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Shih RD, Alter SM, Wells M, Solano JJ, Engstrom G, Clayton LM, Hughes PG, Goldstein L, Lottenberg L, Ouslander JG. The Florida Geriatric Head Trauma CT Clinical Decision Rule. J Am Geriatr Soc 2024. [PMID: 38959158 DOI: 10.1111/jgs.19057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 05/24/2024] [Accepted: 06/05/2024] [Indexed: 07/05/2024]
Abstract
BACKGROUND Several clinical decision rules have been devised to guide head computed tomography (CT) use in patients with minor head injuries, but none have been validated in patients 65 years or older. We aimed to derive and validate a head injury clinical decision rule for older adults. METHODS We conducted a secondary analysis of an existing dataset of consecutive emergency department (ED) patients >65 years old with blunt head trauma. The main predictive outcomes were significant intracranial injury and Need for Neurosurgical Intervention on CT. The secondary outcomes also considered in the model development and validation were All Injuries and All Intracranial Injuries. Predictor variables were identified using multiple variable logistic regression, and clinical decision rule models were developed in a split-sample derivation cohort and then tested in an independent validation cohort. RESULTS Of 5776 patients, 233 (4.0%) had significant intracranial injury and an additional 104 (1.8%) met CT criteria for Need for Neurosurgical Intervention. The best performing model, the Florida Geriatric Head Trauma CT Clinical Decision Rule, assigns points based on several clinical variables. If the points totaled 25 or more, a CT scan is indicated. The included predictors were arrival via Emergency Medical Services (+30 points), Glasgow Coma Scale (GCS) <15 (+20 points), GCS <14 (+50 points), antiplatelet medications (+17 points), loss of consciousness (+16 points), signs of basilar skull fracture (+50 points), and headache (+20 points). Utilizing this clinical decision rule in the validation cohort, a point total ≥25 had a sensitivity and specificity of 100.0% (95% CI: 96.0-100) and 12.3% (95% CI: 10.9-13.8), respectively, for significant intracranial injury and Need for Neurosurgical Intervention. CONCLUSIONS The Florida Geriatric Head Trauma CT Clinical Decision Rule has the potential to reduce unnecessary CT scans in older adults, without compromising safe emergency medicine practice.
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Affiliation(s)
- Richard D Shih
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
- Depatment of Emergency Medicine, Delray Medical Center, Delray Beach, Florida, USA
| | - Scott M Alter
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
- Depatment of Emergency Medicine, Delray Medical Center, Delray Beach, Florida, USA
- Depatment of Emergency Medicine, Bethesda Hospital East, Boynton Beach, Florida, USA
| | - Mike Wells
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
| | - Joshua J Solano
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
- Depatment of Emergency Medicine, Delray Medical Center, Delray Beach, Florida, USA
- Depatment of Emergency Medicine, Bethesda Hospital East, Boynton Beach, Florida, USA
| | - Gabriella Engstrom
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
| | - Lisa M Clayton
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
- Depatment of Emergency Medicine, Delray Medical Center, Delray Beach, Florida, USA
- Depatment of Emergency Medicine, Bethesda Hospital East, Boynton Beach, Florida, USA
| | - Patrick G Hughes
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
- Depatment of Emergency Medicine, Delray Medical Center, Delray Beach, Florida, USA
- Depatment of Emergency Medicine, Bethesda Hospital East, Boynton Beach, Florida, USA
| | - Lara Goldstein
- Department of Emergency Medicine, Memorial Healthcare System, Hollywood, Florida, USA
| | - Lawrence Lottenberg
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
- Department of Surgery, St. Mary's Medical Center, West Palm Beach, Florida, USA
| | - Joseph G Ouslander
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
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André L, Björkelund A, Ekelund U, Vedin T, Björk J, Forberg JL. The prevalence of clinically relevant delayed intracranial hemorrhage in head trauma patients treated with oral anticoagulants is very low: a retrospective cohort register study. Scand J Trauma Resusc Emerg Med 2024; 32:42. [PMID: 38730480 PMCID: PMC11084042 DOI: 10.1186/s13049-024-01214-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 04/27/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Current guidelines from Scandinavian Neuro Committee mandate a 24-hour observation for head trauma patients on anticoagulants, even with normal initial head CT scans, as a means not to miss delayed intracranial hemorrhages. This study aimed to assess the prevalence, and time to diagnosis, of clinically relevant delayed intracranial hemorrhage in head trauma patients treated with oral anticoagulants. METHOD Utilizing comprehensive two-year data from Region Skåne's emergency departments, which serve a population of 1.3 million inhabitants, this study focused on adult head trauma patients prescribed oral anticoagulants. We identified those with intracranial hemorrhage within 30 days, defining delayed intracranial hemorrhage as a bleeding not apparent on their initial CT head scan. These cases were further defined as clinically relevant if associated with mortality, any intensive care unit admission, or neurosurgery. RESULTS Out of the included 2,362 head injury cases (median age 84, 56% on a direct acting oral anticoagulant), five developed delayed intracranial hemorrhages. None of these five cases underwent neurosurgery nor were admitted to an intensive care unit. Only two cases (0.08%, 95% confidence interval [0.01-0.3%]) were classified as clinically relevant, involving subdural hematomas in patients aged 82 and 87 years, who both subsequently died. The diagnosis of these delayed intracranial hemorrhages was made at 4 and 7 days following initial presentation to the emergency department. CONCLUSION In patients with head trauma, on oral anticoagulation, the incidence of clinically relevant delayed intracranial hemorrhage was found to be less than one in a thousand, with detection occurring four days or later after initial presentation. This challenges the effectiveness of the 24-hour observation period recommended by the Scandinavian Neurotrauma Committee guidelines, suggesting a need to reassess these guidelines to optimise care and resource allocation. TRIAL REGISTRATION This is a retrospective cohort study, does not include any intervention, and has therefore not been registered.
