) | 0.233 |
Note: Proportion of participants with available data: time injury‐arrival: 207/289 (71.6%), Call‐arrival: 275/289 (95.2%), SBP: 298/304 (98.0%), DBP: 293/304 (96.4%), pulse pressure: 293/304 (96.4%), and pulse: 297/304 (97.8%). Respiratory rate 276/304 (90.8%), body temperature 280/304 (92.1%), and GCS: 288/304 (94.7%), 205/304 (67.4%).
Abbreviations: DBP, diastolic blood pressure; GCS, Glasgow Coma Scale; SBP, systolic blood pressure; TXA, tranexamic acid.
Blood transfusion results, in‐hospital course, and outcomes are presented in Table 3. Transfusion within 24 h was required in 11.6% of the patients and was more frequent in the elderly group (15.4% vs. 7.9%, p = 0.015), particularly RBC transfusion (14.0% vs. 2.6%, p = 0.001). Overall, in‐hospital complications occurred in 5.3% of patients, with no significant difference between groups. The overall in‐hospital mortality rate was 1.3%, and no significant differences were observed. Home discharge was more common in the non‐elderly group, while transfer to another hospital after acute management was significantly more frequent in the elderly group (13.1% vs. 3.4%; p = 0.004).
TABLE 3.
Patients' outcome.
| ALL (n = 304) | Elderly (n = 181) | Non‐elderly (n = 123) | p | |
|---|---|---|---|---|
| Any transfusion within 24 h | 34 (11.6%) | 27 (15.4%) | 7 (5.9%) | 0.015 |
| Any RBC transfusion | 27 (9.3%) | 24 (14.0%) | 3 (2.6%) | 0.001 |
| Any FFP transfusion | 7 (2.4%) | 5 (2.9%) | 2 (1.7%) | 0.705 |
| Any platelet transfusion | 2 (0.7%) | 0 | 2 (1.7%) | 0.163 |
| Hospital LOS | 1.0 (1.0–2.5) | 1.0 (1.0–3.0) | 1.0 (1.0–2.0) | 0.050 |
| ICU stay ≥ 1 day | 60 (19.7%) | 37 (20.4%) | 23 (18.7%) | 0.770 |
| Any complications | 16 (5.3%) | 8 (4.4%) | 8 (5.5%) | 0.443 |
| CNS complications | 7 (2.3%) | 3 (1.7%) | 4 (3.3%) | 0.447 |
| Cardiovascular system | 6 (2.0%) | 2 (1.1%) | 4 (3.3%) | 0.226 |
| Respiratory system | 2 (0.7%) | 1 (0.6%) | 1 (0.8%) | 1.000 |
| Others | 3 (1.0%) | 3 (1.7%) | 0 | 0.275 |
| Mortality | 4 (1.3%) | 3 (1.7%) | 1 (0.8%) | 0.650 |
| Discharge to home | 258 (87.5%) | 148 (84.1%) | 110 (92.4%) | 0.048 |
| Interhospital transfer a | 27 (9.2%) | 23 (13.1%) | 4 (3.4%) | 0.004 |
Note: Proportion of participants with available data: 294/304 (96.7%), RBC transfusion: 289/304 (95.1%), FFP transfusion: 289/304 (95.1%), platelet transfusion: 289/304 (95.1%), 289/304 (95.1%), discharge to home: 295/304 (97.0%), and interhospital transfer: 295/304 (97.0%).
Abbreviations: FFP, fresh frozen plasma; LOS, length of stay; RBC, red blood cell.
After acute case.
RBC transfusion within 24 h and interhospital was defined as the outcome. Patients who received RBC transfusion (RBC group, n = 27) were compared with those who did not (non‐RBC group, n = 262). Variables showing significant differences between the groups and those considered clinically relevant factors potentially associated with RBC transfusion based on previous studies were selected for multivariable analysis. Considering the events per variable (EPV), a multivariable logistic regression model was constructed using an enter method. First, age was entered into the multivariable logistic regression model as a continuous variable (Table 4). Age (odds ratio [OR] 1.043, 95% confidence interval [CI] 1.009–1.077, p = 0.012) and systolic blood pressure < 90 mmHg on admission (OR 6.665, 95% CI 2.377–18.685, p < 0.001) were identified as independently associated with the outcome. Subsequently, elderly patients were defined as those aged ≥ 65 years, and an additional multivariable analysis using Age ≥ 65 was performed. Similarly, Age ≥ 65 (OR 4.540, 95% CI 1.272–16.204, p = 0.020) and systolic blood pressure < 90 mmHg on admission (OR 6.124, 95% CI 2.182–17.186, p = 0.001) were confirmed as independently associated with RBC transfusion (Table 5).
TABLE 4.
Logistic regression for any RBC transfusion within 24 h.
| Variables | Odds ratio | 95% CI | p |
|---|---|---|---|
| Age | 1.043 | 1.009–1.077 | 0.012 |
| Anticoagulant use | 2.451 | 0.893–6.728 | 0.082 |
| SBP < 90 mmHg | 6.665 | 2.377–18.685 | < 0.001 |
TABLE 5.
