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The Effect of Time to International Normalized Ratio Reversal on Intracranial Hemorrhage Evolution in Patients With Traumatic Brain Injury. J Trauma Nurs 2018; 24:381-384. [PMID: 29117058 DOI: 10.1097/jtn.0000000000000330] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The incidence of geriatric traumatic brain injury (TBI) is increasing throughout the United States, with many of these patients taking anticoagulation (AC) medication. The purpose of this investigation was to determine the effect of time to international normalized ratio (INR) reversal on intracranial hemorrhage evolution in TBI patients taking prehospital AC medication. We hypothesized that rapid reversal of INR improves outcomes of head-injured patients taking AC medication. Admissions to a Level II trauma center between February 2011 and December 2013 were reviewed. Patients presenting with an initial INR of 2.0 or more, computed tomographic scan positive for intracranial hemorrhage, and INR reversal to less than 1.5 in hospital were included. Patients with nontraumatic intracranial hemorrhage were excluded. Reversal of INR was achieved using some combination of fresh frozen plasma, prothrombin complex concentrate, and vitamin K. A binary logistic regression model assessed the adjusted impact of rapid INR reversal on intracranial hemorrhage evolution. Significance was defined as p < .05. One hundred subjects were included. Four patients with nontraumatic intracranial hemorrhage were excluded, resulting in a final study population of 96 patients. The most common intracranial hemorrhage in the study population was subarachnoid hemorrhage (71.9%), followed by subdural hemorrhage (35.4%). Reversal of INR of less than 5 hr was not associated with intracranial hemorrhage evolution; however, reversal of less than 10 hr was found to be associated with a decreased odds ratio for intracranial hemorrhage evolution (p = .043). Rapid reversal of elevated INR levels (<10 hr) may decrease intracranial hemorrhage evolution in TBI patients taking prehospital AC medication.
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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: 1.3] [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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Puckett Y, Zhang K, Blasingame J, Lorenzana J, Parameswaran S, Brooks Md Facs SE, Baronia BC, Griswold J. Safest Time to Resume Oral Anticoagulation in Patients with Traumatic Brain Injury. Cureus 2018; 10:e2920. [PMID: 30186725 PMCID: PMC6122643 DOI: 10.7759/cureus.2920] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE There is no standard protocol to guide the optimal time to resume anti-clotting agents after traumatic brain injury (TBI) in patients with a continued indication for anticoagulation/antiplatelet therapy (AAT). This study develops baseline data supporting a future prospective cohort study. We predict that there will be significantly decreased adverse events when AAT is started on or after Day 7. METHODS A retrospective chart review of 256 patients was performed. Patients admitted to a level I trauma center in West Texas between January 1, 2009, and December 31, 2012, on anti-clotting agents (specifically acetylsalicylic acid, coumadin, and/or clopidogrel) and who suffered a TBI were included. Patient metrics included admission coagulation studies, type of TBI and treatment, and time to continuation of AAT. Outcomes were assessed using follow-up appointment data. The primary outcome was death (mortality). Secondary outcomes included myocardial infarction, stroke, re-bleed, venous thromboembolism, and pneumonia. RESULTS A total of 256 patients met the inclusion criteria. However, only 85 patients on AAT presented for the six-month follow-up. Time to AAT resumption varied from immediate to 31 days. Out of the 85 patients, 32 patients never resumed AAT, 32 patients were restarted on AAT medication in less than seven days, 10 patients restarted medication between seven and 14 days, and 11 patients restarted AAT in more than 14 days. Adverse events occurred most infrequently in the AAT group resuming therapy between seven and 14 days (10%). Adverse events were most prevalent in the AAT group that never resumed therapy (68.8%). CONCLUSION While most studies suggest that the safest time for resuming AAT lies between three and 10 days, our study revealed that adverse events were minimized in patients on AAT between seven and 9.5 days.
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Affiliation(s)
- Yana Puckett
- Surgery, Texas Tech University Health Sciences Center, Atlanta, USA
| | - Kelly Zhang
- Surgery, Texas Tech Health Sciences Center, Lubbock, USA
| | | | | | | | | | | | - John Griswold
- General Surgery, Texas Tech Health Sciences Center, Lubbock, USA
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Moyer JA, Shah J, Nowakowski K, Martin A, McNicholas A, Muller A, Fernandez FB, Ong AW. Does Antithrombotic Drug Use Mandate Trauma Team Activation in Awake Geriatric Patients with Intracranial Hemorrhage? Am Surg 2018. [DOI: 10.1177/000313481808400734] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Antithrombotic (anticoagulant [AC] and antiplatelet [AP]) drugs have been associated with mortality in geriatric patients with intracranial hemorrhage (ICH). It is unclear whether trauma team activation (TTA) in this cohort impacts outcome. Patients ≥65 years with a Glasgow Coma Scale of ≥13 and ICH over four years were included and were divided into three groups according to type of drug: group 1, AC with or without AP; group 2, AP only and; group 3, no AC or AP. The Rotterdam score was used to characterize the severity of CT findings. The primary outcome was inhospital mortality or transition to comfort measures. The secondary outcome was need for neurosurgical intervention within 48 hours. Logistic regression analysis was performed to evaluate for predictors of each outcome. Of 419 patients, 20.5, 50.4, and 29.1 per cent belonged to groups 1, 2, and 3, respectively, with TTA occurring in 39.5, 18.0, and 32.0 per cent of the respective groups. Within each group, there were no differences for the primary and secondary outcomes whether or not TTA was triggered. TTA patients had shorter times to CT (median, 20 minutes versus 80 minutes, P < 0.0001) and to administration of reversal agents (median, 105 minutes versus 255 minutes, P < 0.0001). Age, head-Abbreviated Injury Score, and the Rotterdam score were predictors for both outcomes by multivariable analysis, whereas antithrombotic drug use and TTA were not. In awake elderly patients on antithrombotic drugs found to have ICH, TTA expedited evaluation and treatment but was not associated with mortality benefit.
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Affiliation(s)
- Jeffrey A. Moyer
- Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania
| | - Jharna Shah
- Division of Neurocritical Care, Reading Hospital, Reading, Pennsylvania
| | - Kevin Nowakowski
- Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania
| | - Anthony Martin
- Section of Trauma and Acute Care Surgery, Department of Surgery, Reading Hospital, Reading, Pennsylvania
| | - Amanda McNicholas
- Section of Trauma and Acute Care Surgery, Department of Surgery, Reading Hospital, Reading, Pennsylvania
| | - Alison Muller
- Section of Trauma and Acute Care Surgery, Department of Surgery, Reading Hospital, Reading, Pennsylvania
| | - Forrest B. Fernandez
- Section of Trauma and Acute Care Surgery, Department of Surgery, Reading Hospital, Reading, Pennsylvania
| | - Adrian W. Ong
- Section of Trauma and Acute Care Surgery, Department of Surgery, Reading Hospital, Reading, Pennsylvania
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Llompart-Pou JA, Pérez-Bárcena J. Geriatric traumatic brain injury: An old challenge. Med Intensiva 2018; 43:44-46. [PMID: 29661567 DOI: 10.1016/j.medin.2018.02.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 02/14/2018] [Accepted: 02/18/2018] [Indexed: 10/17/2022]
Affiliation(s)
- J A Llompart-Pou
- Servei de Medicina Intensiva, Hospital Universitari Son Espases, Institut de Investigació Sanitària Illes Balears (IdISBa), Palma, Spain.