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Affiliation(s)
- Lars André
- Department of Clinical Sciences, Lund University, Lund, Sweden.
- Department of Emergency Medicine, Helsingborg Hospital, Helsingborg, Sweden.
| | - Anders Björkelund
- Centre for Environmental and Climate Science, Lund University, Lund, Sweden
| | - Ulf Ekelund
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Internal medicine and Emergency care, Skåne University Hospital, Lund, Sweden
| | - Tomas Vedin
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Surgery, Skåne University Hospital, Malmö, Sweden
| | - Jonas Björk
- Department of Laboratory Medicine, Lund University, Lund, Sweden
- Skåne University Hospital, Forum South, Clinical Studies Sweden, Lund, Sweden
| | - Jakob Lundager Forberg
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Emergency Medicine, Helsingborg Hospital, Helsingborg, Sweden
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3
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Hinson HE, Radabaugh HL, Li N, Fukuda T, Pollock J, Schreiber M, Rowell S, Ferguson AR. Predicting Progression of Intracranial Hemorrhage in the Prehospital TXA for TBI Trial. J Neurotrauma 2024. [PMID: 38618713 DOI: 10.1089/neu.2023.0626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024] Open
Abstract
Progression of intracranial hemorrhage is a common, potentially devastating complication after moderate/severe traumatic brain injury (TBI). Clinicians have few tools to predict which patients with traumatic intracranial hemorrhage on their initial head computed tomography (hCT) scan will progress. The objective of this investigation was to identify clinical, imaging, and/or protein biomarkers associated with progression of intracranial hemorrhage (PICH) after moderate/severe TBI and to create an accurate predictive model of PICH based on clinical features available at presentation. We analyzed a subset of subjects from the phase II double-blind, multi-center, randomized "Prehospital Tranexamic Acid Use for TBI" trial. This subset was limited to the placebo arm of the parent trial with evidence of hemorrhage on the initial hCT and a follow-up hCT 6 h after. PICH was defined as an increase in hemorrhage size by 30% or more, or the development of new hemorrhage in the intra- and extra-axial intracranial vault between the initial and the follow-up hCT. Two independent radiologists evaluated each hCT, and conflicts were adjudicated by a third. Clinical and radiographic characteristics were collected, along with plasma protein biomarkers at admission. Principal component analysis (PCA) was performed, and each principal component (PC) was interrogated for its association with PICH. Finally, expert opinion and recursive feature extraction (RFE) were used to select input features for the construction of several supervised classification models. Their ability to predict PICH was quantified and compared. In this subset of subjects (n = 104), 46% (n = 48) demonstrated PICH. Univariate analyses showed no association between PICH and age, sex, admission Glasgow Coma Scale (GCS), GCS motor subscore, presence of midline shift, admission platelet count or admission INR. Radiographic severity scores (Marshall score [p = 0.007], Rotterdam score [p = 0.004]), and initial hematoma volume [p = 0.005] were associated with PICH. Higher levels of admission glial fibrillary acidic protein (p < 0.001) and MAP (p = 0.011) were also associated with PICH. Of the PCs, PC1 was significantly associated with PICH (p = 0.0125). Using multimodal data input, machine learning classifiers successfully discriminated patients with or without PICH. Models composed of machine-selected features performed better than models composed of expert-selected variables (reaching an average of 77% accuracy, AUC = 0.78 versus AUC = 0.68 for the expert-selected variables). Predictive models utilizing variables measured at admission can accurately predict PICH, confirmed by the 6-hour follow-up hCT. Our best-performing models must now be externally validated in a separate cohort of TBI patients with low GCS and initial hCT positive for hemorrhage.
