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1
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Seo GY, Das A, Manzanero S, Kim K, Lisec C, Muller M. The influence of pre-injury anticoagulant or antiplatelet agents on outcomes in trauma patients sustaining abdominal solid organ injuries: A scoping review. Injury 2025; 56:112175. [PMID: 39842106 DOI: 10.1016/j.injury.2025.112175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2024] [Revised: 01/16/2025] [Accepted: 01/16/2025] [Indexed: 01/24/2025]
Abstract
BACKGROUND Indications for, and usage of, anticoagulant (AC) and antiplatelet (AP) agents is increasing. In this context, it is important to understand the evidence base of the effect of pre-injury AC/AP agents on patient outcomes in the context of traumatic solid organ injury (SOI) to inform management protocols. METHODS A scoping review of the literature was undertaken with a systematic search strategy within the PubMed and Scopus databases. Study characteristics, clinical outcomes and outcome measures including mortality, hospital length of stay, admission to intensive care units, length of stay in intensive care and management details were extracted from included studies. RESULTS The search identified six eligible studies reporting results from a total of 26,960 patients. Patients on AC/AP are more likely to fail non-operative management (NOM) than their non-AC/AP counterparts; at the same time, they are less likely to be operated on as a first line of management. Clinical outcome measures (mortality, length of stay, admission to intensive care units, and length of intensive care unit stay) were heterogeneous across studies, but it is likely that AC/AP patients have poorer outcomes in SOI. Results on transfusion requirements were inconclusive. CONCLUSION Few studies have examined the effect of pre-injury anticoagulation on outcomes in trauma patients sustaining solid organ injuries. Future studies should more closely examine solid organ trauma within the elderly group, as well as the effect of newer AC/AP agents in current use.
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Affiliation(s)
- Gi Young Seo
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia; Department of General Surgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Arpita Das
- Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; School of Clinical Sciences, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Silvia Manzanero
- Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; School of Clinical Sciences, Queensland University of Technology, Brisbane, Queensland, Australia; Australian Institute of Bioengineering and Nanotechnology, University of Queensland, Brisbane, Queensland, Australia
| | - Keeyeon Kim
- Department of General Surgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Carl Lisec
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia; Department of General Surgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; Trauma Service, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Michael Muller
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia; Department of General Surgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; Trauma Service, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.
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2
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Wang S, Mesias M. Things We Do for No Reason™: Discontinuing anticoagulation in older patients with atrial fibrillation and a high risk of falls. J Hosp Med 2025; 20:288-290. [PMID: 39033419 DOI: 10.1002/jhm.13464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 06/01/2024] [Accepted: 06/28/2024] [Indexed: 07/23/2024]
Affiliation(s)
- Samantha Wang
- Division of Hospital Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Matthew Mesias
- Section of Geriatric Medicine, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
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Yin CY, Scott MM, Kimura M, Hakimjavadi R, Girard CI, Clarke A, Sood MM, Siegal DM, Tanuseputro P, Fung C, Sobala M, de Wit K, Hsu AT, Backman C, Kobewka D. Oral Anticoagulant Use and Post-Fall Mortality in Long-Term Care Home Residents. J Am Med Dir Assoc 2024; 25:105233. [PMID: 39222662 DOI: 10.1016/j.jamda.2024.105233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Revised: 07/24/2024] [Accepted: 07/29/2024] [Indexed: 09/04/2024]
Abstract
OBJECTIVES Long-term care (LTC) residents are susceptible to falling and the risk of subsequent morbidity and mortality may be compounded with concurrent anticoagulation use. Uncertainty exists around the benefit and harm of anticoagulation use for residents with a high risk for falls because of concerns of major bleeding complications. We aimed to examine if anticoagulant use increases mortality risk among LTC residents who fall. DESIGN A retrospective cohort study. SETTING AND PARTICIPANTS Older adults (≥65 years) admitted to a LTC facility in Ontario, Canada between January 1, 2010, and December 1, 2019, who were transferred to emergency departments for fall-related injuries. METHODS The exposure was the use of an oral anticoagulant (OAC). The primary outcome was mortality within 30 days of transfer. Secondary outcomes were major hemorrhage and care utilization. We used hierarchical logistic regression models to examine the association between the use of OAC and 30-day mortality. RESULTS There were 56,419 residents transferred to the hospital for a fall, of whom 9611 (17.0%) were on an OAC. At 30 days, 5794 (10.3%) of the cohort had died: 12.0% (1151) on an OAC and 9.90% (4643) not on an OAC [risk difference (RD), 2.1%; 95% CI, 1.40%-2.82%]. There were 485 major hemorrhage cases: 1.3% (125) on an OAC and 0.8% (360) not on an OAC (RD, 0.5%; 95% CI, 0.26%-0.74%). Multivariable analysis found no significant association between OAC use and 30-day mortality [odds ratio (OR), 0.98; 95% CI, 0.90-1.06], but an increased risk of major hemorrhage (OR, 1.31; 95% CI, 1.04-1.66). Both groups had similar health system and neurosurgical care utilization. CONCLUSIONS AND IMPLICATIONS Among LTC residents transferred to the emergency department for fall-related injuries, OACs did not increase the risk of post-fall mortality. OAC prescribing for frail older adults who experience falls should consider their individual risk profile.
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Affiliation(s)
- Christina Y Yin
- Bruyère Research Institute, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
| | - Mary M Scott
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; The Public Health Agency of Canada, Ottawa, Ontario, Canada
| | - Maren Kimura
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Céline I Girard
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; ICES uOttawa, Ottawa, Ontario, Canada
| | - Anna Clarke
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; ICES uOttawa, Ottawa, Ontario, Canada
| | - Manish M Sood
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Deborah M Siegal
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter Tanuseputro
- ICES uOttawa, Ottawa, Ontario, Canada; Department of Family Medicine and Primary Care, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong SAR, China
| | - Celeste Fung
- St. Patrick's Home of Ottawa, Ottawa, Ontario, Canada; Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Monica Sobala
- St. Patrick's Home of Ottawa, Ottawa, Ontario, Canada
| | - Kerstin de Wit
- Department of Emergency Medicine and Medicine, Queen's University, Kingston, Ontario, Canada; Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Amy T Hsu
- Bruyère Research Institute, Ottawa, Ontario, Canada; Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Chantal Backman
- Bruyère Research Institute, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - Daniel Kobewka
- Bruyère Research Institute, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; ICES uOttawa, Ottawa, Ontario, Canada
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Dash J, Andereggen E, Bentellis I, Massalou D. Comparison of adult versus elderly patients with abdominal trauma: A retrospective database analysis. PLoS One 2024; 19:e0309174. [PMID: 39159197 PMCID: PMC11332922 DOI: 10.1371/journal.pone.0309174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 08/06/2024] [Indexed: 08/21/2024] Open
Abstract
BACKGROUND The growing geriatric population has specific medical characteristics that should be taken into account especially in trauma setting. There is little evidence on management of abdominal trauma in the elderly and this article compares the management and outcomes of younger and older patients in order to highlight fields of improvement. METHOD We conducted a retrospective database analysis from two European university hospitals selecting patients admitted for abdominal injury and extracted the following data: epidemiological data, mechanisms of the trauma, vital signs, blood tests, injuries, applied treatments, trauma scores and outcomes. We compared to different age group (16-64 and 65+ years old) using uni- and multivariable analysis. RESULTS 1181 patients were included for statistical analysis. The main mechanisms of injury in both group were traffic accidents and in the elderly group, falls were more frequent. Both had similar Abbreviated Injury Score except for the thoracic injuries, which was higher in the elderly group. We reported a death rate of 13% in the elderly group and 7% in the younger group. However, multivariable analysis did not report age as an independent predictor of mortality. The management including surgery, blood transfusion and need for intensive care were similar in both groups. CONCLUSION Although elderly patients suffering abdominal trauma have an almost two fold higher mortality, their management is quite similar leading to an important point of improvement in regards to triage and lower threshold for more aggressive management and surveillance. Age itself does not seem to be a reliable predictor of mortality. Introducing a frailty score when taking care of elderly trauma patients could improve the outcomes.
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Affiliation(s)
- Jeremy Dash
- Departement of Digestive Surgery, Geneva University Hospitals, Geneva, Switzerland
| | - Elisabeth Andereggen
- Departement of Digestive Surgery, Geneva University Hospitals, Geneva, Switzerland
| | - Imad Bentellis
- Departement of Urology, University Hospital of Nice, Nice, France
| | - Damien Massalou
- Emergency Surgery Unit, Digestive Surgery, University Hospital of Nice, Nice, France
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De Vincentis A, Soraci L, Arena E, Sciacqua A, Armentaro G, Aucella F, Corsonello A, Aucella F, Antonelli Incalzi R. Appropriateness of direct oral anticoagulant prescribing in older subjects with atrial fibrillation discharged from acute medical wards. Br J Clin Pharmacol 2024; 90:1231-1239. [PMID: 38321367 DOI: 10.1111/bcp.16010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Revised: 01/08/2024] [Accepted: 01/09/2024] [Indexed: 02/08/2024] Open
Abstract
AIMS Knowledge on the prescriptive practice of direct oral anticoagulants (DOACs) in older subjects with atrial fibrillation (AF) hospitalized in acute medical wards is limited. This study aimed to evaluate the prevalence and appropriateness of DOAC prescriptions in hospitalized older subjects with AF, discharged from acute medical wards. METHODS We analysed a cohort of 609 subjects with AF, aged ≥65 years (mean age 85 years) enrolled from 39 geriatric and nephrology wards in Italy. DOAC prescriptive appropriateness was evaluated according to the summary of product characteristics (smPC), 2019 Beers and STOPP criteria, and drug-drug interactions (DDIs). RESULTS At hospital discharge, 33% of patients with AF were prescribed with DOAC, 26% with vitamin-K antagonist, while 41% did not receive any anticoagulant. Among subjects on DOAC therapy, 31% presented a violation of the smPC criteria (mainly underdosage-17%), while 48% and 18% presented a Beers/STOPP inappropriate prescription, or a DDI, respectively. Older age, lower body mass index (BMI), cancer and higher estimated glomerular filtration rate (eGFR) were independently associated with DOAC underdosage or missed prescription (age: adjusted odds ratio [aOR] 1.06, 95% confidence interval [95% CI] 1.00-1.12 for underdosage; eGFR: aOR 1.04, 95% CI 1.02-1.07 for underdosage; BMI: aOR 0.95, 95% CI 0.91-0.99 for missed prescription; cancer: aOR 1.93, 95% CI 1.19-3.13 for missed prescription). CONCLUSIONS This study showed a suboptimal DOAC prescriptive practice in older in-patients, with frequent missed prescription and DOAC underdosage. Contrary to current recommendations, physicians appear overly concerned by bleeding risk in real-life older and frailer subjects. Strategies should be developed to promote appropriate DOAC prescription in the hospital setting.