| | - J Pérez-Bárcena
- Servei de Medicina Intensiva, Hospital Universitari Son Espases, Institut de Investigació Sanitària Illes Balears (IdISBa), Palma, Spain
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Gardner RC, Dams-O'Connor K, Morrissey MR, Manley GT. Geriatric Traumatic Brain Injury: Epidemiology, Outcomes, Knowledge Gaps, and Future Directions. J Neurotrauma 2018; 35:889-906. [PMID: 29212411 PMCID: PMC5865621 DOI: 10.1089/neu.2017.5371] [Citation(s) in RCA: 244] [Impact Index Per Article: 40.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
This review of the literature on traumatic brain injury (TBI) in older adults focuses on incident TBI sustained in older adulthood ("geriatric TBI") rather than on the separate, but related, topic of older adults with a history of earlier-life TBI. We describe the epidemiology of geriatric TBI, the impact of comorbidities and pre-injury function on TBI risk and outcomes, diagnostic testing, management issues, outcomes, and critical directions for future research. The highest incidence of TBI-related emergency department visits, hospitalizations, and deaths occur in older adults. Higher morbidity and mortality rates among older versus younger individuals with TBI may contribute to an assumption of futility about aggressive management of geriatric TBI. However, many older adults with TBI respond well to aggressive management and rehabilitation, suggesting that chronological age and TBI severity alone are inadequate prognostic markers. Yet there are few geriatric-specific TBI guidelines to assist with complex management decisions, and TBI prognostic models do not perform optimally in this population. Major barriers in management of geriatric TBI include under-representation of older adults in TBI research, lack of systematic measurement of pre-injury health that may be a better predictor of outcome and response to treatment than age and TBI severity alone, and lack of geriatric-specific TBI common data elements (CDEs). This review highlights the urgent need to develop more age-inclusive TBI research protocols, geriatric TBI CDEs, geriatric TBI prognostic models, and evidence-based geriatric TBI consensus management guidelines aimed at improving short- and long-term outcomes for the large and growing geriatric TBI population.
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Affiliation(s)
- Raquel C. Gardner
- Department of Neurology, University of California San Francisco, and San Francisco VA Medical Center, San Francisco, California
- University of California San Francisco Weill Institute for Neurosciences, San Francisco, California
| | - Kristen Dams-O'Connor
- Department of Rehabilitation Medicine, Icahn School of Medicine at Mt. Sinai, New York, New York
| | - Molly Rose Morrissey
- Department of Neurosurgery, Brain and Spinal Injury Center, University of California San Francisco and Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Geoffrey T. Manley
- University of California San Francisco Weill Institute for Neurosciences, San Francisco, California
- Department of Neurosurgery, Brain and Spinal Injury Center, University of California San Francisco and Zuckerberg San Francisco General Hospital, San Francisco, California
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57
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Tollefsen MH, Vik A, Skandsen T, Sandrød O, Deane SF, Rao V, Moen KG. Patients with Moderate and Severe Traumatic Brain Injury: Impact of Preinjury Platelet Inhibitor or Warfarin Treatment. World Neurosurg 2018. [PMID: 29524716 DOI: 10.1016/j.wneu.2018.02.167] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE We aimed to examine the effect of preinjury antithrombotic medication on clinical and radiologic neuroworsening in traumatic brain injury (TBI) and study the effect on outcome. METHODS A total of 184 consecutive patients ≥50 years old with moderate and severe TBI admitted to a level 1 trauma center were included. Neuroworsening was assessed clinically by using the Glasgow Coma Scale (GCS) score and radiologically by using the Rotterdam CT score on repeated time points. Functional outcome was assessed with the Glasgow Outcome Scale Extended 6 months after injury. RESULTS The platelet inhibitor group (mean age, 77.3 years; n = 43) and the warfarin group (mean age, 73.2 years; n = 20) were significantly older than the nonuser group (mean age, 63.7 years; n = 121; P ≤ 0.001). In the platelet inhibitor group 74% and in the warfarin group, 85% were injured by falls. Platelet inhibitors were not significantly associated with clinical or radiologic neuroworsening (P = 0.37-1.00), whereas warfarin increased the frequency of worsening in GCS score (P = 0.001-0.028) and Rotterdam CT score (P = 0.004). In-hospital mortality was higher in the platelet inhibitor group (28%; P = 0.030) and the warfarin group (50%; P < 0.001) compared with the nonuser group (13%). Platelet inhibitors did not predict mortality or worse outcome after adjustment for age, preinjury disability, GCS score, and Rotterdam CT score, whereas warfarin predicted both mortality and worse outcome. CONCLUSIONS In this study of patients with moderate and severe TBI, preinjury platelet inhibitors did not cause neuroworsening or predict higher mortality or worse outcome. In contrast, preinjury warfarin caused neuroworsening and was an independent risk factor for mortality and worse outcome at 6 months. Hence, fall prevention and liberal use of computed tomography examinations is important in this patient group.
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Affiliation(s)
- Marie Hexeberg Tollefsen
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Anne Vik
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; Department of Neurosurgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Toril Skandsen
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; Department of Physical Medicine and Rehabilitation, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Oddrun Sandrød
- Department of Anesthesiology and Intensive Care Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Susan Frances Deane
- Department of Radiology and Nuclear Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Vidar Rao
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; Department of Neurosurgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Kent Gøran Moen
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; Department of Medical Imaging, Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger, Norway.
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58
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Management of the Trauma Patient on Direct Oral
Anticoagulants. CURRENT ANESTHESIOLOGY REPORTS 2018. [DOI: 10.1007/s40140-018-0253-x] [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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59
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Nishijima DK, Gaona SD, Waechter T, Maloney R, Blitz A, Elms AR, Farrales RD, Montoya J, Bair T, Howard C, Gilbert M, Trajano RP, Hatchel KM, Faul M, Bell JM, Coronado VC, Vinson DR, Ballard DW, Tancredi DJ, Garzon H, Mackey KE, Shahlaie K, Holmes JF. The Incidence of Traumatic Intracranial Hemorrhage in Head-Injured Older Adults Transported by EMS with and without Anticoagulant or Antiplatelet Use. J Neurotrauma 2018; 35:750-759. [PMID: 29108469 DOI: 10.1089/neu.2017.5232] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Field triage guidelines recommend transport of head-injured patients on anticoagulants or antiplatelets to a higher-level trauma center based on studies suggesting a high incidence of traumatic intracranial hemorrhage (tICH). We compared the incidence of tICH in older adults transported by emergency medical services (EMS) with and without anticoagulation or antiplatelet use and evaluated the accuracies of different sets of field triage criteria to identify tICH. This was a prospective, observational study at five EMS agencies and 11 hospitals. Older adults (≥55 years) with head trauma and transported by EMS from August 2015 to September 2016 were eligible. EMS providers completed standardized data forms and patients were followed through emergency department (ED) or hospital discharge. We enrolled 1304 patients; 1147 (88%) received a cranial computed tomography (CT) scan and were eligible for analysis. Four hundred thirty-four (33%) patients had anticoagulant or antiplatelet use and 112 (10%) had tICH. The incidence of tICH in patients with (11%, 95% confidence interval [CI] 8%-14%) and without (9%, 95% CI 7%-11%) anticoagulant or antiplatelet use was similar. Anticoagulant or antiplatelet use was not predictive of tICH on adjusted analysis. Steps 1-3 criteria alone were not sensitive in identifying tICH (27%), whereas the addition of anticoagulant or antiplatelet criterion improved sensitivity (63%). Other derived sets of triage criteria were highly sensitive (>98%) but poorly specific (<11%). The incidence of tICH was similar between patients with and without anticoagulant or antiplatelet use. Use of anticoagulant or antiplatelet medications was not a risk factor for tICH. We were unable to identify a set of triage criteria that was accurate for trauma center need.