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Affiliation(s)
- H E Hinson
- Department of Neurology, University of California, San Francisco, California, USA
| | - Hannah L Radabaugh
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Nincheng Li
- Department of Radiology, Division of Interventional Radiology University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Toshinori Fukuda
- Department of Radiology, Oregon Health and Science University, Portland, Oregon, USA
| | - Jeffrey Pollock
- Department of Radiology, Oregon Health and Science University, Portland, Oregon, USA
| | - Martin Schreiber
- Donald D. Trunkey Center for Civilian and Combat Casualty Care, Oregon Health and Science University, Portland, Oregon, USA
| | - Susan Rowell
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Adam R Ferguson
- Department of Neurological Surgery, University of California, San Francisco, California, USA
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Mower WR, Akie TE, Morizadeh N, Gupta M, Hendey GW, Wilson JL, Leonid Duvergne LP, Ma P, Krishna P, Rodriguez RM. Blunt Head Injury in the Elderly: Analysis of the NEXUS II Injury Cohort. Ann Emerg Med 2024; 83:457-466. [PMID: 38340132 DOI: 10.1016/j.annemergmed.2024.01.003] [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: 09/28/2023] [Revised: 12/06/2023] [Accepted: 01/02/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND Changes with aging make older patients vulnerable to blunt head trauma and alter the potential for injury and the injury patterns seen among this expanding cohort. High-quality care requires a clear understanding of the factors associated with blunt head injuries in the elderly. Our objective was to develop a detailed assessment of the injury mechanisms, presentations, injury patterns, and outcomes among older blunt head trauma patients. METHODS We conducted a planned secondary analysis of patients aged 65 or greater who were enrolled in the National Emergency X-Radiography Utilization Study (NEXUS) Head Computed Tomography validation study. We performed a detailed assessment of the demographics, mechanisms, presentations, injuries, interventions, and outcomes among older patients. RESULTS We identified 3,659 patients aged 65 years or greater, among the 11,770 patients enrolled in the NEXUS validation study. Of these older patients, 325 (8.9%) sustained significant injuries, as compared with significant injuries in 442 (5.4%) of the 8,111 younger patients. Older females (1,900; 51.9%) outnumbered older males (1,753; 47.9%), and occult presentations (exhibiting no high-risk clinical criteria beyond age) occurred in 48 (14.8%; 95% confidence interval (CI) 11.1 to 19.1) patients with significant injuries. Subdural hematomas (377 discreet lesions in 299 patients) and subarachnoid hemorrhages (333 discreet instances in 256 patients) were the most frequent types of injuries occurring in our elderly population. A ground-level fall was the most frequent mechanism of injury among all patients (2,211; 69.6%), those sustaining significant injuries (180; 55.7%), and those who died of their injuries (37; 46.3%), but mortality rates were highest among patients experiencing a fall from a ladder (11.8%; 4 deaths among 34 cases [95% CI 3.3% to 27.5%]) and automobile versus pedestrian events (10.7%; 16 deaths among 149 cases [95% CI 6.3% to 16.9%]). Among older patients who required neurosurgical intervention for their injuries, only 16.4% (95% CI 11.1% to 22.9%) were able to return home, 32.1% (95% CI 25.1% to 39.8%) required extended facility care, and 41.8% (95% CI 34.2% to 49.7%) died from their injuries. CONCLUSIONS Older blunt head injury patients are at high risk of sustaining serious intracranial injuries even with low-risk mechanisms of injury, such as ground-level falls. Clinical evaluation is unreliable and frequently fails to identify patients with significant injuries. Outcomes, particularly after intervention, can be poor, with high rates of long-term disability and mortality.
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Affiliation(s)
- William R Mower
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA.
| | - Thomas E Akie
- Department of Emergency Medicine, UMass Chan Medical School, Worcester, MA
| | | | - Malkeet Gupta
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Emergency Medicine, Antelope Valley Medical Center, Lancaster, CA
| | - Gregory W Hendey
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Jake L Wilson
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | | | - Phillip Ma
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Pravin Krishna
- Department of Emergency Medicine, Antelope Valley Medical Center, Lancaster, CA
| | - Robert M Rodriguez
- Department of Emergency Medicine, UCSF School of Medicine, San Francisco, CA
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Vande Vyvere T, Pisică D, Wilms G, Claes L, Van Dyck P, Snoeckx A, van den Hauwe L, Pullens P, Verheyden J, Wintermark M, Dekeyzer S, Mac Donald CL, Maas AIR, Parizel PM. Imaging Findings in Acute Traumatic Brain Injury: a National Institute of Neurological Disorders and Stroke Common Data Element-Based Pictorial Review and Analysis of Over 4000 Admission Brain Computed Tomography Scans from the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) Study. J Neurotrauma 2024. [PMID: 38482818 DOI: 10.1089/neu.2023.0553] [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: 04/20/2024] Open
Abstract