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Affiliation(s)
- Antonio De Vincentis
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
- Research Unit of Internal Medicine, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Luca Soraci
- Unit of Geriatric Medicine, IRCCS INRCA, Cosenza, Italy
| | - Elena Arena
- Research Unit of Internal Medicine, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Angela Sciacqua
- Unit of Geriatric Medicine, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, Italy
| | - Giuseppe Armentaro
- Unit of Geriatric Medicine, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, Italy
| | - Francesco Aucella
- SC di Nefrologia e Dialisi, IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Italy
| | | | - Filippo Aucella
- SC di Nefrologia e Dialisi, IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Italy
| | - Raffaele Antonelli Incalzi
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
- Research Unit of Internal Medicine, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
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Burton KR, Magidson PD. Trauma (Excluding Falls) in the Older Adult. Clin Geriatr Med 2023; 39:519-533. [PMID: 37798063 DOI: 10.1016/j.cger.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
Trauma in the older adult will increasingly become important to emergency physicians hoping to optimize their patient care. The geriatric patient population possesses higher rates of comorbidities that increase their risk for trauma and make their care more challenging. By considering the nuances that accompany the critical stabilization and injury-specific management of geriatric trauma patients, emergency physicians can decrease the prevalence of adverse outcomes.
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Affiliation(s)
- Kyle R Burton
- Department of Emergency Medicine, Johns Hopkins Hospital, 1830 Eas, Monument Street, Suite 6-110, Baltimore, MD 21287, USA
| | - Phillip D Magidson
- Johns Hopkins Hospital, Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, Suite A150, Baltimore, MD 21224, USA.
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Ahmed N, Kuo YH. Outcomes of care at higher-level trauma centers in octogenarians with a history of anticoagulant use who fall from ground level. Injury 2023; 54:110718. [PMID: 37127447 DOI: 10.1016/j.injury.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 03/23/2023] [Accepted: 04/09/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND The appropriate care of octogenarian trauma patients after a fall from ground level (FFGL) is a key factor for better outcomes. The purpose of this study is to use data from a national database to evaluate the outcomes of patients who are 80-89 years old with a history of anticoagulant use, sustained a FFGL, and were treated at a higher-level care institution. METHODS The Trauma Quality Improvement Program (TQIP) database of the calendar year 2017-2018 was accessed for the study. All hospitalized trauma patients between the ages of 80-89 years old with a history of anticoagulant use and sustaining an injury after FFGL were included in the study. Other variables included in the study are sex [male], race [white], initial systolic blood pressure (SBP mmHg), Injury Severity Score (ISS), Glasgow Coma Scale (GCS), hypotension with an SBP<110 mmHg and other comorbidities. The outcomes of the patients were compared with the care at higher-level trauma centers (Level I & Level II) and lower-level trauma centers (Level III) using propensity matched analysis. RESULTS After propensity matching, 2348 patients were identified in each group. There was no clinically significant difference between the patients' characteristics who were treated at higher-level and lower-level care centers. A paired matched analysis showed greater mortality in patients who were treated at higher-level care centers compared to lower-level care centers (3.7% vs 2.6%, P = 0.03). The absolute difference in mortality was 1.1%[95% CI: 0.001, 0.022] which may not have any clinical relevance. A greater number of patients were discharged to home and a lesser number of patients were discharged to a skilled nursing facility (SNF) when they were treated at higher-level trauma centers. CONCLUSION & RELEVANCE The care at higher-level trauma centers did not show any benefit in-hospital mortality in the short term. A higher number of patients was discharged to home without assistance.
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Affiliation(s)
- Nasim Ahmed
- Division of Trauma & Surgical Critical Care, Jersey Shore University Medical Center, Neptune, NJ, USA; Hackensack Meridian School of Medicine, Nutley, NJ, USA.
| | - Yen-Hong Kuo
- Office of Research Administration, Jersey Shore University Medical Center, Neptune, NJ, USA; Hackensack Meridian School of Medicine, Nutley, NJ, USA
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Mohd Mokhtar MA, Azhar ZI, Jamaluddin SF, Cone DC, Shin SD, Shaun GE, Chiang WC, Kajino K, Song KJ, Son DN, Norzan NA. Analysis of Trauma Characteristics Between the Older and Younger Adult Patient from the Pan Asian Trauma Outcome Study Registry (PATOS). PREHOSP EMERG CARE 2023; 27:875-885. [PMID: 37459651 DOI: 10.1080/10903127.2023.2237107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 06/27/2023] [Accepted: 07/01/2023] [Indexed: 08/31/2023]
Abstract
OBJECTIVE Asia is experiencing a demographic shift toward an aging population at an unrivaled rate. This can influence the characteristics and outcomes of trauma. We aim to examine different characteristics of older adult trauma patients compared to younger adult trauma patients and describe factors that affect the outcomes in Asian countries. METHODS This is a retrospective, international, multicenter study of trauma across participating centers in the Pan Asian Trauma Outcome Study (PATOS) registry, which included trauma cases aged ≥18 years, brought to the emergency department (ED) by emergency medical services (EMS) from October 2015 to November 2018. Data of older adults (≥65 years) and younger adults (<65 years) were analyzed and compared. The primary outcome measure was in-hospital mortality, and secondary outcomes were disability at discharge and hospital and intensive care unit (ICU) length of stays. RESULTS Of 39,804 trauma patients, 10,770 (27.1%) were older adults. Trauma occurred more among older adult women (54.7% vs 33.2%, p < 0.001). Falls were more frequent in older adults (66.3% vs 24.9%, p < 0.001) who also had higher mean Injury Severity Score (ISS) compared to the younger adult trauma patient (5.4 ± 6.78 vs 4.76 ± 8.60, p < 0.001). Older adult trauma patients had a greater incidence of poor Glasgow Outcome Scale (GOS) (13.4% vs 4.1%, p < 0.001), higher hospital mortality (1.5% vs 0.9%, p < 0.001) and longer median hospital length of stay (12.8 vs 9.8, p < 0.001). Multiple logistic regression revealed age (adjusted odds ratio [AOR] 1.06, 95%CI 1.02-1.04, p < 0.001), male sex (AOR 1.60, 95%CI 1.04-2.46, p = 0.032), head and face injuries (AOR 3.25, 95%CI 2.06-5.11, p < 0.001), abdominal and pelvic injuries (AOR 2.78, 95%CI 1.48-5.23, p = 0.002), cardiovascular (AOR 2.71, 95%CI 1.40-5.22, p = 0.003), pulmonary (AOR 3.13, 95%CI 1.30-7.53, p = 0.011) and cancer (AOR 2.03, 95%CI 1.02-4.06, p = 0.045) comorbidities, severe ISS (AOR 2.06, 95%CI 1.23-3.45, p = 0.006), and Glasgow Coma Scale (GCS) ≤8 (AOR 12.50, 95%CI 6.95-22.48, p < 0.001) were significant predictors of hospital mortality. CONCLUSIONS Older trauma patients in the Asian region have a higher mortality rate than their younger counterparts, with many significant predictors. These findings illustrate the different characteristics of older trauma patients and their potential to influence the outcome. Preventive measures for elderly trauma should be targeted based on these factors.
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Affiliation(s)
- Mohd Amin Mohd Mokhtar
- Faculty of Medicine, Universiti Teknologi MARA, UiTM Sungai Buloh Campus, Sungai Buloh, Malaysia
| | - Zahir Izuan Azhar
- Faculty of Medicine, Universiti Teknologi MARA, UiTM Sungai Buloh Campus, Sungai Buloh, Malaysia
| | | | | | - Sang Do Shin
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, South Korea
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, South Korea
| | - Goh E Shaun
- Department of Acute and Emergency Care, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Wen Chu Chiang
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Emergency Medicine, Yunlin Branch, National Taiwan University Hospital, Douliu City, Taiwan
| | - Kentaro Kajino
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Hirakata, Japan
| | - Kyoung Jun Song
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, South Korea
- Department of Emergency Medicine, Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Do Ngoc Son
- Center for Emergency Medicine, Bach Mai Hospital, Hanoi, Vietnam
| | - Nurul Azlean Norzan
- Emergency and Trauma Department, Sungai Buloh Hospital, Sungai Buloh, Malaysia
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9
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Mitchell A, Elmasry Y, van Poelgeest E, Welsh TJ. Anticoagulant use in older persons at risk for falls: therapeutic dilemmas-a clinical review. Eur Geriatr Med 2023; 14:683-696. [PMID: 37392359 PMCID: PMC10447288 DOI: 10.1007/s41999-023-00811-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 06/02/2023] [Indexed: 07/03/2023]
Abstract
PURPOSE The aim of this clinical narrative review was to summarise the existing knowledge on the use of anticoagulants and potential adverse events in older people at risk of falls with a history of atrial fibrillation or venous thromboembolism. The review also offers practical steps prescribers can take when (de-)prescribing anticoagulants to maximise safety. METHODS Literature searches were conducted using PubMed, Embase and Scopus. Additional articles were identified by searching reference lists. RESULTS Anticoagulants are often underused in older people due to concerns about the risk of falls and intracranial haemorrhage. However, evidence suggests that the absolute risk is low and outweighed by the reduction in stroke risk. DOACs are now recommended first line for most patients due to their favourable safety profile. Off-label dose reduction of DOACs is not recommended due to reduced efficacy with limited reduction in bleeding risk. Medication review and falls prevention strategies should be implemented before prescribing anticoagulation. Deprescribing should be considered in severe frailty, limited life expectancy and increased bleeding risk (e.g., cerebral microbleeds). CONCLUSION When considering whether to (de-)prescribe anticoagulants, it is important to consider the risks associated with stopping therapy in addition to potential adverse events. Shared decision-making with the patient and their carers is crucial as patient and prescriber views often differ.
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Affiliation(s)
- Anneka Mitchell
- Research Institute for the Care of Older People (RICE), Bath, UK.
- Pharmacy Department, University Hospitals Plymouth NHS Trust, Plymouth, UK.
- Life Sciences Department, University of Bath, Bath, UK.
| | - Yasmin Elmasry
- Pharmacy Department, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | | | - Tomas J Welsh
- Research Institute for the Care of Older People (RICE), Bath, UK
- Bristol Medical School, University of Bristol, Bristol, UK
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
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10
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Zhu M, O'Brien M, Shaikh SP, Brahmbhatt TS, LeBedis C, Scantling D, Sanchez SE. Utilization of torso computed tomography for the evaluation of ground level falls: More imaging does not equal better care. Injury 2023; 54:105-111. [PMID: 36470767 DOI: 10.1016/j.injury.2022.11.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 11/11/2022] [Accepted: 11/23/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Computed tomography (CT) of the chest (CTC), abdomen, and pelvis (CTAP) is common when assessing trauma patients in the emergency department. However, unnecessary imaging can expose patients to unneeded radiation and increase healthcare costs. Here, we characterize the use of torso CT imaging for the evaluation of ground level falls (GLF) at a single level 1 trauma center. PATIENTS AND METHODS We conducted a retrospective review of all patients ≥18 years old presenting to a single level 1 trauma center with a GLF (1m or less) in 2015-2019. Data were obtained through chart review. Descriptive statistics were used to summarize patient characteristics. Multivariable logistic regression was used to assess factors leading to patients obtaining torso CT imaging. The utility of CT imaging in identifying injuries that changed management was also evaluated. RESULTS Of the 1,195 patients captured during the study period, 492 patients had a positive torso physical exam (PE), and 703 had a negative torso PE. Of patients with a negative torso PE, 127 CTC and 142 CTAP were obtained, with only 5.5% CTC identifying traumatic injuries not previously diagnosed on chest radiograph (CXR), and only 0.7% CTAP identifying new injuries not identified on pelvic radiograph (PXR). Multivariable logistic regression demonstrated that only a positive PE was significantly associated with the identification of abnormal imaging findings on torso CT. A negative PE, CXR, and PXR have a negative predictive value of 98%. DISCUSSION These data suggest that patients with a negative PE, even if intoxicated, intubated, or with a decreased GCS, are highly unlikely to have new, clinically relevant findings on torso CT imaging. CONCLUSION Using PE, CXR, and PXR as a screening tool in patients sustaining GLF, which if negative close to obviates the need for torso CT, may reduce healthcare costs and radiation exposure without compromising patient care.