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Affiliation(s)
- Daniel K Nishijima
- Department of Emergency Medicine, UC Davis School of Medicine, Sacramento, California
| | - Samuel D Gaona
- Department of Emergency Medicine, UC Davis School of Medicine, Sacramento, California
| | - Trent Waechter
- City of Sacramento Fire Department, Sacramento, California
| | - Ric Maloney
- Sacramento Metropolitan Fire Department, Sacramento, California
| | - Adam Blitz
- American Medical Response, Sacramento, California
| | - Andrew R Elms
- Kaiser Permanente South Sacramento Medical Center, Sacramento, California
| | | | | | - Troy Bair
- Cosumnes Community Services District Fire Department, Elk Grove, California
| | | | - Megan Gilbert
- Department of Emergency Medicine, UC Davis School of Medicine, Sacramento, California
| | - Renee P Trajano
- Department of Emergency Medicine, UC Davis School of Medicine, Sacramento, California
| | - Kaela M Hatchel
- Department of Emergency Medicine, UC Davis School of Medicine, Sacramento, California
| | - Mark Faul
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jeneita M Bell
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Victor C Coronado
- Centers for Disease Control and Prevention, Atlanta, Georgia.,Bridge to Heath, Atlanta, Georgia
| | - David R Vinson
- Kaiser Permanente Division of Research, Oakland, California.,Kaiser Permanente Sacramento Medical Center, Sacramento, California
| | - Dustin W Ballard
- Kaiser Permanente Division of Research, Oakland, California.,Kaiser Permanente San Rafael Medical Center, San Rafael, California
| | - Daniel J Tancredi
- Department of Emergency Medicine, UC Davis School of Medicine, Sacramento, California
| | - Hernando Garzon
- Department of Emergency Medicine, UC Davis School of Medicine, Sacramento, California
| | - Kevin E Mackey
- Kaiser Permanente South Sacramento Medical Center, Sacramento, California
| | - Kiarash Shahlaie
- Department of Neurological Surgery, UC Davis School of Medicine, Sacramento, California
| | - James F Holmes
- Department of Emergency Medicine, UC Davis School of Medicine, Sacramento, California
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60
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Maegele M, Grottke O, Schöchl H, Sakowitz OA, Spannagl M, Koscielny J. Direct Oral Anticoagulants in Emergency Trauma Admissions. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 113:575-82. [PMID: 27658470 DOI: 10.3238/arztebl.2016.0575] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 05/17/2016] [Accepted: 05/17/2016] [Indexed: 01/22/2023]
Abstract
BACKGROUND Direct (non-vitamin-K-dependent) oral anticoagulants (DOAC) are given as an alternative to vitamin K antagonists (VKA) to prevent stroke and embolic disease in patients with atrial fibrillation that is not due to pathology of the heart valves. Fatal hemorrhage is rarer when DOACs are given (nonvalvular atrial fibrillation: odds ratio [OR] 0.68; 95% confidence interval [95% CI: 0.48; 0.96], and venous thromboembolism: OR 0.54; [0.22; 1.32]). 48% of emergency trauma patients need an emergency operation or early surgery. Clotting disturbances elevate the mortality of such patients to 43%, compared to 17% in patients without a clotting disturbance. This underscores the impor tance of the proper, targeted treatment of trauma patients who are aking DOAC. METHODS This review is based on articles retrieved by a selective search in PubMed and on a summary of expert opinion and the recommendations of the relevant medical specialty societies. RESULTS Peak DOAC levels are reached 2-4 hours after the drug is taken. In patients with normal renal and hepatic function, no drug accumulation, and no drug interactions, the plasma level of DOAC 24 hours after administration is generally too low to cause any clinically relevant risk of bleeding. The risk of drug accumulation is higher in patients with renal dysfunction (creatinine clearance [CrCl] of 30 mL/min or less). Dabigatran levels can be estimated from the thrombin time, ecarin clotting time, and diluted thrombin time, while levels of factor Xa inhibitors can be estimated by means of calibrated chromogenic anti-factor Xa activity tests. Routine clotting studies do not reliably reflect the anticoagulant activity of DOAC. Surgery should be postponed, if possible, until at least 24-48 hours after the last dose of DOAC. For patients with mild, non-life threatening hemorrhage, it suffices to discontinue DOAC; for patients with severe hemorrhage, there are special treatment algorithms that should be followed. CONCLUSION DOACs in the setting of hemorrhage are a clinical challenge in the traumatological emergency room because of the inadequate validity of the relevant laboratory tests. An emergency antidote is now available only for dabigatran.
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Affiliation(s)
- Marc Maegele
- Department of Trauma and Orthopedic Sugery, Cologne-Merheim Medical Center (CMMC), Witten/Herdecke University, Cologne and Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University, Campus Cologne-Merheim, Cologne, Experimental Hemostaseology, Department of Anesthesiology, University Hospital RWTH Aachen, Aachen, Department of Anesthesiology and Intensive Care Medicine, AUVA Emergency Hospital, Salzburg (Austria), Department of Neurosurgery, Ludwigsburg Hospital, Ludwigsburg, Department of Anesthesiology, Ludwig Maximilian University of Munich, Munich, Institute for Transfusion Medicine, Charité University Medicine Berlin, Berlin
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61
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Sumiyoshi K, Hayakawa T, Yatsushige H, Shigeta K, Momose T, Enomoto M, Sato S, Takasato Y. Outcome of traumatic brain injury in patients on antiplatelet agents: a retrospective 20-year observational study in a single neurosurgery unit. Brain Inj 2017; 31:1445-1454. [DOI: 10.1080/02699052.2017.1377349] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Kyoko Sumiyoshi
- Division of Neurosurgery, National Hospital Organization Disaster Medical Center, Tachikawa, Tokyo, Japan
| | - Takanori Hayakawa
- Division of Neurosurgery, National Hospital Organization Disaster Medical Center, Tachikawa, Tokyo, Japan
| | - Hiroshi Yatsushige
- Division of Neurosurgery, National Hospital Organization Disaster Medical Center, Tachikawa, Tokyo, Japan
| | - Keigo Shigeta
- Division of Neurosurgery, National Hospital Organization Disaster Medical Center, Tachikawa, Tokyo, Japan
| | - Toshiya Momose
- Division of Neurosurgery, National Hospital Organization Disaster Medical Center, Tachikawa, Tokyo, Japan
| | - Masaya Enomoto
- Division of Neurosurgery, National Hospital Organization Disaster Medical Center, Tachikawa, Tokyo, Japan
| | - Shin Sato
- Division of Neurosurgery, National Hospital Organization Disaster Medical Center, Tachikawa, Tokyo, Japan
| | - Yoshio Takasato
- Division of Neurosurgery, National Hospital Organization Disaster Medical Center, Tachikawa, Tokyo, Japan
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62
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Novel oral anticoagulants and trauma: The results of a prospective American Association for the Surgery of Trauma Multi-Institutional Trial. J Trauma Acute Care Surg 2017; 82:827-835. [PMID: 28431413 DOI: 10.1097/ta.0000000000001414] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The number of anticoagulated trauma patients is increasing. Trauma patients on warfarin have been found to have poor outcomes, particularly after intracranial hemorrhage (ICH). However, the effect of novel oral anticoagulants (NOAs) on trauma outcomes is unknown. We hypothesized that patients on NOAs would have higher rates of ICH, ICH progression, and death compared with patients on traditional anticoagulant and antiplatelet agents. METHODS This was a prospective observational trial across 16 trauma centers. Inclusion criteria was any trauma patient admitted on aspirin, clopidogrel, warfarin, dabigatran, rivaroxaban, or apixaban. Demographic data, admission vital signs, mechanism of injury, injury severity scores, laboratory values, and interventions were collected. Outcomes included ICH, progression of ICH, and death. RESULTS A total of 1,847 patients were enrolled between July 2013 and June 2015. Mean age was 74.9 years (SD ± 13.8), 46% were female, 77% were non-Hispanic white. At least one comorbidity was reported in 94% of patients. Blunt trauma accounted for 99% of patients, and the median Injury Severity Score was 9 (interquartile range, 4-14). 50% of patients were on antiplatelet agents, 33% on warfarin, 10% on NOAs, and 7% on combination therapy or subcutaneous agents.Patients taking NOAs were not at higher risk for ICH on univariate (24% vs. 31%) or multivariate analysis (incidence rate ratio, 0.78; confidence interval 0.61-1.01, p = 0.05). Compared with all other agents, patients on aspirin (90%, 81 mg; 10%, 325 mg) had the highest rate (35%) and risk (incidence rate ratio, 1.27; confidence interval, 1.13-1.43; p < 0.001) of ICH. Progression of ICH occurred in 17% of patients and was not different between medication groups. Study mortality was 7% and was not significantly different between groups on univariate or multivariate analysis. CONCLUSION Patients on NOAs were not at higher risk for ICH, ICH progression, or death. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III.