In 2010, the National Institute of Neurological Disorders and Stroke (NINDS) created a set of common data elements (CDEs) to help standardize the assessment and reporting of imaging findings in traumatic brain injury (TBI). However, as opposed to other standardized radiology reporting systems, a visual overview and data to support the proposed standardized lexicon are lacking. We used over 4000 admission computed tomography (CT) scans of patients with TBI from the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study to develop an extensive pictorial overview of the NINDS TBI CDEs, with visual examples and background information on individual pathoanatomical lesion types, up to the level of supplemental and emerging information (e.g., location and estimated volumes). We documented the frequency of lesion occurrence, aiming to quantify the relative importance of different CDEs for characterizing TBI, and performed a critical appraisal of our experience with the intent to inform updating of the CDEs. In addition, we investigated the co-occurrence and clustering of lesion types and the distribution of six CT classification systems. The median age of the 4087 patients in our dataset was 50 years (interquartile range, 29-66; range, 0-96), including 238 patients under 18 years old (5.8%). Traumatic subarachnoid hemorrhage (45.3%), skull fractures (37.4%), contusions (31.3%), and acute subdural hematoma (28.9%) were the most frequently occurring CT findings in acute TBI. The ranking of these lesions was the same in patients with mild TBI (baseline Glasgow Coma Scale [GCS] score 13-15) compared with those with moderate-severe TBI (baseline GCS score 3-12), but the frequency of occurrence was up to three times higher in moderate-severe TBI. In most TBI patients with CT abnormalities, there was co-occurrence and clustering of different lesion types, with significant differences between mild and moderate-severe TBI patients. More specifically, lesion patterns were more complex in moderate-severe TBI patients, with more co-existing lesions and more frequent signs of mass effect. These patients also had higher and more heterogeneous CT score distributions, associated with worse predicted outcomes. The critical appraisal of the NINDS CDEs was highly positive, but revealed that full assessment can be time consuming, that some CDEs had very low frequencies, and identified a few redundancies and ambiguity in some definitions. Whilst primarily developed for research, implementation of CDE templates for use in clinical practice is advocated, but this will require development of an abbreviated version. In conclusion, with this study, we provide an educational resource for clinicians and researchers to help assess, characterize, and report the vast and complex spectrum of imaging findings in patients with TBI. Our data provides a comprehensive overview of the contemporary landscape of TBI imaging pathology in Europe, and the findings can serve as empirical evidence for updating the current NINDS radiologic CDEs to version 3.0.
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Affiliation(s)
- Thijs Vande Vyvere
- Department of Radiology, Antwerp University Hospital, Antwerp, Belgium
- Department of Molecular Imaging and Radiology (MIRA), Faculty of Medicine and Health Science, University of Antwerp, Antwerp, Belgium
| | - Dana Pisică
- Department of Neurosurgery, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Public Health, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Guido Wilms
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Lene Claes
- icometrix, Research and Development, Leuven, Belgium
| | - Pieter Van Dyck
- Department of Radiology, Antwerp University Hospital, Antwerp, Belgium
- Department of Molecular Imaging and Radiology (MIRA), Faculty of Medicine and Health Science, University of Antwerp, Antwerp, Belgium
| | - Annemiek Snoeckx
- Department of Radiology, Antwerp University Hospital, Antwerp, Belgium
- Department of Molecular Imaging and Radiology (MIRA), Faculty of Medicine and Health Science, University of Antwerp, Antwerp, Belgium
| | - Luc van den Hauwe
- Department of Radiology, Antwerp University Hospital, Antwerp, Belgium
| | - Pim Pullens
- Department of Imaging, University Hospital Ghent; IBITech/MEDISIP, Engineering and Architecture, Ghent University; Ghent Institute for Functional and Metabolic Imaging, Ghent University, Belgium
| | - Jan Verheyden
- icometrix, Research and Development, Leuven, Belgium
| | - Max Wintermark
- Department of Neuroradiology, University of Texas MD Anderson Center, Houston, Texas, USA
| | - Sven Dekeyzer
- Department of Radiology, Antwerp University Hospital, Antwerp, Belgium
- Department of Radiology, University Hospital Ghent, Belgium
| | - Christine L Mac Donald
- Department of Neurological Surgery, School of Medicine, Harborview Medical Center, Seattle, Washington, USA
- Department of Neurological Surgery, School of Medicine, University of Washington, Seattle, Washington, USA
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital, Antwerp, Belgium
- Department of Translational Neuroscience, Faculty of Medicine and Health Science, University of Antwerp, Antwerp, Belgium
| | - Paul M Parizel
- Department of Radiology, Royal Perth Hospital (RPH) and University of Western Australia (UWA), Perth, Australia; Western Australia National Imaging Facility (WA NIF) node, Australia
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Broderick M, Tripodi G, Dwyer K. Utility of Repeat Head Computed Tomography in Detecting Delayed Intracranial Hemorrhage in Falls on Direct Oral Anticoagulants. Am Surg 2024; 90:691-694. [PMID: 37853510 DOI: 10.1177/00031348231206582] [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: 10/20/2023]
Abstract
INTRODUCTION Ground level falls in the elderly often lead to complications due to use of anticoagulants (ACs). Intracranial hemorrhage (ICH), immediate or delayed, is a feared consequence of such falls. The rate of delayed ICH (dICH) in patients taking anticoagulants or antiplatelet (AP) agents ranges from .6% to 6%. Patients on warfarin have a persistent rate of dICH, leading to implementation of routine repeat head CTs at our institution. This policy was extended to direct oral anticoagulants (DOACs). This study aims to determine institutional incidence of DOAC-associated dICH. METHODS With IRB waiver approval, we conducted a retrospective review of trauma evaluations for falls on DOACs from 2016 to 2018. We reviewed records for neurologic status, DOAC use, and results of initial and delayed head CTs. Exclusion criteria included initial GCS ≤14, new neurologic deficits, traumatic findings on initial CT, concurrent use of additional AC/AP, or absence of repeat head CT. RESULTS Among 632 patients evaluated for falls on AC/AP therapy, 159 (25%) of patients were included in the review. The age range was 19-98 years old, with 99 females and 60 males. Half of the patients were on apixaban, with the rest on dabigatran or rivaroxaban. Ten patients presented with GCS of 14. No delayed hemorrhages were detected in this population. CONCLUSION The necessity of a repeat head CT in patients taking DOACs is debated in the literature. Our analysis failed to demonstrate any delayed hemorrhage in neurologically intact patients after head strike on DOAC, suggesting no indication for follow-up imaging in this group.