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Affiliation(s)
- Max Zhu
- Boston University Chobanian & Avedisian School of Medicine, United States
| | - Mollie O'Brien
- Boston Medical Center, Department of Surgery, Division of Trauma, Acute Care Surgery, and Surgical Critical Care, United States
| | - Shamsh P Shaikh
- Boston University Chobanian & Avedisian School of Medicine, United States
| | - Tejal S Brahmbhatt
- Boston University Chobanian & Avedisian School of Medicine, United States; Boston Medical Center, Department of Surgery, Division of Trauma, Acute Care Surgery, and Surgical Critical Care, United States
| | - Christina LeBedis
- Boston University Chobanian & Avedisian School of Medicine, United States; Boston Medical Center, Department of Radiology, Division of Body Imaging, United States
| | - Dane Scantling
- Boston University Chobanian & Avedisian School of Medicine, United States; Boston Medical Center, Department of Surgery, Division of Trauma, Acute Care Surgery, and Surgical Critical Care, United States
| | - Sabrina E Sanchez
- Boston University Chobanian & Avedisian School of Medicine, United States; Boston Medical Center, Department of Surgery, Division of Trauma, Acute Care Surgery, and Surgical Critical Care, United States.
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Sartini S, Spadaro M, Cutuli O, Castellani L, Sartini M, Cristina ML, Canepa P, Tognoni C, Lo A, Canata L, Rosso M, Arboscello E. Does Antithrombotic Therapy Affect Outcomes in Major Trauma Patients? A Retrospective Cohort Study from a Tertiary Trauma Centre. J Clin Med 2022; 11:jcm11195764. [PMID: 36233632 PMCID: PMC9573302 DOI: 10.3390/jcm11195764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 08/24/2022] [Accepted: 09/26/2022] [Indexed: 11/16/2022] Open
Abstract
Antithrombotic therapy may affect outcomes in major trauma but its role is not fully understood. We aimed to investigate adverse outcomes among those with and without antithrombotic treatment in major trauma. Material and methods: This is a retrospective study conducted at the Emergency Department (ED) of the University Hospital of Genoa, a tertiary trauma center, including all major trauma between January 2019 and December 2020. Adverse outcomes were reviewed among those without antithrombotic treatment (Group 0), on antiplatelet treatment (Group 1), and on anticoagulant treatment (Group 2). Results: We reviewed 349 electronic charts for full analysis. Group 0 were n = 310 (88.8%), Group 1 were n = 26 (7.4%), and Group 2 were n = 13 (3.7%). In-hospital death and ICU admission, respectively, were: n = 16 (5.6%) and n = 81 (26%) in Group 0, none and n = 6 (25%) in Group 1, and n = 2 (15.8%) and n = 4 (30.8%) in Group 2 (p = 0.123-p = 0.874). Altered INR (OR 5.2) and increasing D-dimer levels (AUC: 0.81) correlated to increased mortality. Discussion: Group 2 showed higher mortality than Group 0 and Group 1, however Group 2 had fewer active treatments. Of clotting factors, only altered INR and elevated D-dimer levels were significantly correlated to adverse outcomes. Conclusions: Anticoagulant but not antiplatelet treatment seems to produce the worst outcomes in major trauma.
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Affiliation(s)
- Stefano Sartini
- Emergency Medicine Department, UOC MECAU, San Martino Policlinic University Hospital, Largo Rosanna Benzi 10, 16132 Genoa, Italy
- Correspondence: (S.S.); (M.S.); (M.L.C.)
| | - Marzia Spadaro
- Emergency Medicine Department, UOC MECAU, San Martino Policlinic University Hospital, Largo Rosanna Benzi 10, 16132 Genoa, Italy
| | - Ombretta Cutuli
- Emergency Medicine Department, UOC MECAU, San Martino Policlinic University Hospital, Largo Rosanna Benzi 10, 16132 Genoa, Italy
| | - Luca Castellani
- Emergency Medicine Department, UOC MECAU, San Martino Policlinic University Hospital, Largo Rosanna Benzi 10, 16132 Genoa, Italy
| | - Marina Sartini
- Department of Health Sciences, University of Genova, 16128 Genoa, Italy
- Hospital Hygiene Unit, Galliera Hospital, Via Alessandro Volta 8, 16128 Genoa, Italy
- Correspondence: (S.S.); (M.S.); (M.L.C.)
| | - Maria Luisa Cristina
- Department of Health Sciences, University of Genova, 16128 Genoa, Italy
- Hospital Hygiene Unit, Galliera Hospital, Via Alessandro Volta 8, 16128 Genoa, Italy
- Correspondence: (S.S.); (M.S.); (M.L.C.)
| | - Paolo Canepa
- Emergency Medicine Post-Graduate School, University of Genoa, Via Balbi 5, 16126 Genoa, Italy
| | - Chiara Tognoni
- Emergency Medicine Post-Graduate School, University of Genoa, Via Balbi 5, 16126 Genoa, Italy
| | - Agnese Lo
- Emergency Medicine Post-Graduate School, University of Genoa, Via Balbi 5, 16126 Genoa, Italy
| | - Lorenzo Canata
- Emergency Medicine Post-Graduate School, University of Genoa, Via Balbi 5, 16126 Genoa, Italy
| | - Martina Rosso
- School of Medicine, University of Genoa, Via Balbi 5, 16126 Genoa, Italy
| | - Eleonora Arboscello
- Emergency Medicine Department, UOC MECAU, San Martino Policlinic University Hospital, Largo Rosanna Benzi 10, 16132 Genoa, Italy
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12
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Vervoordt SM, Hamze MK, Dell KC, Staph J, Hillary FG. Effects of preexisting stroke on acute hospital outcomes for older adults admitted with neurotrauma and orthopedic injury. Brain Inj 2022; 36:1109-1117. [PMID: 35996331 DOI: 10.1080/02699052.2022.2109742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
OBJECTIVE We aimed to examine acute trauma outcomes, specifically among those with neurotrauma (NT), in patients with preexisting cerebrovascular accident (CVA). METHODS We identified patients treated for neurotrauma or orthopedic trauma at hospitals in Pennsylvania with and without an identified history of stroke with residual deficits, aged 50-99 across four groups of N = 11,648 each. We assessed mortality, craniotomy, and total hospital, ICU, step-down, and ventilator days, functional status at discharge (FSD), and discharge destination. RESULTS Stroke history did not influence mortality but was predictive of patients undergoing craniotomy (OR = 1.25, p = 0.008). There was a moderate group effect on total ICU days, with the CVA+NT group in the ICU the longest (η2 = 0.10, p < 0.001). Patients with stroke history were less likely to be discharged to home (OR = 0.65, p < 0.001) and had poorer FSD scores across the various domains assessed. CONCLUSIONS Trauma patients with preexisting CVA were found to have poorer outcomes on a number of different metrics when compared to those without stroke history. While it is possible that functional differences pre-injury influenced FSD and discharge destination, given these results, clinicians should assess for possible comorbidities that may influence treatment.
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Affiliation(s)
- Samantha M Vervoordt
- Department of Psychology, The Pennsylvania State University, University Park, PA, USA
| | - Mohamad K Hamze
- Larner College of Medicine, The University of Vermont, Burlington, VT, USA
| | - Kristine C Dell
- Department of Psychology, The Pennsylvania State University, University Park, PA, USA
| | - Jason Staph
- Department of Psychology, The Pennsylvania State University, University Park, PA, USA
| | - Frank G Hillary
- Department of Psychology, The Pennsylvania State University, University Park, PA, USA
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13
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Bouget J, Jouhanny A, Soulat L, Oger E. Ground-level falls among nonagenarians: the impact of pre-injury antithrombotic therapy. Intern Emerg Med 2022; 17:1309-1319. [PMID: 35112277 DOI: 10.1007/s11739-021-02914-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 12/16/2021] [Indexed: 12/21/2022]
Abstract
Among nonagenarians admitted to our emergency department (ED) for ground-level falls, we assessed the impact of pre-injury antithrombotic (AT) treatment on the post-traumatic consequences, and identified risk factors for 1-month mortality. All eligible patients were consecutively included over an 18-month period. Head trauma was attested by reliable medical history, witnesses or recent external signs. Patient characteristics, post-traumatic consequences and outcomes were compared across patients with and without AT. Risk factors for 1-month mortality were assessed using multivariate logistic regression analyses. 1014 consecutive nonagenarians were analysed, 675 (66.6%) with AT and 339 (33.4%) without. Head trauma (n = 429, 42.3%) was significantly more frequent among patients with AT (49.2 vs 28.6%, p < 0.001). Intracranial hemorrhage (ICH, n = 43, 4.2%), mostly subdural hematomas (58%), were more frequently found among patients with AT (p < 0.015). At least one fracture was diagnosed for 23.9% of the population, mostly hip fractures, without any significant association with AT. At 1 month, 103 patients (10.2%) had died. The independent risk factors for 1-month mortality were: ICH associated with head trauma (OR = 5.9, 95% CI 2.5-14), Glasgow coma score ≤ 12 at admission (OR = 10; 95% CI 2.2-46), atrial fibrillation (OR = 2.2, 95% CI 1.4-3.4) and age ≥ 95 years (OR = 1.6, 95% CI 1.0-2.5). Our results support accurate and regular assessment of the benefit/risk ratio for antithrombotic treatment among elderly people at high risk for falls.
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Affiliation(s)
- Jacques Bouget
- Emergency Department, University Hospital, 35033, Rennes, France.