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63
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Stocchetti N, Carbonara M, Citerio G, Ercole A, Skrifvars MB, Smielewski P, Zoerle T, Menon DK. Severe traumatic brain injury: targeted management in the intensive care unit. Lancet Neurol 2017; 16:452-464. [PMID: 28504109 DOI: 10.1016/s1474-4422(17)30118-7] [Citation(s) in RCA: 230] [Impact Index Per Article: 32.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 03/20/2017] [Accepted: 03/27/2017] [Indexed: 12/11/2022]
Abstract
Severe traumatic brain injury (TBI) is currently managed in the intensive care unit with a combined medical-surgical approach. Treatment aims to prevent additional brain damage and to optimise conditions for brain recovery. TBI is typically considered and treated as one pathological entity, although in fact it is a syndrome comprising a range of lesions that can require different therapies and physiological goals. Owing to advances in monitoring and imaging, there is now the potential to identify specific mechanisms of brain damage and to better target treatment to individuals or subsets of patients. Targeted treatment is especially relevant for elderly people-who now represent an increasing proportion of patients with TBI-as preinjury comorbidities and their therapies demand tailored management strategies. Progress in monitoring and in understanding pathophysiological mechanisms of TBI could change current management in the intensive care unit, enabling targeted interventions that could ultimately improve outcomes.
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Affiliation(s)
- Nino Stocchetti
- Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Department of Anaesthesia and Critical Care, Neuroscience Intensive Care Unit, Milan, Italy; University of Milan, Department of Pathophysiology and Transplants, Milan, Italy.
| | - Marco Carbonara
- Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Department of Anaesthesia and Critical Care, Neuroscience Intensive Care Unit, Milan, Italy
| | - Giuseppe Citerio
- University of Milan-Bicocca, School of Medicine and Surgery, Milan, Italy; San Gerardo Hospital, Neurointensive Care, ASST, Monza, Italy
| | - Ari Ercole
- Addenbrooke's Hospital, Division of Anaesthesia, University of Cambridge, Cambridge, UK
| | - Markus B Skrifvars
- Monash University, Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Melbourne, VIC, Australia; University of Helsinki and Helsinki University Hospital, Division of Intensive Care, Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki, Finland
| | - Peter Smielewski
- University of Cambridge Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge, UK
| | - Tommaso Zoerle
- Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Department of Anaesthesia and Critical Care, Neuroscience Intensive Care Unit, Milan, Italy
| | - David K Menon
- Addenbrooke's Hospital, Division of Anaesthesia, University of Cambridge, Cambridge, UK
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Ang D, Kurek S, Mckenney M, Norwood S, Kimbrell B, Barquist E, Liu H, O'Dell A, Ziglar M, Hurst J. Outcomes of Geriatric Trauma Patients on Preinjury Anticoagulation: A Multicenter Study. Am Surg 2017. [DOI: 10.1177/000313481708300614] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Outpatient anticoagulation in the geriatric trauma patient is a challenging clinical problem. The aim of this study is to determine clinical outcomes associated with class of preinjury anticoagulants (PA) used by this population. This is a multicenter retrospective cohort study among four Level II trauma centers. A total of 1642 patients were evaluated; 684 patients were on anticoagulation and 958 patients were not. Patients on PA were compared with those who were not. Drug classes were divided into thromboxane A2 inhibitors, vitamin K factor-dependent inhibitors, antithrombin III activation, platelet P2Y12 inhibitors, and thrombin inhibitors. Multivariate regression was used to adjust for age, gender, race, mechanism of injury, and Injury Severity Score. No single or combination of anticoagulation agents had a significant association with mortality; however, there were positive trends toward increased mortality were noted for all antiplatelet groups involving thromboxane A2 inhibitors and platelet P2Y12 inhibitors classes. The likelihood of complications was significantly higher with platelet P2Y12 inhibitors adjusted odds ratio (aOR) 2.39 [95% confidence interval (CI) 1.32, 4.3]. The likelihood of blood transfusion was increased with vitamin K inhibitors aOR 2.89 (95% CI 1.3, 6.5), P2Y12 inhibitors aOR 2.76 (95% CI 1.12, 6.76), and combined thromboxane A2 and P2Y12 inhibitors aOR 2.89 (95% CI 1.13, 7.46). P2Y12 inhibitors were also more likely associated with traumatic brain injury aOR 2.16 (95% CI 1.01, 4.6). All classes of PA were associated with solid organ injury. There were no significant differences in the use of antiplatelet agents between patients with major indications for PA and those without major indications. Geriatric trauma patients on outpatient anticoagulants have a higher likelihood of developing complications, packed red blood cell transfusions, traumatic brain injury, and solid organ injury. Attention should be paid to patients on platelet P2Y12 inhibitors, vitamin K inhibitors, and thromboxane A2 inhibitor agents combined with platelet P2Y12 inhibitors. Opportunities exist to address the use of antiplatelet agents among patients without major indications to improve patient outcomes.
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Affiliation(s)
- Darwin Ang
- University of South Florida, Department of Surgery, Tampa, Florida
- Ocala Health System, Ocala, Florida
| | - Stan Kurek
- University of South Florida, Department of Surgery, Tampa, Florida
- Lawnwood Medical Center, Fort Pierce, Florida
| | - Mark Mckenney
- University of South Florida, Department of Surgery, Tampa, Florida
- Ocala Health System, Ocala, Florida
| | - Scott Norwood
- University of South Florida, Department of Surgery, Tampa, Florida
- Bayonet Point Medical Center, Hudson, Florida
| | - Brian Kimbrell
- University of South Florida, Department of Surgery, Tampa, Florida
- Blake Medical Center, Bradenton, Florida
| | - Erik Barquist
- University of South Florida, Department of Surgery, Tampa, Florida
- Central Florida Medical Center, Sanford, Florida
| | - Huazhi Liu
- University of South Florida, Department of Surgery, Tampa, Florida
- Ocala Health System, Ocala, Florida
| | - Annette O'Dell
- University of South Florida, Department of Surgery, Tampa, Florida
| | | | - James Hurst
- University of South Florida, Department of Surgery, Tampa, Florida
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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: 0.6] [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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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: 66] [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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Koscielny J, Rosenthal C, von Heymann C. Nicht-Vitamin-K-abhängige orale Antikoagulanzien. Notf Rett Med 2017. [DOI: 10.1007/s10049-017-0289-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Scantling D, Fischer C, Gruner R, Teichman A, McCracken B, Eakins J. The role of delayed head CT in evaluation of elderly blunt head trauma victims taking antithrombotic therapy. Eur J Trauma Emerg Surg 2017; 43:741-746. [PMID: 28439613 DOI: 10.1007/s00068-017-0793-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 04/18/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Increasing active longevity has created an increasing surge of elderly trauma patients. The majority of these patients suffer blunt trauma and many are taking antithrombotic agents. The literature is mixed regarding the utility of routine repeat head CT in patients taking antithrombotic medications with a GCS of 15 and initial negative head CT. We hypothesized that scheduled delayed CT head 12 h after admission (D-CTH) in elderly blunt trauma victims would not identify clinically significant new hemorrhages or change management. METHODS A retrospective chart review using our institutional trauma registry of patients ≥65 years sustaining blunt head injuries from 2010 to 2012 was performed. By hospital protocol, all such patients on antithrombotic therapy receive a routine D-CTH. All of these patients were included. Demographics, injuries, medications, laboratory values, LOS, mental status, and management were analyzed. RESULTS Of the 234 patients meeting inclusion criteria, 8 initially were identified as having D-ICH. Upon further review, five patients had the same findings on both initial and delayed CT scans and one patient was determined to actually have had a hemorrhage stroke. Ultimately, only two patients (0.85%, 95% CI 0.1-3.1%) had new ICH discovered on D-CTH. None of the patients on warfarin demonstrated any new injury on D-CTH (95% CI ≤ 4.6%). Only one patient taking aspirin as a sole agent had a delayed injury on D-CTH (1.1%, 95% CI 0-4.2%). The remaining patient was taking a combination of aspirin and clopidogrel representing 2.2% of 45 patients on combination therapy (95% CI 0.1-11.8%). Only two patients taking a direct thrombin inhibitor (dabigatran) met inclusion criteria and neither endured a bleed (95% CI ≤ 77.6%). Further analysis revealed no cases with clinical changes or surgical intervention for new ICH on delayed imaging. No inference could be made to predict which patients would suffer D-ICH. CONCLUSIONS D-CTH in elderly trauma patients taking antithrombotic agents shows no statistically significant or clinical benefit for diagnosing delayed intracranial hemorrhage after minor head injury. In those with delayed imaging showing new ICH, management was not significantly altered. Not enough data were available to predict which patients would develop D-ICH, even if asymptomatic.