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Affiliation(s)
| | | | - Kevin Dwyer
- Department of Surgery, Stamford Hospital, Stamford, CT, USA
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Heinonen A, Rauhala M, Isokuortti H, Raj R, Kataja A, Nikula M, Öhman J, Iverson GL, Luoto T. Incidence of surgically treated chronic subdural hematoma after head injury with normal initial computed tomography. Acta Neurochir (Wien) 2024; 166:144. [PMID: 38514587 PMCID: PMC10957655 DOI: 10.1007/s00701-024-06040-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 03/12/2024] [Indexed: 03/23/2024]
Abstract
PURPOSE The objective was to determine the incidence of surgically treated chronic subdural hematoma (cSDH) within six months after head trauma in a consecutive series of head injury patients with a normal initial computed tomography (CT). METHODS A total of 1941 adult patients with head injuries who underwent head CT within 48 h after injury and were treated at the Tampere University Hospital's emergency department were retrospectively evaluated from medical records (median age = 59 years, IQR = 39-79 years, males = 58%, patients using antithrombotic medication = 26%). Patients with no signs of acute traumatic intracranial pathology or any type of subdural collection on initial head CT were regarded as CT negative (n = 1573, 81%). RESULTS Two (n = 2) of the 1573 CT negative patients received surgical treatment for cSDH. Consequently, the incidence of surgically treated cSDH after a normal initial head CT during a six-month follow-up was 0.13%. Both patients sustained mild traumatic brain injuries initially. One of the two patients was on antithrombotic medication (warfarin) at the time of trauma, hence incidence of surgically treated cSDH among patients with antithrombotic medication in CT negative patients (n = 376, 23.9%) was 0.27%. Additionally, within CT negative patients, one subdural hygroma was operated shortly after trauma. CONCLUSION The extremely low incidence of surgically treated cSDH after a normal initial head CT, even in patients on antithrombotic medication, supports the notion that routine follow-up imaging after an initial normal head CT is not indicated to exclude the development of cSDH. Additionally, our findings support the concept of cSDH not being a purely head trauma-related disease.
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Affiliation(s)
- Aaro Heinonen
- The Faculty of Medicine and Health Technology, Tampere University, Arvo Ylpön katu 34, 33520, Tampere, Finland.
| | - Minna Rauhala
- Department of Neurosurgery, Tampere University Hospital, Tampere, Finland
| | - Harri Isokuortti
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Rahul Raj
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Anneli Kataja
- Department of Radiology, Medical Imaging Centre, Tampere University Hospital, Tampere, Finland
| | - Milaja Nikula
- The Faculty of Medicine and Health Technology, Tampere University, Arvo Ylpön katu 34, 33520, Tampere, Finland
| | - Juha Öhman
- Department of Neurosurgery, Tampere University Hospital, Tampere, Finland
| | - Grant L Iverson
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and the Schoen Adams Research Institute at Spaulding Rehabilitation, Charlestown, MA, USA
| | - Teemu Luoto
- The Faculty of Medicine and Health Technology, Tampere University, Arvo Ylpön katu 34, 33520, Tampere, Finland
- Department of Neurosurgery, Tampere University Hospital, Tampere, Finland
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8
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Sakkas A, Weiß C, Wilde F, Ebeling M, Thiele OC, Mischkowski RA, Pietzka S. Impact of antithrombotic therapy on acute and delayed intracranial haemorrhage and evaluation of the need of short-term hospitalisation based on CT findings after mild traumatic brain injury: experience from an oral and maxillofacial surgery unit. Eur J Trauma Emerg Surg 2024; 50:157-172. [PMID: 36707437 DOI: 10.1007/s00068-023-02228-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 01/13/2023] [Indexed: 01/28/2023]
Abstract
PURPOSE The primary aim was to compare the prevalence of acute and delayed intracranial haemorrhage (ICH) following mild traumatic brain injury (mTBI) in patients on antithrombotic medication referred to a clinic for oral and plastic maxillofacial surgery. The secondary aim was to evaluate the need for short-term hospitalisation based on initial radiological and clinical findings. METHODS This was an observational retrospective single-centre study of all patients on antithrombotic medication who were admitted to our department of oral and plastic maxillofacial surgery with mTBI over a 5 year period. Demographic and anamnesis data, injury characteristics, antithrombotic medication, radiological findings, treatment, and outcome were analysed. Patients were divided into the following four groups based on their antithrombotic medication: (1) single antiplatelet users, (2) vitamin K antagonist users, (3) direct oral anticoagulant users, and (4) double antithrombotic users. All patients underwent an emergency cranial CT (CT0) at admission. Based on