- University of Rennes, CHU Rennes, EA 7449 (Pharmacoepidemiology and Health Services Research) REPERES, University Hospital, F-35043, Rennes, France.
| | - Alexia Jouhanny
- Emergency Department, University Hospital, 35033, Rennes, France
| | - Louis Soulat
- Emergency Department, University Hospital, 35033, Rennes, France
| | - Emmanuel Oger
- University of Rennes, CHU Rennes, EA 7449 (Pharmacoepidemiology and Health Services Research) REPERES, University Hospital, F-35043, Rennes, France
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14
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The onset of falls and its effects on perceived social exclusion and loneliness. Evidence from a nationally representative longitudinal study. Arch Gerontol Geriatr 2022; 100:104622. [DOI: 10.1016/j.archger.2022.104622] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 12/19/2021] [Accepted: 01/15/2022] [Indexed: 12/11/2022]
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15
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Manoukian MAC, Tancredi DJ, Nishijima DK. Effect of age on the efficacy of tranexamic acid: An analysis of heterogeneity of treatment effect within the CRASH-2 dataset. Am J Emerg Med 2021; 53:37-40. [PMID: 34971920 DOI: 10.1016/j.ajem.2021.12.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 12/07/2021] [Accepted: 12/13/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Trauma is a major cause of morbidity and mortality in older adults and will become more common as the population ages. Tranexamic acid (TXA) is a lysine analogue frequently used in the setting of significant trauma with hemorrhage. The aim of this study is to investigate the heterogeneity of treatment effect of TXA as it relates to patient age during trauma care. METHODS We included patients from the CRASH-2 trial who were randomized within 3 h of injury. Patients were stratified into age groups <26 years, 26 to 35 years, 36 to 45 years, 46 to 55 years, and >55 years. Multiple logistic regression models were utilized to evaluate adjusted odds ratios (OR) with 95% confidence intervals (CI) for mortality. Heterogeneity of treatment effect was evaluated using Akaike and Bayesian information criteria to determine the optimum logistic regression model after which a Wald Chi-square test was utilized to evaluate statistical significance. RESULTS On univariate analysis, TXA administration decreased mortality within the <26 years cohort (decrease of 2.1%, 95% CI 0.2 to 4.0), 46 to 55 years cohort (decrease 6.7%, 95% CI 2.7 to 10.7), and >55 years cohort (decrease of 5.3%, 95% CI 0.4 to 10.3). On adjusted analysis, when compared to the 36 to 45 years cohort, the <26 year cohort experienced a decreased mortality (OR 0.72, 95% CI 0.62 to 0.85) whereas the >55 year cohort experienced increased mortality (OR 1.8, 95% CI 1.5 to 2.2). Assessment for heterogeneity of treatment effect of TXA administration between groups approached but did not reach statistical significance (p = 0.11). CONCLUSIONS Mortality related to trauma increases with age, however, there does not appear to be heterogeneity of treatment effect for TXA administration among different age groups.
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Affiliation(s)
- Martin A C Manoukian
- Department of Emergency Medicine, UC Davis School of Medicine, Sacramento, CA, United States of America.
| | - Daniel J Tancredi
- Department of Emergency Medicine, UC Davis School of Medicine, Sacramento, CA, United States of America; Department of Pediatrics, UC Davis School of Medicine, Sacramento, CA, United States of America
| | - Daniel K Nishijima
- Department of Emergency Medicine, UC Davis School of Medicine, Sacramento, CA, United States of America
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16
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Goldwag JL, Porter ED, Wilcox AR, Li Z, ScD TDT, Crockett AO, Wolffing AB, Mancini DJ, Martin ED, Scott JW, Briggs A. Geriatric All-Terrain Vehicle Trauma: An Unhelmeted and Severely Injured Population. J Surg Res 2021; 270:555-563. [PMID: 34826691 DOI: 10.1016/j.jss.2021.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 08/17/2021] [Accepted: 09/16/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND All-terrain vehicle (ATV) use is widespread, however, little is known about injury patterns and outcomes in geriatric patients. We hypothesized that geriatric patients would have distinct and more severe injuries than non-geriatric adults after ATV trauma. METHODS A retrospective cohort study was performed using the National Trauma Databank comparing non-geriatric (18-64) and geriatric adults (≥65) presenting after ATV trauma at Level 1 and 2 trauma centers from 2011 to 2015. Demographic, admission, and outcomes data were collected, including injury severity score (ISS), abbreviated injury scale (AIS) score, discharge disposition, and mortality. We performed univariate statistical tests between cohorts and multiple logistic regression models to assess for risk factors associated with severe injury (ISS>15) and mortality. RESULTS 23,568 ATV trauma patients were identified, of whom 1,954 (8.3%) were geriatric. Geriatric patients had higher rates of severe injury(29.2 v 22.5%,p<0.0001), and thoracic (55.2 v 37.8%,p<0.0001) and spine (31.5 v 26.0%,p<0.0001) injuries, but lower rates of abdominal injuries (14.6 v 17.9%,p<0.001) as compared to non-geriatric adults. Geriatric patients had overall lower head injury rates (39.2 v 42.1%,p=0.01), but more severe head injuries (AIS>3) (36.2 vs 30.2%,p<0.001). Helmet use was significantly lower in geriatric patients (12.0 v 22.8%,p<0.0001). On multivariate analysis age increased the odds for both severe injury (OR 1.50, 95% CI 1.31-1.72, p<0.0001) and mortality (OR 5.07, 95% CI 3.42-7.50, p<0.0001). CONCLUSIONS While severe injury and mortality after ATV trauma occurred in all adults, geriatric adults suffered distinct injury patterns and were at greater risk for severe injury and mortality.
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Affiliation(s)
- Jenaya L Goldwag
- Department of Surgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Dr, Lebanon, NH, 03756
| | - Eleah D Porter
- Department of Surgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Dr, Lebanon, NH, 03756
| | - Allison R Wilcox
- Department of Surgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Dr, Lebanon, NH, 03756
| | - Zhongze Li
- Biomedical Data Science Department, Geisel School of Medicine at Dartmouth College
| | - Tor D Tosteson ScD
- Biomedical Data Science Department, Geisel School of Medicine at Dartmouth College
| | - Andrew O Crockett
- Department of Surgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Dr, Lebanon, NH, 03756; Geisel School of Medicine, 1 Rope Ferry Rd, Hanover, NH, 03755
| | - Andrea B Wolffing
- Department of Surgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Dr, Lebanon, NH, 03756; Geisel School of Medicine, 1 Rope Ferry Rd, Hanover, NH, 03755
| | - D Joshua Mancini
- Department of Surgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Dr, Lebanon, NH, 03756; Geisel School of Medicine, 1 Rope Ferry Rd, Hanover, NH, 03755
| | - Eric D Martin
- Department of Surgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Dr, Lebanon, NH, 03756; Geisel School of Medicine, 1 Rope Ferry Rd, Hanover, NH, 03755
| | - John W Scott
- Department of Surgery, University of Michigan, Ann Arbor, MI, 48109
| | - Alexandra Briggs
- Department of Surgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Dr, Lebanon, NH, 03756; Geisel School of Medicine, 1 Rope Ferry Rd, Hanover, NH, 03755.
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17
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Trauma Response for Elderly Anticoagulated Patients: An Initiative to Reduce Trauma Resource Utilization in the Emergency Department. J Trauma Nurs 2021; 28:159-165. [PMID: 33949350 DOI: 10.1097/jtn.0000000000000577] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Trauma centers are challenged to have appropriate criteria to identify injured patients needing a trauma activation; one population that is difficult to triage is injured elderly patients taking anticoagulation or antiplatelet (ACAP) medications with suspected head injury. OBJECTIVE The study purpose was to evaluate a hospital initiative to improve the trauma triage response for this population. METHODS A retrospective study at a Level I trauma center evaluated revised trauma response criteria. In Phase 1 (June 2017 to April 2018; n = 91), a limited activation occurred in the trauma bay for injured patients 55 years and older, taking ACAP medications with evidence of head injury. In Phase 2 (June 2018 to April 2019; n = 142), patients taking ACAP medications with evidence of head injury received a rapid emergency department (ED) response. Primary outcomes were timeliness of ED interventions and hospital admission rates. Differences between phases were assessed with Kruskal-Wallis tests. RESULTS An ED rapid response significantly reduced trauma team involvement (100%-13%, p < .001). Compared with Phase 1, patients in Phase 2 were more frequently discharged from the ED (48% vs. 68%, p = .003), and ED disposition decision was made more quickly (147 vs. 120 min, p = .01). In Phase 2, time to ED disposition decision was longer for patients who required hospital admission (108 vs. 179 min, p < .001); however, there were no significant differences between phases in reversal intervention (6% vs. 11%, p = .39) or timeliness of reversal intervention (49 vs. 118 min, p = .51). CONCLUSION The ED rapid response delivered safe, timely evaluation to injured elderly patients without overutilizing trauma team activations.
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18
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Influence of Oral Anticoagulation and Antiplatelet Drugs on Outcome of Elderly Severely Injured Patients. J Clin Med 2021; 10:jcm10081649. [PMID: 33924389 PMCID: PMC8069499 DOI: 10.3390/jcm10081649] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/01/2021] [Accepted: 04/07/2021] [Indexed: 12/14/2022] Open
Abstract
Introduction: Severely injured elderly patients have a poorer prognosis and higher mortality rates after severe trauma compared with younger patients. The aim of this study was to correlate the influence of pre-existing oral anticoagulation (OAC) and antiplatelet drugs (PAI) on the outcome of severely injured elderly patients. Methods: Using a prospective cohort study model over an 11-year period, severely injured elderly patients (≥65 years and ISS ≥ 16) were divided into two groups (no anticoagulation/platelet inhibitors: nAP and OAC/PAI). A comparison of the groups was conducted regarding injury frequency, trauma mechanism, severity of head injuries, and medication-related mortality. Results: In total, 254 out of 301 patients were analyzed (nAP: n = 145; OAC/PAI: n = 109, unknown data: n = 47). The most relevant injury was falling from low heights (<3 m), which led to a significantly higher number of severe injuries in patients with OAC/PAI. Patients with pre-existing OAC/PAI showed a significantly higher overall mortality rate compared to the group without (38.5% vs. 24.8%; p = 0.019). The severity of head injuries in OAC/PAI was also higher on average (AIS 3.7 ± 1.6 vs. 2.8 ± 1.9; p = 0.000). Conclusion: Pre-existing oral anticoagulation and/or platelet aggregation inhibitors are related to a higher mortality rate in elderly polytrauma patients. Low-energy trauma can lead to even more severe head injuries due to pre-existing medication than is already the case in elderly patients without OAC/PAI.