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Affiliation(s)
- D Scantling
- Hahnemann University Hospital, Drexel University College of Medicine, 215 N 15th St MS 413, Philadelphia, PA, 19102, USA.
| | - C Fischer
- Hahnemann University Hospital, Drexel University College of Medicine, 215 N 15th St MS 413, Philadelphia, PA, 19102, USA
| | - R Gruner
- Hahnemann University Hospital, Drexel University College of Medicine, 215 N 15th St MS 413, Philadelphia, PA, 19102, USA
| | - A Teichman
- Hahnemann University Hospital, Drexel University College of Medicine, 215 N 15th St MS 413, Philadelphia, PA, 19102, USA
| | - B McCracken
- Hahnemann University Hospital, Drexel University College of Medicine, 215 N 15th St MS 413, Philadelphia, PA, 19102, USA
| | - J Eakins
- AtlantiCare Regional Medical Center, 1925 Pacific Avenue, Atlantic City, NJ, 08401, USA
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Newgard CD, Platts-Mills TF. Can an Out-of-Hospital Medication History Save Lives for Injured Older Adults? Ann Emerg Med 2017; 70:139-141. [PMID: 28363397 DOI: 10.1016/j.annemergmed.2017.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Craig D Newgard
- Center for Policy and Research in Emergency Medicine, the Department of Emergency Medicine, Oregon Health & Science University, Portland, OR.
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70
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Routine neurosurgical consultation is not necessary in mild blunt traumatic brain injury. J Trauma Acute Care Surg 2017; 82:776-780. [DOI: 10.1097/ta.0000000000001388] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Management of anticoagulation with rivaroxaban in trauma and acute care surgery. J Trauma Acute Care Surg 2017; 82:542-549. [DOI: 10.1097/ta.0000000000001340] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Nishijima DK, Gaona SD, Waechter T, Maloney R, Bair T, Blitz A, Elms AR, Farrales RD, Howard C, Montoya J, Bell JM, Faul M, Vinson DR, Garzon H, Holmes JF, Ballard DW. Out-of-Hospital Triage of Older Adults With Head Injury: A Retrospective Study of the Effect of Adding "Anticoagulation or Antiplatelet Medication Use" as a Criterion. Ann Emerg Med 2017; 70:127-138.e6. [PMID: 28238499 DOI: 10.1016/j.annemergmed.2016.12.018] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Revised: 12/08/2016] [Accepted: 12/14/2016] [Indexed: 01/09/2023]
Abstract
STUDY OBJECTIVE Field triage guidelines recommend that emergency medical services (EMS) providers consider transport of head-injured older adults with anticoagulation use to trauma centers. However, the triage patterns and the incidence of intracranial hemorrhage or neurosurgery in these patients are unknown. Our objective is to describe the characteristics and outcomes of older adults with head trauma who are transported by EMS, particularly for patients who do not meet physiologic, anatomic, or mechanism-of-injury (steps 1 to 3) field triage criteria but are receiving anticoagulant or antiplatelet medications. METHODS This was a retrospective study at 5 EMS agencies and 11 hospitals (4 trauma centers, 7 nontrauma centers). Patients aged 55 years or older with head trauma who were transported by EMS were included. The primary outcome was the presence of intracranial hemorrhage. The secondary outcome was a composite measure of inhospital death or neurosurgery. RESULTS Of the 2,110 patients included, 131 (6%) had intracranial hemorrhage and 41 (2%) had inhospital death or neurosurgery. There were 162 patients (8%) with steps 1 to 3 criteria. Of the remaining 1,948 patients without steps 1 to 3 criteria, 566 (29%) had anticoagulant or antiplatelet use. Of these patients, 52 (9%) had traumatic intracranial hemorrhage and 15 (3%) died or had neurosurgery. The sensitivity (adjusted for clustering by EMS agency) of steps 1 to 3 criteria was 19.8% (26/131; 95% confidence interval [CI] 5.5% to 51.2%) for identifying traumatic intracranial hemorrhage and 34.1% (14/41; 95% CI 9.9% to 70.1%) for death or neurosurgery. The additional criterion of anticoagulant or antiplatelet use improved the sensitivity for intracranial hemorrhage (78/131; 59.5%; 95% CI 42.9% to 74.2%) and death or neurosurgery (29/41; 70.7%; 95% CI 61.0% to 78.9%). CONCLUSION Relatively few patients met steps 1 to 3 triage criteria. For individuals who did not have steps 1 to 3 criteria, nearly 30% had anticoagulant or antiplatelet use. A relatively high proportion of these patients had intracranial hemorrhage, but a much smaller proportion died or had neurosurgery during hospitalization. Use of steps 1 to 3 triage criteria alone is not sufficient in identifying intracranial hemorrhage and death or neurosurgery in this patient population. The additional criterion of anticoagulant or antiplatelet use improves the sensitivity of the instrument, with only a modest decrease in specificity.
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Affiliation(s)
- Daniel K Nishijima
- Department of Emergency Medicine, UC Davis School of Medicine, Sacramento, CA.
| | - Samuel D Gaona
- Department of Emergency Medicine, UC Davis School of Medicine, Sacramento, CA
| | | | - Ric Maloney
- Sacramento Metropolitan Fire Department, Sacramento, CA
| | - Troy Bair
- Cosumnes Community Services District Fire Department, Elk Grove, CA
| | - Adam Blitz
- American Medical Response, Sacramento, CA
| | - Andrew R Elms
- Kaiser Permanente South Sacramento Medical Center, Sacramento, CA
| | | | | | | | | | - Mark Faul
- Centers for Disease Control and Prevention, Atlanta, GA
| | - David R Vinson
- Kaiser Permanente Sacramento Medical Center, Sacramento, CA
| | | | - James F Holmes
- Department of Emergency Medicine, UC Davis School of Medicine, Sacramento, CA
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Scheetz LJ, Horst MA, Arbour RB. Early neurological deterioration in older adults with traumatic brain injury. Int Emerg Nurs 2017; 37:29-34. [PMID: 28082072 DOI: 10.1016/j.ienj.2016.11.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 11/14/2016] [Accepted: 11/26/2016] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Traumatic brain injuries (TBIs) and resulting fatalities among older adults increased considerably in recent years. Neurological deterioration often goes unrecognized at the injury scene and patients arrive at emergency departments with near-normal Glasgow Coma Scale (GCS) scores. This study examined the proportion of older adults experiencing early neurological deterioration (prehospital to emergency department), associated factors, and association of the magnitude of neurological deterioration with TBI severity. METHODS This secondary analysis of National Trauma Data Bank Research Datasets included patients who were age ⩾65, sustained a TBI, and transported from the injury scene to an emergency department. Data analysis included chi-square analysis, t-tests, and logistic regression. Long-term anticoagulant/antiplatelet therapy was not associated with deterioration. RESULTS Of the sample of 91,886 patients, 13,913 (15.1%) experienced early neurological deterioration. Adjusting for covariates, age, gender, head AISmax injury severity, and probability of death were associated with early deterioration. Patients with severe and critical head injuries had the highest odds of early neurological deterioration (OR=1.41 [CI=1.22-1.63] and OR=1.98 [CI=1.63-2.40], p<0.001). DISCUSSION/CONCLUSIONS Prehospital providers, nurses, physicians, and other providers have opportunities to optimize outcomes from older adult TBI through early recognition of neurological deterioration, rapid transport to facilities for definitive treatment, and targeted rehabilitation.