clinical and radiological evaluation, different treatment protocols were applied. Patients with positive CT0 findings and patients with secondary neurological deterioration received a control CT (CT1) before discharge. Acute and delayed ICH and patient's outcome during hospitalisation were evaluated using descriptive statistical analysis. RESULTS A total of 696 patients (mean age, 71.6 years) on antithrombotic medication who presented at our department with mTBI were included in the analysis. Most injuries were caused by a ground-level fall (76.9%). Thirty-six patients (5.1%) developed an acute traumatic ICH, and 47 intracerebral lesions were detected by radiology-most of these in patients taking acetylsalicylic acid. No association was detected between ICH and antithrombotic medication (p = 0.4353). In total, 258 (37.1%) patients were admitted for 48 h in-hospital observation. The prevalence of delayed ICH was 0.1%, and the mortality rate was 0.1%. Multivariable analysis identified a Glasgow Coma Scale (GCS) of < 15, loss of consciousness, amnesia, headache, dizziness, and nausea as clinical characteristics significantly associated with an increased risk of acute ICH, whereas age, sex, and trauma mechanism were not associated with ICH prevalence. Of the 39 patients who underwent a control CT1, most had a decreasing or at least constant intracranial lesion; in three patients, intracranial bleeding increased but was not clinically relevant. CONCLUSION According to our experience, antithrombotic therapy does not increase the rate of ICH after mTBI. A GCS of < 15, loss of consciousness, amnesia, headache, dizziness, and nausea are indicators of higher ICH risk. A second CT scan is more effective in patients with secondary neurological deterioration. Initial CT findings were not clinically relevant and should not indicate in-hospital observation.
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Affiliation(s)
- Andreas Sakkas
- Department of Cranio-Maxillo-Facial-Surgery, German Armed Forces Hospital Ulm, Oberer Eselsberg 40, 89081, Ulm, Germany.
- Department of Cranio-Maxillo-Facial-Surgery, University Hospital Ulm, Ulm, Germany.
| | - Christel Weiß
- Medical Statistics and Biomathematics, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Frank Wilde
- Department of Cranio-Maxillo-Facial-Surgery, German Armed Forces Hospital Ulm, Oberer Eselsberg 40, 89081, Ulm, Germany
- Department of Cranio-Maxillo-Facial-Surgery, University Hospital Ulm, Ulm, Germany
| | - Marcel Ebeling
- Department of Cranio-Maxillo-Facial-Surgery, German Armed Forces Hospital Ulm, Oberer Eselsberg 40, 89081, Ulm, Germany
| | | | | | - Sebastian Pietzka
- Department of Cranio-Maxillo-Facial-Surgery, German Armed Forces Hospital Ulm, Oberer Eselsberg 40, 89081, Ulm, Germany
- Department of Cranio-Maxillo-Facial-Surgery, University Hospital Ulm, Ulm, Germany
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Bergenfeldt H, Forberg JL, Lehtinen R, Anefjäll E, Vedin T. Delayed intracranial hemorrhage after head trauma seems rare and rarely needs intervention-even in antiplatelet or anticoagulation therapy. Int J Emerg Med 2023; 16:54. [PMID: 37667208 PMCID: PMC10476369 DOI: 10.1186/s12245-023-00530-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 08/20/2023] [Indexed: 09/06/2023] Open
Abstract
BACKGROUND Traumatic brain injury causes morbidity, mortality, and at least 2,500,000 yearly emergency department visits in the USA. Computerized tomography of the head is the gold standard to detect traumatic intracranial hemorrhage. Some are not diagnosed at the first scan, and they are denoted "delayed intracranial hemorrhages. " To detect these delayed hemorrhages, current guidelines for head trauma recommend observation and/or rescanning for patients on anticoagulation therapy but not for patients on antiplatelet therapy. The aim of this study was to investigate the prevalence and need for interventions of delayed intracranial hemorrhage after head trauma. METHODS The study was a retrospective review of medical records of adult patients with isolated head trauma presenting at Helsingborg General Hospital between January 1, 2020, and December 31, 2020. Univariate statistical analyses were performed. RESULTS In total, 1627 patients were included and four (0.25%, 95% confidence interval 0.06-0.60%) patients had delayed intracranial hemorrhage. One of these patients was diagnosed within 24 h and three within 2-30 days. The patient was diagnosed within 24 h, and one of the patients diagnosed within 2-30 days was on antiplatelet therapy. None of these four patients was prescribed anticoagulation therapy, and no intensive care, no neurosurgical operations, or deaths were recorded. CONCLUSION Traumatic delayed intracranial hemorrhage is rare and consequences mild and antiplatelet and anticoagulation therapy might confer similar risk. Because serious complications appear rare, observing, and/or rescanning all patients with either of these medications can be debated. Risk stratification of these patients might have the potential to identify the patients at risk while safely reducing observation times and rescanning.