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19
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Lindley RI. Balancing the benefits and harms of oral anticoagulation in non-valvular atrial fibrillation. Aust Prescr 2021; 44:49-52. [PMID: 33911332 PMCID: PMC8075749 DOI: 10.18773/austprescr.2021.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Non-valvular atrial fibrillation is becoming more common in Australia and globally The direct oral anticoagulants apixaban, dabigatran and rivaroxaban offer an improved safety profile over warfarin Patient preferences are important and shared decision-making supports better adherence to treatment
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Affiliation(s)
- Richard I Lindley
- Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney.,George Institute for Global Health, Sydney
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20
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Narula N, Tsikis S, Jinadasa SP, Parsons CS, Cook CH, Butt B, Odom SR. The Effect of Anticoagulation and Antiplatelet Use in Trauma Patients on Mortality and Length of Stay. Am Surg 2021; 88:1137-1145. [PMID: 33522831 DOI: 10.1177/0003134821989043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Though many trauma patients are on anticoagulation or antiplatelet therapy (AAT), there are few generalizable data on the risks for these patients. The purpose of this study was to analyze the impact of anticoagulation (AC) and antiplatelet (AP) therapy on mortality and length of stay (LOS) in general trauma patients. METHODS A retrospective review was performed of patients in the institutional trauma registry during 2019 to determine AAT use on admission and discharge. Outcomes were compared using standard statistics. RESULTS Of 2261 patients who met the inclusion criteria, 2 were excluded due to an incomplete medication reconciliation, resulting in 2259 patients. Patients on AAT had a higher mortality (4.5% vs 2.1%). On multivariable analysis, preadmission AC (odds ratio OR, 3.325, P = .001), age (OR 1.040, P < .001), and injury severity score ((ISS) 1.094, P < .001) were associated with mortality. Anticoagulation use was also associated with longer LOS on multivariable analysis (OR: 1.626, P = .005). Antiplatelet use was not associated with higher mortality or longer LOS. More patients on AAT were unable to be discharged home. However, patients on AAT did not have a greater blood transfusion requirement or need more hemorrhage control procedures. Lastly, 23.7% of patients on preadmission AAT were not discharged on any AAT. DISCUSSION These data demonstrate that patients on AC, but not AP, have greater mortality and longer hospital LOS. This may provide guidance for those being newly started on AAT. Further work to determine which patients benefit most from restarting AAT would lead to improvement in the care of trauma patients.
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Affiliation(s)
- Nisha Narula
- Department of Surgery, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Savas Tsikis
- Department of Surgery, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Sayuri P Jinadasa
- Department of Surgery, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Charles S Parsons
- Department of Surgery, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Charles H Cook
- Department of Surgery, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Bonnie Butt
- Department of Surgery, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Stephen R Odom
- Department of Surgery, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
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21
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Kim SH, Sul YH, Lee JY, Ye JB, Lee JS, Kim HR, Yoon SY, Kim JS. History of anticoagulant and antiplatelet therapy as a predictive factor for transfusion requirement in elderly trauma patients in intensive care: A retrospective registry–based cohort analysis. HONG KONG J EMERG ME 2020. [DOI: 10.1177/1024907920961271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Introduction: With increased life expectancy, the proportion of elderly trauma admissions has increased. Elderly patients frequently have underlying diseases necessitating anticoagulant/antiplatelet medication, which worsens coagulopathy. We ascertained the relationship between preinjury anticoagulants/antiplatelet medication use and transfusion requirements in patients older than 65 years. Methods: This retrospective study enrolled patients admitted to the trauma intensive care unit of Chungbuk National University Hospital during January 2016 to June 2019. Data on medication history, clinical features, and component transfusions were analyzed with the chi-square test, independent t-test, one-way analysis of variance, and analysis of covariance. Results: Overall, 142 and 324 (overall 466) patients did and did not receive anticoagulant/antiplatelet medication, respectively. Falls were more frequent ( p < 0.001) in the medicated group ( n = 36; 25.4% vs n = 25; 7.7%). Head and neck injuries were more frequent among patients in the medicated group (58.5% vs 46.6%, p = 0.02), and they had a lower Injury Severity Score (ISS; 18.2 vs 20.2, p = 0.03), with no difference in serum hemoglobin level and coagulation function. The non-medicated group received more red blood cell transfusions within 4 h of arrival (2.24 vs 1.42 units, p = 0.03). Post hoc analysis revealed differences in red blood cell transfusions within 4 h of arrival between the non-medicated and warfarin groups (2.24 vs 0.33 units). Patients with head and neck injuries received less red blood cells than patients with other injuries (head and neck 1.07; chest and abdomen 2.73; pelvic and extremity 3.34 units, p < 0.001). On linear regression analysis, the Injury Severity Score and Glasgow Coma Scale score influenced the transfusion volume. Multivariate analysis controlled for Injury Severity Score, Glasgow Coma Scale score, and main injury site showed no intergroup differences in transfusion requirements. Conclusion: Preinjury anticoagulant/antiplatelet medication use was not significantly associated with transfusion amounts in patients older than 65 years.
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Affiliation(s)
- Se Heon Kim
- Department of Trauma Surgery, Chungbuk National University Hospital, Cheongju, Korea
| | - Young Hoon Sul
- Department of Trauma Surgery, Chungbuk National University Hospital, Cheongju, Korea
- Depratment of Trauma Surgery, College of Medicine, Chungbuk National University, Cheongju, Korea
| | - Jin Young Lee
- Department of Trauma Surgery, Chungbuk National University Hospital, Cheongju, Korea
| | - Jin Bong Ye
- Department of Trauma Surgery, Chungbuk National University Hospital, Cheongju, Korea
| | - Jin Suk Lee
- Department of Trauma Surgery, Chungbuk National University Hospital, Cheongju, Korea
| | - Hong Rye Kim
- Department of Neurosurgery, Chungbuk National University Hospital, Cheongju, Korea
| | - Soo Young Yoon
- Department of Thoracic and Cardiovascular Surgery, Chungbuk National University Hospital, Cheongju, Korea
| | - Joong Suck Kim
- Department of Trauma Surgery, Cheju Halla General Hospital, Jeju, Korea
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22
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Ocular trauma associated with falls in older people: A 10-year review from a state trauma service. Injury 2020; 51:2009-2015. [PMID: 32690213 DOI: 10.1016/j.injury.2020.07.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 06/23/2020] [Accepted: 07/10/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Falls are the leading cause of injury-related emergency presentations, hospital admissions and deaths in Victorians over the age of 65. While there is extensive literature analysing traumatic injuries resulting from falls in older patients, there is little data on ocular injuries in this patient group. METHODOLOGY A retrospective audit of all patients over 65 years referred to the Ophthalmology Department of a tertiary hospital following fall from standing height between January 2009 and December 2018 to determine the demographics, injury setting, ophthalmic injuries, interventions and outcomes of ocular trauma secondary to falls. RESULTS Two hundred and seventy patients (F = 155, M = 115) were included, with a mean age of 81 years. 180 falls (66.7%) occurred in a residential environment. The most common reason for referral was orbital fracture (n = 155). Severe ocular injuries included globe rupture (n = 23), retro-bulbar haematoma (n = 22), retinal detachment (n = 6) and traumatic optic neuropathy (n = 6). Forty patients (14.8%) presented with a visual acuity (VA) below 6/60 while 34 patients (12.5%) had a non-assessable VA secondary to delirium or intubation. Of these 34, 9 had a significant ocular injury. A total of 28 patients (10.4%) were permanently blinded by their injuries. Twenty-three patients (8.5%) required admission to ICU and 16 patients (5.93%) died during their in-hospital stay. Thirty-six injuries were referred beyond the 24-hour mark, including a globe rupture and a case of traumatic optic neuropathy. With the exception of the missed globe rupture, all other injuries requiring emergency surgery were operated on within 24 h. CONCLUSION Falls in older people may be associated with sight-threatening ocular injuries which are common and easy to miss in this population demographic. The presence of ocular injuries in this patient group is associated with significant rates of in-hospital mortality and poor functional outcomes. It is therefore essential for trauma practitioners to perform a detailed and systematic assessment in order to identify sight-threatening ocular injuries and allow for expedient sight-saving intervention to be performed.
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Cuevas-Østrem M, Røise O, Wisborg T, Jeppesen E. Geriatric Trauma - A Rising Tide. Assessing Patient Safety Challenges in a Vulnerable Population Using Norwegian Trauma Registry Data and Focus Group Interviews: Protocol for a Mixed Methods Study. JMIR Res Protoc 2020; 9:e15722. [PMID: 32352386 PMCID: PMC7226039 DOI: 10.2196/15722] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 11/27/2019] [Accepted: 12/17/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Elderly trauma patients constitute a vulnerable group, with a substantial risk of morbidity and mortality even after low-energy falls. As the world's elderly population continues to increase, the number of elderly trauma patients is expected to increase. Limited data are available about the possible patient safety challenges that elderly trauma patients face. The outcomes and characteristics of the Norwegian geriatric trauma population are not described on a national level. OBJECTIVE The aim of this project is to investigate whether patient safety challenges exist for geriatric trauma patients in Norway. An important objective of the study is to identify risk areas that will facilitate further work to safeguard and promote quality and safety in the Norwegian trauma system. METHODS This is a population-based mixed methods project divided into 4 parts: 3 quantitative retrospective cohort studies and 1 qualitative interview study. The quantitative studies will compare adult (aged 16-64 years) and elderly (aged ≥65 years) trauma patients captured in the Norwegian Trauma Registry (NTR) with a date of injury from January 1, 2015, to December 31, 2018. Descriptive statistics and relevant statistical methods to compare groups will be applied. The qualitative study will comprise focus group interviews with doctors responsible for trauma care, and data will be analyzed using a thematic analysis to identify important themes. RESULTS The project received funding in January 2019 and was approved by the Oslo University Hospital data protection officer (No. 19/16593). Registry data have been extracted for 33,344 patients, and the analysis of these data has begun. Focus group interviews will be conducted from spring 2020. Results from this project are expected to be ready for publication from fall 2020. CONCLUSIONS By combining data from the NTR with interviews with doctors responsible for treatment and transfer of elderly trauma patients, we will provide increased knowledge about trauma in Norwegian geriatric patients on a national level that will form the basis for further research aiming at developing interventions that hopefully will make the trauma system better equipped to manage the rising tide of geriatric trauma. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/15722.
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Affiliation(s)
- Mathias Cuevas-Østrem
- Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway
- Norwegian Trauma Registry, Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Olav Røise
- Norwegian Trauma Registry, Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Torben Wisborg
- Norwegian National Advisory Unit on Trauma, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
- Anaesthesia and Critical Care Research Group, Faculty of Health Sciences, University of Tromsø - The Arctic University of Norway, Tromsø, Norway
| | - Elisabeth Jeppesen
- Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway
- Norwegian Trauma Registry, Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
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24
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Lobraico-Fernandez J, Baksh S, Nemec E. Elderly Bleeding Risk of Direct Oral Anticoagulants in Nonvalvular Atrial Fibrillation: A Systematic Review and Meta-Analysis of Cohort Studies. Drugs R D 2020; 19:235-245. [PMID: 31127504 PMCID: PMC6738514 DOI: 10.1007/s40268-019-0275-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Introduction The 2014 American Heart Association (AHA)/American College of Cardiology (ACC)/Heart Rhythm Society (HRS) guidelines recommend anticoagulation to reduce clot formation and the risk of thromboembolic events in patients with atrial fibrillation but does not specify guidelines for the elderly population. Direct oral anticoagulants (DOACs) are newer US FDA-approved alternatives to warfarin and include dabigatran, rivaroxaban, apixaban and edoxaban. The efficacy of DOACs is heavily researched, but few studies have evaluated their bleeding risk. Objectives This systematic review and meta-analysis investigates which DOAC has the lowest bleeding risk in elderly patients with nonvalvular atrial fibrillation (NVAF). Methods CINAHL and MEDLINE databases were searched using specific keywords, and 244 results were identified and screened. Inclusion criteria required a major bleeding event requiring hospitalization as an outcome and excluded patients with severe renal failure. Articles that met inclusion criteria were assessed for risk of bias using the Cochrane Tool to Assess Risk of Bias in Cohort Studies. Review Manager (version 5) was used to perform the random-effects model meta-analysis. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated. P < 0.05 was considered statistically significant. Results Six articles met inclusion criteria and encompassed 446,042 patients in total. Apixaban and dabigatran had statistically significant risk reductions compared with warfarin, whereas rivaroxaban did not (HR 0.60 [95% CI 0.52–0.69], p < 0.00001; HR 0.79 [95% CI 0.70–0.90], p = 0.0005; HR 1.03 [95% CI 0.86–1.22], p = 0.77, respectively.) Data regarding edoxaban were limited and thus not included in the analysis. Conclusion Apixaban and dabigatran have a significantly decreased major bleeding risk (40 and 21%, respectively) compared with warfarin. There was no statistical difference in bleeding risk between rivaroxaban and warfarin. Head-to-head prospective randomized controlled trials are required to assess the true bleeding risk of each DOAC.