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Affiliation(s)
- Linda J Scheetz
- Department of Nursing, Lehman College and The Graduate Center, City University of New York, 250 Bedford Park Blvd West, Bronx, NY 10468, United States.
| | - Michael A Horst
- Research Data & Biostatistics, Lancaster General Research Institute, Lancaster General Hospital, Lancaster, PA, United States
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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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Catapano JS, Chapman AJ, Horner LP, Lu M, Fraser DR, Fildes JJ. Pre-injury polypharmacy predicts mortality in isolated severe traumatic brain injury patients. Am J Surg 2016; 213:1104-1108. [PMID: 27596800 DOI: 10.1016/j.amjsurg.2016.07.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 07/11/2016] [Accepted: 07/14/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND The use of 5 or more medications is defined as polypharmacy (PPM). The clinical impact of PPM on the isolated severe traumatic brain injury (TBI) patient has not been defined. METHODS A retrospective cohort study was performed at our academic level 1 trauma center examining patients with isolated TBI. Pre-injury medications were reviewed, and inhospital mortality was the primary measured outcome. RESULTS There were 698 patients with an isolated TBI over the 5-year study period; 177 (25.4%) patients reported pre-injury PPM. There were 18 (10.2%) deaths in the PPM cohort and 24 (4.6%) deaths in the non-PPM cohort (P < .0001). Stepwise logistic regression analysis revealed a 2.3 times greater risk of mortality in the PPM patients (P = .019). CONCLUSIONS Pre-injury PPM increases mortality in patients with isolated severe TBI. This knowledge may provide opportunities for intervention in this population.
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Affiliation(s)
- Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA.
| | - Alistair J Chapman
- Department of Surgery, University of Nevada School of Medicine, Las Vegas, NV, USA
| | - Lance P Horner
- Department of Neurosurgery, University of Nevada School of Medicine, Reno, NV, USA
| | - Minggen Lu
- Department of Community Health Sciences, University of Nevada, Reno, NV, USA
| | - Douglas R Fraser
- Department of Surgery, University of Nevada School of Medicine, Las Vegas, NV, USA
| | - John J Fildes
- Department of Surgery, University of Nevada School of Medicine, Las Vegas, NV, USA
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Abou-Abbass H, Bahmad H, Abou-El-Hassan H, Zhu R, Zhou S, Dong X, Hamade E, Mallah K, Zebian A, Ramadan N, Mondello S, Fares J, Comair Y, Atweh S, Darwish H, Zibara K, Mechref Y, Kobeissy F. Deciphering glycomics and neuroproteomic alterations in experimental traumatic brain injury: Comparative analysis of aspirin and clopidogrel treatment. Electrophoresis 2016; 37:1562-76. [PMID: 27249377 PMCID: PMC4963819 DOI: 10.1002/elps.201500583] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Revised: 02/09/2016] [Accepted: 02/11/2016] [Indexed: 12/16/2022]
Abstract
As populations age, the number of patients sustaining traumatic brain injury (TBI) and concomitantly receiving preinjury antiplatelet therapy such as aspirin (ASA) and clopidogrel (CLOP) is rising. These drugs have been linked with unfavorable clinical outcomes following TBI, where the exact mechanism(s) involved are still unknown. In this novel work, we aimed to identify and compare the altered proteome profile imposed by ASA and CLOP when administered alone or in combination, prior to experimental TBI. Furthermore, we assessed differential glycosylation PTM patterns following experimental controlled cortical impact model of TBI, ASA, CLOP, and ASA + CLOP. Ipsilateral cortical brain tissues were harvested 48 h postinjury and were analyzed using an advanced neuroproteomics LC-MS/MS platform to assess proteomic and glycoproteins alterations. Of interest, differential proteins pertaining to each group (22 in TBI, 41 in TBI + ASA, 44 in TBI + CLOP, and 34 in TBI + ASA + CLOP) were revealed. Advanced bioinformatics/systems biology and clustering analyses were performed to evaluate biological networks and protein interaction maps illustrating molecular pathways involved in the experimental conditions. Results have indicated that proteins involved in neuroprotective cellular pathways were upregulated in the ASA and CLOP groups when given separately. However, ASA + CLOP administration revealed enrichment in biological pathways relevant to inflammation and proinjury mechanisms. Moreover, results showed differential upregulation of glycoproteins levels in the sialylated N-glycans PTMs that can be implicated in pathological changes. Omics data obtained have provided molecular insights of the underlying mechanisms that can be translated into clinical bedside settings.
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Affiliation(s)
- Hussein Abou-Abbass
- Department of Biochemistry and Molecular Genetics, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
- Faculty of Medicine, Beirut Arab University, Beirut, Lebanon
| | - Hisham Bahmad
- Faculty of Medicine, Beirut Arab University, Beirut, Lebanon
- Department of Anatomy, Cell Biology and Physiological Sciences, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | | | - Rui Zhu
- Department of Chemistry and Biochemistry, Texas Tech University, Lubbock, TX, USA
| | - Shiyue Zhou
- Department of Chemistry and Biochemistry, Texas Tech University, Lubbock, TX, USA
| | - Xue Dong
- Department of Chemistry and Biochemistry, Texas Tech University, Lubbock, TX, USA
| | - Eva Hamade
- ER045—Laboratory of Stem Cells, DSST, Lebanese University, Beirut, Lebanon
- Department of Biology, Faculty of Sciences-I, Lebanese University, Beirut, Lebanon
| | - Khalil Mallah
- ER045—Laboratory of Stem Cells, DSST, Lebanese University, Beirut, Lebanon
- Department of Biology, Faculty of Sciences-I, Lebanese University, Beirut, Lebanon
| | - Abir Zebian
- Department of Biochemistry and Molecular Genetics, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Naify Ramadan
- Department of Biochemistry and Molecular Genetics, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | | | - Jawad Fares
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Youssef Comair
- Department of Surgery, Division of Neurosurgery, Lebanese American University, Beirut, Lebanon
| | - Samir Atweh
- Department of Neurology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Hala Darwish
- Faculty of Medicine-School of Nursing, American University of Beirut, New York, NY, USA
| | - Kazem Zibara
- ER045—Laboratory of Stem Cells, DSST, Lebanese University, Beirut, Lebanon
- Department of Biology, Faculty of Sciences-I, Lebanese University, Beirut, Lebanon
| | - Yehia Mechref
- Department of Chemistry and Biochemistry, Texas Tech University, Lubbock, TX, USA
| | - Firas Kobeissy
- Department of Biochemistry and Molecular Genetics, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
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Mercier E, Mitra B, Cameron PA. Challenges in assessment of the mild traumatic brain injured geriatric patient. Injury 2016; 47:985-7. [PMID: 27125183 DOI: 10.1016/j.injury.2016.04.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Eric Mercier
- School of Public Health and Preventive Medicine, Monash University, Australia; Emergency and Trauma Centre, The Alfred Hospital, Alfred Health, Australia; Department of General Family Medicine and Emergency Medicine, Laval University, Canada.