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Affiliation(s)
- Henrik Bergenfeldt
- Clinical Research Centre, Department of Clinical Sciences, Skåne University Hospital, Lund University, Box 50332, 20213 Malmö, Sweden
| | - Jakob Lundager Forberg
- Clinical Sciences, Helsingborg General Hospital, Lund University, Svartbrödragränden 3-5, 25187 Helsingborg, Sweden
| | - Riikka Lehtinen
- Clinical Sciences, Helsingborg General Hospital, Lund University, Svartbrödragränden 3-5, 25187 Helsingborg, Sweden
| | - Ebba Anefjäll
- Clinical Sciences, Helsingborg General Hospital, Lund University, Svartbrödragränden 3-5, 25187 Helsingborg, Sweden
| | - Tomas Vedin
- Clinical Research Centre, Department of Clinical Sciences, Skåne University Hospital, Lund University, Box 50332, 20213 Malmö, Sweden
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Sakkas A, Weiß C, Ebeling M, Wilde F, Pietzka S, Mohammad Q, Thiele OC, Mischkowski RA. Clinical Indicators for Primary Cranial CT Imaging after Mild Traumatic Brain Injury-A Retrospective Analysis. J Clin Med 2023; 12:jcm12103563. [PMID: 37240668 DOI: 10.3390/jcm12103563] [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: 04/21/2023] [Revised: 05/08/2023] [Accepted: 05/16/2023] [Indexed: 05/28/2023] Open
Abstract
The primary aim was to determine the clinical indicators for primary cranial CT imaging in patients after mild traumatic brain injury (mTBI). The secondary aim was to evaluate the need for post-traumatic short-term hospitalization based on primary clinical and CT findings. This was an observational retrospective single-centre study of all the patients who were admitted with mTBI over a five-year period. Demographic and anamnesis data, the clinical and radiological findings, and the outcome were analyzed. An initial cranial CT (CT0) was performed at admission. Repeat CT scans (CT1) were performed after positive CT0 findings and in cases with in-hospital secondary neurological deterioration. Intracranial hemorrhage (ICH) and the patient's outcome were evaluated using descriptive statistical analysis. A multivariable analysis was performed to find associations between the clinical variables and the pathologic CT findings. A total of 1837 patients (mean age: 70.7 years) with mTBI were included. Acute ICH was detected in 102 patients (5.5%), with a total of 123 intracerebral lesions. In total, 707 (38.4%) patients were admitted for 48 h for in-hospital observation and six patients underwent an immediate neurosurgical intervention. The prevalence of delayed ICH was 0.05%. A Glasgow Coma Scale (GCS) of <15, loss of consciousness, amnesia, seizures, cephalgia, somnolence, dizziness, nausea, and clinical signs of fracture were identified as clinical factors with significantly higher risk of acute ICH. None of the 110 CT1 presented clinical relevance. A GCS of <15, loss of consciousness, amnesia, seizures, cephalgia, somnolence, dizziness, nausea, and clinical signs of cranial fractures should be considered absolute indicators for primary cranial CT imaging. The reported incidence of immediate and delayed traumatic ICH was very low and hospitalization should be decided individually considering both the clinical and CT findings.
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Affiliation(s)
- Andreas Sakkas
- Department of Cranio-Maxillo-Facial-Surgery, University Hospital Ulm, 89081 Ulm, Germany
- Department of Cranio-Maxillo-Facial-Surgery, German Armed Forces Hospital Ulm, 89081 Ulm, Germany
| | - Christel Weiß
- Medical Statistics and Biomathematics, University Medical Centre Mannheim, Heidelberg University, 69167 Mannheim, Germany
| | - Marcel Ebeling
- Department of Cranio-Maxillo-Facial-Surgery, German Armed Forces Hospital Ulm, 89081 Ulm, Germany
| | - Frank Wilde
- Department of Cranio-Maxillo-Facial-Surgery, University Hospital Ulm, 89081 Ulm, Germany
- Department of Cranio-Maxillo-Facial-Surgery, German Armed Forces Hospital Ulm, 89081 Ulm, Germany
| | - Sebastian Pietzka
- Department of Cranio-Maxillo-Facial-Surgery, University Hospital Ulm, 89081 Ulm, Germany
- Department of Cranio-Maxillo-Facial-Surgery, German Armed Forces Hospital Ulm, 89081 Ulm, Germany
| | - Qasim Mohammad
- Institute for Diagnostic and Interventional Radiology, Ludwigshafen Hospital, 67063 Ludwigshafen, Germany
| | - Oliver Christian Thiele
- Department of Cranio-Maxillo-Facial-Surgery, Ludwigshafen Hospital, 67063 Ludwigshafen, Germany
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11
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Valente JH, Anderson JD, Paolo WF, Sarmiento K, Tomaszewski CA, Haukoos JS, Diercks DB, Diercks DB, Anderson JD, Byyny R, Carpenter CR, Friedman B, Gemme SR, Gerardo CJ, Godwin SA, Hahn SA, Hatten BW, Haukoos JS, Kaji A, Kwok H, Lo BM, Mace SE, Moran M, Promes SB, Shah KH, Shih RD, Silvers SM, Slivinski A, Smith MD, Thiessen MEW, Tomaszewski CA, Trent S, Valente JH, Wall SP, Westafer LM, Yu Y, Cantrill SV, Finnell JT, Schulz T, Vandertulip K. Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Mild Traumatic Brain Injury: Approved by ACEP Board of Directors, February 1, 2023 Clinical Policy Endorsed by the Emergency Nurses Association (April 5, 2023). Ann Emerg Med 2023; 81:e63-e105. [PMID: 37085214 PMCID: PMC10617828 DOI: 10.1016/j.annemergmed.2023.01.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/23/2023]