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Affiliation(s)
| | - Salma Baksh
- Columbia University Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Eric Nemec
- Sacred Heart University Physician Assistant Studies, Fairfield, CT, USA.
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25
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Anticoagulation in Patients Prone to Falling. Am J Ther 2019; 26:e495-e498. [PMID: 31299015 DOI: 10.1097/mjt.0000000000000712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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26
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Peterer L, Ossendorf C, Jensen KO, Osterhoff G, Mica L, Seifert B, Werner CML, Simmen HP, Pape HC, Sprengel K. Implementation of new standard operating procedures for geriatric trauma patients with multiple injuries: a single level I trauma centre study. BMC Geriatr 2019; 19:359. [PMID: 31856739 PMCID: PMC6923826 DOI: 10.1186/s12877-019-1380-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Accepted: 12/10/2019] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The demographic changes towards ageing of the populations in developed countries impose a challenge to trauma centres, as geriatric trauma patients require specific diagnostic and therapeutic procedures. This study investigated whether the integration of new standard operating procedures (SOPs) for the resuscitation room (ER) has an impact on the clinical course in geriatric patients. The new SOPs were designed for severely injured adult trauma patients, based on the Advanced Trauma Life Support (ATLS) and imply early whole-body computed tomography (CT), damage control surgery, and the use of goal-directed coagulation management. METHODS Single-centre cohort study. We included all patients ≥65 years of age with an Injury Severity Score (ISS) ≥ 9 who were admitted to our hospital primarily via ER. A historic cohort was compared to a cohort after the implementation of the new SOPs. RESULTS We enrolled 311 patients who met the inclusion criteria between 2000 and 2006 (group PreSOP) and 2010-2012 (group SOP). There was a significant reduction in the mortality rate after the implementation of the new SOPs (P = .001). This benefit was seen only for severely injured patients (ISS ≥ 16), but not for moderately injured patients (ISS 9-15). There were no differences with regard to infection rates or rate of palliative care. CONCLUSIONS We found an association between implementation of new ER SOPs, and a lower mortality rate in severely injured geriatric trauma patients, whereas moderately injured patients did not obtain the same benefit. TRIAL REGISTRATION Clinicaltrials.gov NCT03319381, retrospectively registered 24 October 2017.
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Affiliation(s)
- Lorenz Peterer
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Christian Ossendorf
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Kai Oliver Jensen
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Georg Osterhoff
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Ladislav Mica
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Burkhardt Seifert
- Department of Biostatistics at Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Hirschengraben 84, 8001 Zurich, Switzerland
| | - Clément M. L. Werner
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Hans-Peter Simmen
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Hans-Christoph Pape
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Kai Sprengel
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
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27
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Evaluating the outcomes of blunt thoracic trauma in elderly patients following a fall from a ground level: higher level care institution vs. lower level care institution. Eur J Trauma Emerg Surg 2019; 47:955-963. [PMID: 31583421 DOI: 10.1007/s00068-019-01230-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 09/03/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND The purpose of the study is to evaluate the outcomes of higher level care institutions of elderly patients who sustained a thoracic injury after a ground-level fall (GLF). HYPOTHESIS Higher level care institutions have a better survival. METHODS The National Trauma Data Bank (NTDB) data set of 2012-2014 was accessed for the study. All patients, 65 years of age and older, who experienced a GLF and sustained a thoracic injury, were included in the study. Patient demography, injury characteristics including injury severity score (ISS), Glasgow coma scale (GCS) motor score, comorbidities, and patient outcomes were compared between the higher level care institution [American College of Surgeon (ACS) level I and level II trauma centers) and lower level care institution (ACS level III and level IV and unranked-trauma centers). On univariate analysis, some significant patient characteristic differences were found; therefore, propensity score matching and paired analyses were performed. All P values are two sided, and a P value < 0.05 was considered statistically significant. RESULTS Out of the 15,256 patients who satisfied the inclusion criteria, approximately 52% (7994) of patients were treated at a higher level care institution. On univariate analysis, significant differences were found between the lower level care institution and higher level care institution regarding male gender (44.2% vs.46%, P = 0.03), ISS median [interquartile] (9 [5-12] vs. 9 [5-13], P < 0.001), history of alcohol abuse (4.2% vs. 5.3%, P = 0.007), dementia (8.7% vs. 9.8%, P = 0.02), bleeding disorder or history of anticoagulation use (17% vs. 18.4%, P = 0.03), obesity (5% vs. 6.6%, P < 0.001), and abbreviated injury scale (AIS) thorax (2 [1-3] vs. 3 [2-3], P < 0.001). After propensity score matching, the majority of the characteristics were balanced with few exceptions, including ISS, AIS ≥ 3 head and abdomen, and P values < 0.05. The overall in-hospital mortality was not significantly different between the higher level care institution vs. the lower level care institution (4.4% vs. 3.9%, P = 0.14). The median hospital length of stay and 95% confidence interval between both groups was (5 [5, 5] and 5 [5, 5], P = 0.72). CONCLUSION Treating elderly patients with blunt chest trauma in higher level care institutions failed to show any benefit in overall survival or hospital length of stay. LEVEL OF EVIDENCE IV. STUDY TYPE Observational cohort.
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28
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Dougherty K, Collins J, Burgess J, Martyak M. Failure of Nonoperative Management of Splenic Injuries in Trauma Patients on Anticoagulation. Am Surg 2019. [DOI: 10.1177/000313481908500835] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Although nonoperative management or embolization with preservation of splenic tissue is preferable, there is a significant risk of continued bleeding ultimately requiring splenectomy. It has been established that elderly patients on anticoagulation (AC) have an increased risk of splenic injury, but there are little data to show whether AC plays a role in outcomes of splenic injury in the setting of trauma. This is a retrospective cohort study, including 168 adults aged 50 to 79 years who presented as a trauma patient to Sentara Norfolk General Hospital from January 1, 2010, to March 31, 2018. The primary outcome is the management of the splenic injury. Of the 168 patients, 30 were presently taking AC at the time of their injury, and 138 were not taking any AC. These groups were similar in average Injury Severity Score, average grade of splenic injury, and average systolic blood pressure on arrival. However, the groups differed significantly in age and hemoglobin on arrival. We found that patients taking AC at the time of injury underwent splenectomy 23.3 per cent of the time, whereas patients not taking AC underwent splenectomy 11.6 per cent of the time ( P = 0.045). Patients taking AC failed nonoperative management 20 per cent of the time, whereas patients not taking AC failed 0.7 per cent of the time ( P < 0.05). We found that patients taking AC at the time of their traumatic injury were more likely to undergo splenectomy than patients not taking AC. We also found that patients taking AC were more likely to fail nonoperative management.
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Affiliation(s)
| | - Jay Collins
- From the Eastern Virginia Medical School, Norfolk, Virginia
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29
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Consideration of Anticoagulation: Surgical Care for the Elderly in Current Geriatrics Reports. CURRENT GERIATRICS REPORTS 2019. [DOI: 10.1007/s13670-019-00290-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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30
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Fiordellisi W, White K, Schweizer M. A Systematic Review and Meta-analysis of the Association Between Vitamin K Antagonist Use and Fracture. J Gen Intern Med 2019; 34:304-311. [PMID: 30511289 PMCID: PMC6374254 DOI: 10.1007/s11606-018-4758-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 10/04/2018] [Accepted: 11/16/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Vitamin K antagonist (VKA) anticoagulant use is suspected to increase the risk of bone fracture through inhibition of vitamin K-dependent cofactors of bone formation, an effect not seen with non-vitamin K antagonist oral anticoagulants (NOACs). The purpose of our systematic review and meta-analysis is to investigate the association between VKA use and fracture. METHODS We searched PubMed, EMBASE, and Cochrane Library for studies analyzing fracture in adults using VKAs versus controls. Two authors independently reviewed articles. We assessed for risk of bias using the Newcastle-Ottawa Quality Assessment Scale and the Cochrane Risk of Bias Tool and calculated pooled effects using random effects models. RESULTS We included 23 articles (22 observational studies and 1 randomized controlled trial), studying 1,121,582 subjects. There was no increased odds of fracture in VKA users versus controls (pooled OR 1.01, 95% CI 0.89, 1.14) or in VKA users versus NOAC users (pooled OR 0.95, 95% CI 0.78, 1.15). Subjects using a VKA for 1 year or longer did not have increased odds of fracture (pooled OR 1.07, 95% CI 0.90, 1.27). Compared to controls, there was increased odds of fracture in women (pooled OR 1.11, 95% CI 1.02, 1.21) and older VKA users (≥ 65) (pooled OR 1.07, 95% CI 1.01, 1.14). DISCUSSION We found no increase in odds of fracture in VKA users versus controls or NOAC users. There was a small increase in odds of fracture among female and elderly VKA users, which may not be clinically important when accounting for other considerations in choosing an anticoagulant. Our findings suggest that, when anticoagulation is necessary, fracture risk should not be a major consideration in choice of an agent. Future studies directly comparing VKA to NOAC users and studies with longer duration of VKA use may be needed.