| | - Biswadev Mitra
- School of Public Health and Preventive Medicine, Monash University, Australia; Emergency and Trauma Centre, The Alfred Hospital, Alfred Health, Australia; National Trauma Research Institute, Melbourne, Australia
| | - Peter A Cameron
- School of Public Health and Preventive Medicine, Monash University, Australia; Emergency and Trauma Centre, The Alfred Hospital, Alfred Health, Australia; National Trauma Research Institute, Melbourne, Australia
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Hopp S, Albert-Weissenberger C, Mencl S, Bieber M, Schuhmann MK, Stetter C, Nieswandt B, Schmidt PM, Monoranu CM, Alafuzoff I, Marklund N, Nolte MW, Sirén AL, Kleinschnitz C. Targeting coagulation factor XII as a novel therapeutic option in brain trauma. Ann Neurol 2016; 79:970-82. [PMID: 27043916 PMCID: PMC5074329 DOI: 10.1002/ana.24655] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 03/17/2016] [Accepted: 03/27/2016] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Traumatic brain injury is a major global public health problem for which specific therapeutic interventions are lacking. There is, therefore, a pressing need to identify innovative pathomechanism-based effective therapies for this condition. Thrombus formation in the cerebral microcirculation has been proposed to contribute to secondary brain damage by causing pericontusional ischemia, but previous studies have failed to harness this finding for therapeutic use. The aim of this study was to obtain preclinical evidence supporting the hypothesis that targeting factor XII prevents thrombus formation and has a beneficial effect on outcome after traumatic brain injury. METHODS We investigated the impact of genetic deficiency of factor XII and acute inhibition of activated factor XII with a single bolus injection of recombinant human albumin-fused infestin-4 (rHA-Infestin-4) on trauma-induced microvascular thrombus formation and the subsequent outcome in 2 mouse models of traumatic brain injury. RESULTS Our study showed that both genetic deficiency of factor XII and an inhibition of activated factor XII in mice minimize trauma-induced microvascular thrombus formation and improve outcome, as reflected by better motor function, reduced brain lesion volume, and diminished neurodegeneration. Administration of human factor XII in factor XII-deficient mice fully restored injury-induced microvascular thrombus formation and brain damage. INTERPRETATION The robust protective effect of rHA-Infestin-4 points to a novel treatment option that can decrease ischemic injury after traumatic brain injury without increasing bleeding tendencies. Ann Neurol 2016;79:970-982.
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Affiliation(s)
- Sarah Hopp
- Department of Neurology, University Hospital of Würzburg, Würzburg, Germany.,Department of Neurosurgery, University Hospital of Würzburg, Würzburg, Germany
| | - Christiane Albert-Weissenberger
- Department of Neurology, University Hospital of Würzburg, Würzburg, Germany.,Department of Neurosurgery, University Hospital of Würzburg, Würzburg, Germany
| | - Stine Mencl
- Department of Neurology, University Hospital of Würzburg, Würzburg, Germany
| | - Michael Bieber
- Department of Neurology, University Hospital of Würzburg, Würzburg, Germany.,Comprehensive Heart Failure Center (DZHI), University Hospital of Würzburg, Würzburg, Germany
| | | | - Christian Stetter
- Department of Neurosurgery, University Hospital of Würzburg, Würzburg, Germany
| | - Bernhard Nieswandt
- Rudolf Virchow Center, German Research Society Research Center for Experimental Biomedicine, Julius Maximilian University, Würzburg, Germany
| | - Peter M Schmidt
- CSL Limited, Bio21 Molecular Science and Biotechnology Institute, Parkville, Victoria, Australia
| | - Camelia-Maria Monoranu
- Institute of Pathology, Department of Neuropathology, Comprehensive Cancer Center Mainfranken, Julius Maximilian University, Würzburg, Germany
| | - Irina Alafuzoff
- Department of Immunology, Uppsala University, Uppsala, Sweden.,Department of Pathology, Uppsala University, Uppsala, Sweden
| | - Niklas Marklund
- Department of Neuroscience, Neurosurgery, Uppsala University, Uppsala, Sweden
| | | | - Anna-Leena Sirén
- Department of Neurosurgery, University Hospital of Würzburg, Würzburg, Germany
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Yoshizawa J, Namiki J, Nishida Y, Kaneko Y, Hori S. Vitamin K, fresh frozen plasma, and platelet transfusion used to arrest progression of intracranial hemorrhage after traumatic brain injury in a patient taking anticoagulant and antiplatelet agents. Acute Med Surg 2016; 3:392-396. [PMID: 29123820 DOI: 10.1002/ams2.200] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 02/16/2016] [Indexed: 11/11/2022] Open
Abstract
Case An 89-year-old man fell from stairs and sustained head trauma. He was taking warfarin and aspirin. Upon arrival at our hospital, his Glasgow Coma Scale score was 14. Initial head computed tomography showed small acute subdural hematoma. We immediately administered vitamin K and ordered fresh-frozen plasma. Repeat computed tomography 3 and 6 h after trauma revealed the acute subdural hematoma had increased to 14 and 20 mm, respectively, and there were several new intracranial hemorrhages. Fresh-frozen plasma and platelet transfusion were initiated. Outcome Follow-up computed tomography revealed no further progression of intracranial hemorrhages, and the patient's consciousness did not deteriorate further. Conclusion Appropriate administration of vitamin K, fresh-frozen plasma, and platelets successfully arrested progression of traumatic intracranial hemorrhages in this patient taking anticoagulant/antiplatelet agents and may have averted brain surgery.
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Affiliation(s)
- Joe Yoshizawa
- Department of Emergency and Critical Care Medicine Keio University School of Medicine Shinjuku Tokyo Japan
| | - Jun Namiki
- Department of Emergency and Critical Care Medicine Keio University School of Medicine Shinjuku Tokyo Japan
| | - Yusho Nishida
- Department of Emergency and Critical Care Medicine Keio University School of Medicine Shinjuku Tokyo Japan
| | - Yasushi Kaneko
- Department of Emergency and Critical Care Medicine Keio University School of Medicine Shinjuku Tokyo Japan
| | - Shingo Hori
- Department of Emergency and Critical Care Medicine Keio University School of Medicine Shinjuku Tokyo Japan
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Sribnick EA, Hanfelt JJ, Dhall SS. A clinical scale to communicate surgical urgency for traumatic brain injury: A preliminary study. Surg Neurol Int 2015; 6:1. [PMID: 25657854 PMCID: PMC4310045 DOI: 10.4103/2152-7806.148541] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2014] [Accepted: 08/11/2014] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND While the Glasgow Coma Scale (GCS) provides a tool for evaluating traumatic brain injury (TBI) patients, there is no widely used scale that provides guidance for surgical management. This study introduces a scoring system that physicians potentially could use to determine and communicate the need for surgical decompression in TBI patients. The proposed system is designed to be both comprehensive and easy to use. METHODS The Surgical Intervention for Traumatic Injury (SITI) scale uses radiographic and clinical findings. Patients were graded based on their GCS: GCS >12 received 0 points, GCS 9-12 received 1 point, and GCS <9 received 2 points. An enlarged unilateral pupil added 2 points. Computed tomography findings were also graded: midline shift <5 mm received 0 points, 5-10 mm received 2 points, and >10 mm received 4 points. The presence of temporal pathology added 1 point, and epidural hematoma (EDH) ≥10 mm added 2 points. Retrospective analysis of 48 patients was then performed using the SITI scale. RESULTS Of the 48 patients reviewed, 24 patients underwent craniotomy and the other 24 were treated non-operatively. The mean SITI score was 5.7 (range 3-10) for operative patients and 2.5 (range 1-4) for non-operative patients. CONCLUSIONS The proposed SITI scale is designed to be a simple, objective system for assisting in communication between clinical services and for suggesting the need for surgical decompression for TBI. Based upon our initial review, a SITI score of 3 or less correlated with non-operative management and a score of 5 or greater correlated with operative management. Given the results of this study, we believe that further development and research of the SITI scale are warranted.