Logistic regression for any RBC transfusion within 24 h.
| Variables | Odds ratio | 95% CI | p |
|---|---|---|---|
| Age ≥ 65 | 4.540 | 1.272–16.204 | 0.020 |
| Anticoagulant use | 2.626 | 0.966–7.141 | 0.058 |
| SBP < 90 mmHg | 6.124 | 2.182–17.186 | 0.001 |
4. Discussion
This study demonstrated an independent association between age and RBC transfusion within 24 h in patients with isolated scalp lacerations without traumatic intracranial lesions. The odds of transfusion increased by 4.3% for each additional year of age and were 4.54 times higher in patients aged ≥ 65 years than in those aged < 65 years. To our knowledge, only a few studies have focused on this patient population.
Elderly patients often have reduced physiological reserve and blunted compensatory responses to hemorrhage, and normal vital signs may not exclude occult hypoperfusion [8, 14]. This may partly explain the increased transfusion requirement observed in elderly patients with isolated scalp lacerations.
In addition to these physiological vulnerabilities, elderly patients with trauma are at increased risk of complications, unfavorable outcomes, and mortality, even after apparently minor injuries [8, 15, 16, 17]. Although all patients in the present study sustained minor injuries, mortality tended to be higher in the elderly group (1.7% vs. 0.8%), despite the absence of statistical significance.
While many prior studies have focused on mortality, elderly patients with apparently minor head injuries may experience unexpected clinical deterioration requiring resuscitative interventions, even without death. Some are also unable to return home after acute care, requiring interhospital transfer. However, these outcomes remain underexplored, particularly in low‐mortality populations.
Therefore, studies such as ours highlight the clinical association between advanced age and an increased likelihood of transfusion and unfavorable outcomes after minor head injury. The Geriatric Trauma Outcome Score incorporates transfusion status as a predictor of mortality in elderly trauma patients, underscoring the prognostic importance of transfusion requirements [18]. Consistent with our findings, Loftus et al. reported significantly greater RBC transfusion volumes in elderly trauma patients than in younger patients [19]. Furthermore, SBP has been associated with massive transfusion in elderly trauma patients, and prehospital SBP < 110 mmHg has been proposed as a predictor of massive transfusion [20]. In our study, SBP < 90 mmHg on arrival was independently associated with RBC transfusion within 24 h (OR 6.124), suggesting that patients presenting with hypotension may have had a greater need for transfusion.
Ground‐level falls are the most common mechanism of injury among elderly trauma patients and are frequently associated with undertriage despite increased risks of adverse outcomes [1, 8, 21]. Consistent with previous reports, they were also the most common mechanism of injury in the elderly group in the present study.
Many previous studies included patients with traumatic brain injury (TBI) or other major abdominal injuries, even when injuries were classified as mild. TBI, as well as advanced age and anticoagulant use, has been reported to be associated with increased mortality [22, 23]. In contrast, our study excluded patients with TBI and demonstrated that advanced age remained independently associated with RBC transfusion in patients with isolated scalp lacerations. This finding is clinically significant because elderly patients with isolated scalp injuries are often underestimated and may be transported to non‐trauma centers. Our results suggest that these patients are at substantial risk of clinical deterioration. Although anticoagulant use was not independently associated with RBC transfusion in the present study, the limited sample size may have affected this result. Larger studies are warranted to determine whether anticoagulant use is a significant risk factor for RBC transfusion in patients with isolated scalp lacerations.
This study has several limitations. First, this was a retrospective observational study using the JTDB, which primarily includes relatively severe trauma cases. Consequently, selection bias may have overestimated unfavorable outcomes, such as blood transfusion and interhospital transfer. However, similar trauma registries, including the National Trauma Data Bank, have also been used in studies of minor trauma [24]. Second, interhospital transfer was more frequent in the geriatric group. However, transfer decisions are influenced by factors beyond age, including frailty, comorbidities, and post‐fall functional status. Therefore, the observed difference in transfer rates should be interpreted with caution, and the specific factors underlying these decisions could not be determined. Finally, because Japan is a super‐aged society, these findings may not be fully generalizable to populations with different demographic characteristics. Given the limited sample size, only a limited number of potential confounders could be included in the multivariable models, and residual confounding cannot be excluded.
5. Conclusion
Despite these limitations, advanced age was independently associated with RBC transfusion within 24 h. Thus, elderly patients with isolated scalp lacerations may require careful evaluation and observation despite the injury appearing anatomically minor.
Ethics Statement
This study was approved by the Institutional Clinical Research Ethics Committee of Teikyo University (management number: 15‐027‐5).
Consent
The authors have nothing to report.
Conflicts of Interest
The authors declare no conflicts of interest.
Acknowledgments
We would like to thank Editage (https://www.editage.jp/) for English language editing.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.