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Affiliation(s)
- Wendy Fiordellisi
- Division of General Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
| | - Katherine White
- Division of General Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Marin Schweizer
- Division of General Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.,Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA, USA
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31
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Nagaraj G, Hullick C, Arendts G, Burkett E, Hill KD, Carpenter CR. Avoiding anchoring bias by moving beyond 'mechanical falls' in geriatric emergency medicine. Emerg Med Australas 2018; 30:843-850. [PMID: 30091183 DOI: 10.1111/1742-6723.13129] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 06/12/2018] [Indexed: 12/14/2022]
Affiliation(s)
- Guruprasad Nagaraj
- Hornsby Ku-ring-gai Hospital, Sydney, New South Wales, Australia.,Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Carolyn Hullick
- Emergency Department, John Hunter Hospital, Newcastle, New South Wales, Australia.,School of Medicine and Public Health, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Glenn Arendts
- Department of Emergency Medicine, The University of Western Australia, Perth, Western Australia, Australia
| | - Ellen Burkett
- Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Keith D Hill
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
| | - Christopher R Carpenter
- Department of Emergency Medicine, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
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32
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Mason MD, Spilman SK, Fuchsen EA, Olson SD, Sidwell RA, Swegle JR, Sahr SM. Anticoagulated Trauma Patients: A Level I Trauma Center's Response to a Growing Geriatric Population. J Emerg Med 2018; 53:458-466. [PMID: 29079066 DOI: 10.1016/j.jemermed.2017.05.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 05/08/2017] [Accepted: 05/30/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Injured older adults often receive delayed care in the emergency department (ED) because they do not meet criteria for trauma team activation (TTA). This is particularly dangerous for the increasing number of patients taking anticoagulant or antiplatelet (AC/AP) medication at the time of injury. OBJECTIVES The present study examined improvements in processes of care and triage accuracy when TTA criteria include an escalated response for older anticoagulated patients. METHODS A retrospective study was performed at a Level I trauma center. The study population (referred to as A55) included patients aged 55 years or older who were taking an AC/AP medication at the time of injury. Study periods included 11 months prior to the criteria change (Phase 1: July 2013-May 2014; n = 107) and 11 months after the change (Phase 2: July 2014-May 2015; n = 211). Differences were assessed with Kruskal-Wallis and chi-squared tests. RESULTS More A55 patients received a full or limited TTA after criteria were revised (70% vs. 26%, p < 0.001). Undertriage was reduced from 13% to 2% (p < 0.001). The trauma center significantly decreased time to first laboratory result, time to first computed tomography scan, and total time in ED prior to admission for A55 patients arriving from the scene of injury or by private vehicle. CONCLUSION Criteria that escalated the trauma response for A55 patients led to reductions in undertriage for anticoagulated older adults, as well as more timely mobilization of important clinical resources.
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Affiliation(s)
- Mark D Mason
- General Surgery Residency Program, Iowa Methodist Medical Center, Des Moines, Iowa
| | | | | | | | - Richard A Sidwell
- General Surgery Residency Program, Iowa Methodist Medical Center, Des Moines, Iowa; Trauma Services, UnityPoint Health, Des Moines, Iowa; The Iowa Clinic, Des Moines, Iowa
| | - James R Swegle
- Trauma Services, UnityPoint Health, Des Moines, Iowa; The Iowa Clinic, Des Moines, Iowa
| | - Sheryl M Sahr
- Trauma Services, UnityPoint Health, Des Moines, Iowa; The Iowa Clinic, Des Moines, Iowa
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33
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Heppner HJ. [Not Available]. MMW Fortschr Med 2018; 160:19-20. [PMID: 29892875 DOI: 10.1007/s15006-018-0606-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- H -J Heppner
- Klinik für Geriatrie HELIOS Klinikum Schwelm, Lehrstuhl Geriatrie Univ. Witten/Herdecke, Dr.-Moeller-Str. 15, D-58332, Schwelm, Deutschland.
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34
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Wacht S, Salottolo K, Atnip A, Hooks M, Bailie M, Carrick M. Heads Up: Describing and Implementing a Time-Saving Head Strike Protocol at a Level II Trauma Center. J Trauma Nurs 2018. [PMID: 29521777 DOI: 10.1097/jtn.0000000000000353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Head strikes can be fatal for patients taking blood thinners (anticoagulants or antiplatelets). Our trauma center instituted the "head strike protocol" to provide uniform and expedited care for adult trauma patients taking preinjury anticoagulants and antiplatelet medications with suspected head injury. The purpose of this article is to describe the development and implementation of the head strike protocol and compare time metrics and outcomes before and after implementing the protocol. Per the head strike protocol, patients with suspected traumatic intracranial hemorrhage (tICH) were screened for anticoagulants or antiplatelet medications by emergency medical service personnel/at first contact, activated as a Level II trauma and received a computed tomographic scan of the head within 30 min of arrival, and started reversal of blood products within 30 min of tICH confirmation. Compared with patients admitted before establishing the head strike protocol, patients treated postimplementation were significantly more likely to have trauma team activation (77% preprotocol vs. 89% postprotocol) and expeditious initiation of reversal agents (68 min preprotocol vs. 21 min postprotocol) and to survive their head injury for patients taking anticoagulants (42% preprotocol vs. 21% postprotocol). There were no differences in mortality for patients taking antiplatelet agents. This comprehensive nurse-driven reversal protocol presents an algorithm for managing patients with suspected tICH taking any preinjury blood thinners, allowing "ownership" by the nursing staff to ensure there are no delays in initiating blood products. This protocol may be particularly salient with the aging of the trauma population and parallel increase in the use of blood thinners.
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Affiliation(s)
- Sharon Wacht
- Trauma Services Department (Mss Wacht, Atnip, Hooks, and Bailie and Dr Carrick) and Trauma Research Department (Ms Salottolo and Dr Carrick), Medical City Plano, Plano Texas; Trauma Research Department, Swedish Medical Center, Englewood, Colorado (Ms Salottolo); Trauma Research Department, St. Anthony Hospital, Lakewood, Colorado (Ms Salottolo); Trauma Research Department, Penrose Hospital, Colorado Springs, Colorado (Ms Salottolo); and Trauma Research Department, Research Medical Center, Kansas City, Missouri (Ms Salottolo)
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35
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[Anticoagulation in geriatric patients with atrial fibrillation : With what and for whom no more?]. Herz 2017; 43:214-221. [PMID: 29260237 DOI: 10.1007/s00059-017-4665-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Based on established risk scores, such as the CHA2DS2-VASc score, the indications for oral anticoagulation are given for patients over 65 years old with atrial fibrillation and even more so for patients over 75 years old. Before beginning anticoagulation a geriatric assessment for evaluation of the cognitive ability, the activities of daily living and the risk of falling should be made because of the known complications of anticoagulation. Geriatric patients with non-valvular atrial fibrillation (AF) are increasingly being treated with non-vitamin K antagonist oral anticoagulants (NOAC) to prevent ischemic stroke. The European Society for Cardiology (ESC) guidelines for the management of AF recommended NOACs as the preferred treatment and vitamin K antagonists (VKA) only as an alternative option. Meanwhile, apixaban, rivaroxaban, and edoxaban as factor Xa inhibitors and dabigatran as a thrombin inhibitor, are more commonly used in clinical practice in patients with AF. Although, these drugs have pharmacodynamics and pharmacokinetic similarities and are often grouped together, it is important to recognize that the pharmacology and dose regimens differ between compounds. Especially in elderly patients the new drugs have interesting advantages compared to VKA, i. e., less drug-drug interactions with concomitant medication and a more favorable risk-benefit ratio mostly driven by the reduction of bleeding. Treatment of anticoagulation in elderly patients requires weighing the serious risk of stroke with an equally high risk of major bleeding and pharmacoeconomic considerations. The easier practicality of NOACs in routine practice must be emphasized as no international normalized ratio (INR) monitoring is necessary and the interruption of treatment for planned interventions is uncomplicated. A regular monitoring of the indications for NOACs is indispensable (as for all other medications). Especially elderly patients have the greatest benefit from NOAC along with a low renal elimination rate and they should certainly not be withheld from elderly patients who have a clear need for oral anticoagulation.
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36
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Abstract
Old age is a risk factor for poor outcome in trauma patients, as a result of undertriage and the presence of occult life-threatening injuries. The mechanisms of injury for geriatric trauma differ from those in younger patients, with a much higher incidence of low-impact trauma, especially falls from a low height. Frailty is a risk factor for severe injury after minor trauma, and caring for these patients require a multidisciplinary team with both trauma and geriatric expertise. With early recognition and aggressive management, severe injuries can still be associated with good outcomes, even in very elderly patients.
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Affiliation(s)
- Katrin Hruska
- Department of Emergency Medicine, Karolinska University Hospital, Huddinge, Sweden.
| | - Toralph Ruge
- Department of Emergency Medicine, Karolinska University Hospital, Huddinge, Sweden; Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
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Wong H, Lovett N, Curry N, Shah K, Stanworth SJ. Antithrombotics in trauma: management strategies in the older patients. J Blood Med 2017; 8:165-174. [PMID: 29042825 PMCID: PMC5633276 DOI: 10.2147/jbm.s125209] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
The ageing population has resulted in a change in the demographics of trauma, and older adult trauma now accounts for a growing number of trauma admissions. The management of older adult trauma can be particularly challenging, and exhibits differences to that of the younger age groups affected by trauma. Frailty syndromes are closely related with falls, which are the leading cause of major trauma in older adults. Comorbid disease and antithrombotic use are more common in the older population. Physiological changes that occur with ageing can alter the expected clinical presentation of older persons after injury and their susceptibility to injury. Following major trauma, definitive control of hemorrhage remains essential for improving outcomes. In the initial assessment of an injured patient, it is important to consider whether the patient is taking anticoagulants or antiplatelets and if measures to promote hemostasis such as reversal are indicated. After hemostasis is achieved and bleeding has stopped, longer-term decisions to recommence antithrombotic agents can be challenging, especially in older people. In this review, we discuss one aspect of management for the older trauma patients in greater detail, that is, acute and longer-term management of antithrombotic therapy. As we consider the health needs of an ageing population, rise in elderly trauma and increasing use of antithrombotic therapy, the need for research in this area becomes more pressing to establish best practice and evidence-based care.
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Affiliation(s)
- Henna Wong
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust.,Radcliffe Department of Medicine, University of Oxford, Oxford BRC Haematology Theme
| | - Nicola Lovett
- Department of Geratology, Oxford University Hospitals NHS Foundation Trust
| | - Nicola Curry
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust
| | - Ku Shah
- Radcliffe Department of Medicine, University of Oxford, Oxford BRC Haematology Theme
| | - Simon J Stanworth
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust.,Radcliffe Department of Medicine, University of Oxford, Oxford BRC Haematology Theme.,Department of Haematology, NHS Blood and Transplant, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Low baseline (pre-injury) blood pressure predicts inpatient mortality in elderly trauma patients: A bi-institutional study. J Trauma Acute Care Surg 2017; 81:1142-1149. [PMID: 27244581 DOI: 10.1097/ta.0000000000001144] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The relationship between baseline (i.e., pre-injury) blood pressure and trauma outcomes in elderly patients is unknown. We therefore aimed to identify the independent impact of baseline systolic blood pressure (SBP) on inpatient mortality among elderly trauma patients. METHODS The 2004 to 2014 trauma registries of two Level I Trauma Centers were linked to electronic health records then reviewed to identify patients ≥65 years old with available baseline vital signs. Baseline SBP was defined as mean outpatient SBP within 2 years before injury. Trauma SBP was defined as first SBP reading after presentation for trauma. Baseline and Trauma SBP were classified as Low (<110 mm Hg), Normal (110-139 mm Hg), or High (≥140 mm Hg). Logistic multivariable regression models were constructed to assess the independent impact of Baseline SBP on inpatient mortality, controlling for demographics, comorbidities, injury mechanism/severity, and Trauma SBP. RESULTS Of 37,494 patient admissions, 4,233 met inclusion criteria. Median age was 81 years; 63.6% were female. Mortality was 5.39%. In unadjusted analyses, mortality rates were 11.01%, 5.28%, and 4.52% in the Low, Normal, and High Baseline SBP groups, respectively (p = 0.001). In multivariable analyses, patients with Low Baseline SBP had significantly increased mortality risk [OR 3.19 (95% CI 1.62-6.26), p = 0.001] compared to patients with Normal Baseline SBP, in particular when they presented with Low Trauma SBP (<110 mm Hg) [OR 6.14 (2.17-17.36), p = 0.001] or Normal Trauma SBP (110-139 mm Hg) [OR 3.87 (1.43-10.45), p = 0.008]. The mortality risk associated with Low Baseline SBP was particularly elevated among patients with a pre-existing diagnosis of hypertension [OR 4.78 (1.97-11.62), p = 0.001]. CONCLUSION Low baseline pre-injury SBP is independently associated with more than a threefold increase in inpatient mortality among elderly trauma patients and a fivefold increase in mortality risk among patients with pre-existing hypertension. Given that blood pressure control in the elderly offers a long-term survival advantage, the paradoxical finding of decreased survival after trauma warrants further investigation. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III.