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Affiliation(s)
- Eric A. Sribnick
- Department of Neurosurgery, Emory University, 1365 Clifton Road NE, Building B Suite 2200
| | - John J. Hanfelt
- Department of Biostatistics and Bioinformatics, Emory University, Rollins School of Public Health, 1518 Clifton Road NE Atlanta, GA 30322
| | - Sanjay S. Dhall
- Department of Neurosurgical Surgery, University of California at San Francisco, 505 Parnassus Ave., Room 779 M San Francisco, CA 94143-0112
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Dunham CM, Hoffman DA, Huang GS, Omert LA, Gemmel DJ, Merrell R. Traumatic intracranial hemorrhage correlates with preinjury brain atrophy, but not with antithrombotic agent use: a retrospective study. PLoS One 2014; 9:e109473. [PMID: 25279785 PMCID: PMC4184859 DOI: 10.1371/journal.pone.0109473] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Accepted: 09/01/2014] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The impact of antithrombotic agents (warfarin, clopidogrel, ASA) on traumatic brain injury outcomes is highly controversial. Although cerebral atrophy is speculated as a risk for acute intracranial hemorrhage, there is no objective literature evidence. MATERIALS AND METHODS This is a retrospective, consecutive investigation of patients with signs of external head trauma and age ≥60 years. Outcomes were correlated with antithrombotic-agent status, coagulation test results, admission neurologic function, and CT-based cerebral atrophy dimensions. RESULTS Of 198 consecutive patients, 36% were antithrombotic-negative and 64% antithrombotic-positive. ASA patients had higher arachidonic acid inhibition (p = 0.04) and warfarin patients had higher INR (p<0.001), compared to antithrombotic-negative patients. Antithrombotic-positive intracranial hemorrhage rate (38.9%) was similar to the antithrombotic-negative rate (31.9%; p = 0.3285). Coagulopathy was not present on the ten standard coagulation, thromboelastography, and platelet mapping tests with intracranial hemorrhage and results were similar to those without hemorrhage (p≥0.1354). Hemorrhagic-neurologic complication (intracranial hemorrhage progression, need for craniotomy, neurologic deterioration, or death) rates were similar for antithrombotic-negative (6.9%) and antithrombotic-positive (8.7%; p = 0.6574) patients. The hemorrhagic-neurologic complication rate was increased when admission major neurologic dysfunction was present (63.2% versus 2.2%; RR = 28.3; p<0.001). Age correlated inversely with brain parenchymal width (p<0.001) and positively with lateral ventricular width (p = 0.047) and cortical atrophy (p<0.001). Intracranial hemorrhage correlated with cortical atrophy (p<0.001) and ventricular width (p<0.001). CONCLUSIONS Intracranial hemorrhage is not associated with antithrombotic agent use. Intracranial hemorrhage patients have no demonstrable coagulopathy. The association of preinjury brain atrophy with acute intracranial hemorrhage is a novel finding. Contrary to antithrombotic agent status, admission neurologic abnormality is a predictor of adverse post-admission outcomes. Study findings indicate that effective hemostasis is maintained with antithrombotic therapy.
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Affiliation(s)
- C. Michael Dunham
- Trauma/Critical Care Services, St. Elizabeth Health Center, Youngstown, Ohio, United States of America
- * E-mail:
| | - David A. Hoffman
- Division of Cardiology, St. Elizabeth Health Center, Youngstown, Ohio, United States of America
| | - Gregory S. Huang
- Trauma/Critical Care Services, St. Elizabeth Health Center, Youngstown, Ohio, United States of America
| | - Laurel A. Omert
- CSL Behring, King of Prussia, Pennsylvania, United States of America
| | - David J. Gemmel
- Medical Education and Statistics, St. Elizabeth Health Center, Youngstown, Ohio, United States of America
| | - Renee Merrell
- Trauma/Critical Care Services, St. Elizabeth Health Center, Youngstown, Ohio, United States of America
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Anderson K, Jupiter DC, Abernathy SW, Frazee RC. Should clopidogrel be discontinued before laparoscopic cholecystectomy? Am J Surg 2014; 208:926-31; discussion 930-1. [PMID: 25435299 DOI: 10.1016/j.amjsurg.2014.08.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 08/21/2014] [Accepted: 08/25/2014] [Indexed: 01/22/2023]
Abstract
BACKGROUND The perioperative management of clopidogrel remains an area of controversy. METHODS An institutional review board-approved retrospective review of patients undergoing a laparoscopic cholecystectomy while on clopidogrel from 2008 to 2012 was performed. These patients were then matched with a nonclopidogrel cohort based on American Society of Anesthesiologists score and emergent or elective surgery. Intraoperative estimated blood loss, operative time, length of stay, and 30-day morbidity were compared. RESULTS Thirty-six clopidogrel and 36 control patient records were analyzed. There were no significant differences in age, body mass index, sex, or incidence of coronary artery disease, diabetes, hyperlipidemia, and congestive heart failure. Estimated blood loss averaged 50 mL in the clopidogrel group and 47 mL in the control group (P = nonsignificant). There were no significant differences in operative time, 30-day morbidity, or length of stay between the 2 groups. CONCLUSIONS Laparoscopic cholecystectomy performed on patients maintained on clopidogrel during the perioperative period did not produce an increase in blood loss, operative time, 30-day morbidity, or length of stay.
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Affiliation(s)
- Katherine Anderson
- Baylor Scott & White Health, 2401 South 31st Street, Temple, TX 76508, USA
| | - Daniel C Jupiter
- Baylor Scott & White Health, 2401 South 31st Street, Temple, TX 76508, USA
| | | | - Richard C Frazee
- Baylor Scott & White Health, 2401 South 31st Street, Temple, TX 76508, USA.
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Emergency surgery and trauma in patients treated with the new oral anticoagulants. J Trauma Acute Care Surg 2014; 77:486-94; quiz 486-94. [DOI: 10.1097/ta.0000000000000360] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Baumann Kreuziger LM, Keenan JC, Morton CT, Dries DJ. Management of the bleeding patient receiving new oral anticoagulants: a role for prothrombin complex concentrates. BIOMED RESEARCH INTERNATIONAL 2014; 2014:583794. [PMID: 25136597 PMCID: PMC4127295 DOI: 10.1155/2014/583794] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 06/25/2014] [Indexed: 11/17/2022]
Abstract
Ease of dosing and simplicity of monitoring make new oral anticoagulants an attractive therapy in a growing range of clinical conditions. However, newer oral anticoagulants interact with the coagulation cascade in different ways than traditional warfarin therapy. Replacement of clotting factors will not reverse the effects of dabigatran, rivaroxaban, or apixaban. Currently, antidotes for these drugs are not widely available. Fortunately, withholding the anticoagulant and dialysis are freqnently effective treatments, particularly with rivaroxaban and dabigatran. Emergent bleeding, however, requires utilization of Prothrombin Complex Concentrates (PCCs). PCCs, in addition to recombinant factor VIIa, are used to activate the clotting system to reverse the effects of the new oral anticoagulants. In cases of refractory or emergent bleeding, the recommended factor concentrate in our protocols differs between the new oral anticoagulants. In patients taking dabigatran, we administer an activated PCC (aPCC) [FELBA] due to reported benefit in human in vitro studies. Based on human clinical trial evidence, the 4-factor PCC (Kcentra) is suggested for patients with refractory rivaroxaban- or apixaban-associated hemorrhage. If bleeding continues, recombinant factor VIIa may be employed. With all of these new procoagulant agents, the risk of thrombosis associated with administration of factor concentrates must be weighed against the relative risk of hemorrhage.
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Affiliation(s)
| | - Joseph C. Keenan
- University of Minnesota, 420 Delaware Street SE, Minneapolis, MN 55455, USA
| | - Colleen T. Morton
- Regions Hospital, University of Minnesota, 640 Jackson Street, No. 11503C, Saint Paul, MN 55101, USA
| | - David J. Dries
- Regions Hospital, University of Minnesota, 640 Jackson Street, No. 11503C, Saint Paul, MN 55101, USA
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