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Miller M, Morris R, Fisicaro N, Curtis K. Epidemiology and outcomes of missing admission medication history in severe trauma: A retrospective study. Emerg Med Australas 2017; 29:563-569. [PMID: 28571103 DOI: 10.1111/1742-6723.12817] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 01/08/2017] [Accepted: 04/30/2017] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Anticoagulant and antiplatelet (ACAP) drugs are associated with increased mortality in trauma patients, therefore medication history on admission is important. Whether these medications are recorded on trauma admission has not been investigated, nor if absence of a medication history is associated with worse patient outcomes. METHODS We conducted a retrospective database review combining demographic and outcome data from the St George Hospital (Sydney) trauma registry with admission medication history in the electronic record. To contrast medications with a known increased risk (ACAP) to patients with unknown risk, patients were divided into three groups: those on ACAPs, no-ACAP if medication history was present and no-ACAP documented, or no-Hx if no medication history recorded. Inclusion criteria were aged >16 and Injury Severity Score (ISS) >12. Admission demographic data and outcome data were compared between all three groups. RESULTS Of 533 consecutive patients, 21% comprised the no-Hx group, while 22% were on an ACAP and 57% not on an ACAP. No-Hx patients had more severe head injuries and a younger median age compared to ACAP patients (42 vs 82 years old, P < 0.001). Mortality was higher for ACAP (24%; 95% CI 17-33%) compared to no-ACAP (11%; 95% CI 8-16%) or no-Hx patients (12%; 95% CI 7-20%) (P = 0.04). CONCLUSIONS While a large number of severe trauma patients were admitted without a medication history, no-Hx patients did not appear at increased risk of adverse outcomes. ACAP patients had a higher mortality compared to no-ACAP highlighting the vulnerability of this group.
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Affiliation(s)
- Matthew Miller
- Department of Anesthesia, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Richard Morris
- Department of Anaesthesia, St George Hospital, Sydney, New South Wales, Australia.,The University of New South Wales, Sydney, New South Wales, Australia
| | | | - Kate Curtis
- Sydney Nursing School, The University of Sydney, Sydney, New South Wales, Australia.,Trauma Service, St George Hospital, Sydney, New South Wales, Australia
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Appropriateness of Oral Anticoagulants for the Long-Term Treatment of Atrial Fibrillation in Older People: Results of an Evidence-Based Review and International Consensus Validation Process (OAC-FORTA 2016). Drugs Aging 2017; 34:499-507. [DOI: 10.1007/s40266-017-0466-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Llompart-Pou JA, Pérez-Bárcena J, Chico-Fernández M, Sánchez-Casado M, Raurich JM. Severe trauma in the geriatric population. World J Crit Care Med 2017; 6:99-106. [PMID: 28529911 PMCID: PMC5415855 DOI: 10.5492/wjccm.v6.i2.99] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 03/03/2017] [Accepted: 03/17/2017] [Indexed: 02/06/2023] Open
Abstract
Geriatric trauma constitutes an increasingly recognized problem. Aging results in a progressive decline in cellular function which leads to a loose of their capacity to respond to injury. Some medications commonly used in this population can mask or blunt the response to injury. Falls constitute the most common cause of trauma and the leading cause of trauma-related deaths in this population. Falls are complicated by the widespread use of antiplatelets and anticoagulants, especially in patients with brain injury. Under-triage is common in this population. Evaluation of frailty could be helpful to solve this issue. Appropriate triaging and early aggressive management with correction of coagulopathy can improve outcome. Limitation of care and palliative measures must be considered in cases with a clear likelihood of poor prognosis.
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Conway SE, Hwang AY, Ponte CD, Gums JG. Laboratory and Clinical Monitoring of Direct Acting Oral Anticoagulants: What Clinicians Need to Know. Pharmacotherapy 2017; 37:236-248. [DOI: 10.1002/phar.1884] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Susan E. Conway
- Department of Pharmacy: Clinical and Administrative Sciences; University of Oklahoma College of Pharmacy; Oklahoma City Oklahoma
| | - Andrew Y. Hwang
- Department of Pharmacotherapy and Translational Research; University of Florida College of Pharmacy; Gainesville Florida
| | - Charles D. Ponte
- Departments of Clinical Pharmacy and Family Medicine; West Virginia University Schools of Pharmacy and Medicine; Morgantown West Virginia
| | - John G. Gums
- Department of Pharmacotherapy and Translational Research; University of Florida College of Pharmacy; Gainesville Florida
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Abstract
Within the next 15 years, 1 in 5 Americans will be over age 65. $34 billion will be spent yearly on trauma care of this age group. This section covers situations in trauma unique to the geriatric population, who are often under-triaged and have significant injuries underestimated. Topics covered include age-related pathophysiological changes, underlying existing medical conditions and certain daily medications that increase the risk of serious injury in elderly trauma patients. Diagnostic evaluation of this group requires liberal testing, imaging, and a multidisciplinary team approach. Topics germane to geriatric trauma including hypothermia, elder abuse, and depression and suicide are also covered.
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Affiliation(s)
- Casper Reske-Nielsen
- Emergency Medicine, Boston Medical Center, Dowling 1 South, One Boston Medical Center Place, Boston, MA 02118, USA
| | - Ron Medzon
- Emergency Medicine, Boston Medical Center, Dowling 1 South, One Boston Medical Center Place, Boston, MA 02118, USA.
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Rosen T, Reisig C, LoFaso VM, Bloemen EM, Clark S, McCarthy TJ, Mtui EP, Flomenbaum NE, Lachs MS. Describing visible acute injuries: development of a comprehensive taxonomy for research and practice. Inj Prev 2016; 23:340-345. [PMID: 27913598 DOI: 10.1136/injuryprev-2016-042131] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 10/14/2016] [Accepted: 10/19/2016] [Indexed: 11/03/2022]
Abstract
BACKGROUND Little literature exists classifying and comprehensively describing intentional and unintentional acute injuries, which would be valuable for research and practice. In preparation for a study of injury patterns in elder abuse, our goal was to develop a comprehensive taxonomy of relevant types and characteristics of visible acute injuries and evaluate it in geriatric patients. METHODS We conducted an exhaustive review of the medical and forensic literature focusing on injury types, descriptions, patterns and analyses. We then prepared iteratively, through consensus with a multidisciplinary, national panel of elder abuse experts, a comprehensive classification system to describe these injuries. RESULTS We designed a three-step process to fully describe and classify visible acute injuries: (1) determining the type of injury, (2) assigning values to each of the characteristics common to all geriatric injuries and (3) assigning values to additional characteristics relevant for specific injuries. We identified nine unique types of visible injury and seven characteristics critical to describe all these injuries, including body region(s) and precise anatomic location(s). For each injury type, we identified two to seven additional critical characteristics, such as size, shape and cleanliness. We pilot tested it on 323 injuries on 83 physical elder abuse victims and 45 unintentional fall victims from our ongoing research to ensure that it would allow for the complete and accurate description of the full spectrum of visible injuries encountered and made modifications and refinements based on this experience. We then used the classification system to evaluate 947 injuries on 80 physical elder abuse victims and 195 unintentional fall victims to assess its practical utility. CONCLUSIONS Our comprehensive injury taxonomy systematically integrates and expands on existing forensic and clinical research. This new classification system may help standardise description of acute injuries and patterns among clinicians and researchers.
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Affiliation(s)
- Tony Rosen
- Division of Emergency Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Christopher Reisig
- Division of Emergency Medicine, Weill Cornell Medical College, New York, New York, USA.,Division of Geriatric and Palliative Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Veronica M LoFaso
- Division of Geriatric and Palliative Medicine, Weill Cornell Medical College, New York, New York, USA
| | | | - Sunday Clark
- Division of Emergency Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Thomas J McCarthy
- Division of Emergency Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Estomih P Mtui
- Department of Radiology, Weill Cornell Medical College, New York, New York, USA
| | - Neal E Flomenbaum
- Division of Emergency Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Mark S Lachs
- Division of Geriatric and Palliative Medicine, Weill Cornell Medical College, New York, New York, USA
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Abstract
PURPOSE OF REVIEW The landscape of trauma is changing due to an aging population. Geriatric patients represent an increasing number and proportion of trauma admissions and deaths. This review explores recent literature on geriatric trauma, including triage criteria, assessment of frailty, fall-related injury, treatment of head injury complicated by coagulopathy, goals of care, and the need for ongoing education of all surgeons in the care of the elderly. RECENT FINDINGS Early identification of high-risk geriatric patients is imperative to initiate early resuscitative efforts. Geriatric patients are typically undertriaged because of their baseline frailty being underappreciated; however, centers that see more geriatric patients do better. Rapid reversal of anticoagulation is important in preventing progression of brain injury. Anticipation of difficult disposition necessitates early involvement of physical therapy for rehabilitation and case management for appropriate placement. SUMMARY Optimal care of geriatric trauma patients will be based on the well established tenets of trauma resuscitation and injury repair, but with distinct elements that address the physiological and anatomical challenges presented by geriatric patients.
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Bahrmann P, Harms F, Schambeck CM, Wehling M, Flohr J. [New oral anticoagulants for prophylaxis of stroke : Results of an expert conference on practical use in geriatric patients]. Z Gerontol Geriatr 2016; 49:460-1. [PMID: 27357589 DOI: 10.1007/s00391-016-1095-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Philipp Bahrmann
- Institut für Biomedizin des Alterns, Friedrich-Alexander-Universität Erlangen-Nürnberg, Kobergerstr. 60, 90419, Nürnberg, Deutschland.
| | - Fred Harms
- European Health Care Foundation, Zug, Schweiz
| | | | - Martin Wehling
- Institut für Experimentelle und Klinische Pharmakologie und Toxikologie, Medizinische Fakultät Mannheim, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Deutschland
| | - Jürgen Flohr
- Allgemeinmedizinische Gemeinschaftspraxis, Leipzig, Deutschland
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