Abstract
This 2023 Clinical Policy from the American College of Emergency Physicians is an update of the 2008 “Clinical Policy: Neuroimaging and Decisionmaking in Adult Mild Traumatic Brain Injury in the Acute Setting.” A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following questions: 1) In the adult emergency department patient presenting with minor head injury, are there clinical decision tools to identify patients who do not require a head computed tomography? 2) In the adult emergency department patient presenting with minor head injury, a normal baseline neurologic examination, and taking an anticoagulant or antiplatelet medication, is discharge safe after a single head computed tomography? and 3) In the adult emergency department patient diagnosed with mild traumatic brain injury or concussion, are there clinical decision tools or factors to identify patients requiring follow-up care for postconcussive syndrome or to identify patients with delayed sequelae after emergency department discharge? Evidence was graded and recommendations were made based on the strength of the available data. Widespread and consistent implementation of evidence-based clinical recommendations is warranted to improve patient care.
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Miles G, Shank C, Quinlan A, Cavender J. Process improvement using telemedicine consultation to prevent unnecessary interfacility transfers for low-severity blunt head trauma. BMJ Open Qual 2023; 12:bmjoq-2022-002012. [PMID: 36941010 PMCID: PMC10030876 DOI: 10.1136/bmjoq-2022-002012] [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: 06/09/2022] [Accepted: 03/01/2023] [Indexed: 03/22/2023] Open
Abstract
OBJECTIVE Mild traumatic brain injuries (MTBI) associated with intracranial haemorrhage are commonly transferred to tertiary care centres. Recent studies have shown that transfers for low-severity traumatic brain injuries may be unnecessary. Trauma systems can be overwhelmed by low acuity patients justifying standardisation of MTBI transfers. We sought to evaluate the impact of telemedicine services on mitigating unnecessary transfers for those presenting with low-severity blunt head trauma after sustaining a ground level fall (GLF). METHOD A process improvement plan was developed by a task force of transfer centre (TC) administrators, emergency department physicians (EDP), trauma surgeons and neurosurgeons (NS) to facilitate the requesting EDP and the NS on-call to converse directly to mitigate unnecessary transfers. Consecutive retrospective chart review was performed on neurosurgical transfer requests between 1 January 2021 and 31 January 2022. A comparison of transfers preintervention and postintervention (1 January 2021 to 12 September 2021)/(13 September 2021 to 31 January 2022) was performed. RESULTS The TC received 1091 neurological-based transfer requests during the study period (preintervention group: 406 neurosurgical requests; postintervention group: 353 neurosurgical requests). After consultation with the NS on-call, the number of MTBI patients remaining at their respective ED's with no neurological degradation more than doubled from 15 in the preintervention group to 37 in the postintervention group. CONCLUSION TC-mediated telemedicine conversations between the NS and the referring EDP can prevent unnecessary transfers for stable MTBI patients sustaining a GLF if needed. Outlying EDPs should be educated on this process to increase efficacy.
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Affiliation(s)
- Gayla Miles
- Trauma, Texas Health Harris Methodist Hospital Fort Worth, Fort Worth, Texas, USA
| | - Christopher Shank
- Neuro-Trauma, Texas Health Harris Methodist Hospital Fort Worth, Fort Worth, Texas, USA
| | - Ann Quinlan
- Trauma, Texas Health Harris Methodist Hospital Fort Worth, Fort Worth, Texas, USA
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13
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Optimal Management of the Geriatric Trauma Patient. CURRENT SURGERY REPORTS 2023. [DOI: 10.1007/s40137-023-00346-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
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Barber KR, Wasfie T. Inpatient management of complicated mTBI with the BIG assessment tool: Review and summary of the evidence. TRAUMA-ENGLAND 2023. [DOI: 10.1177/14604086221148560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Introduction The management of mild traumatic brain injury has evolved through the years with an emphasis on the safe discharge of patients given current resources. In this article, we discuss key studies published in the past 12 years that have influenced the direction of complicated mild traumatic brain injury (cmTBI) management. We summarize the evidence on the utilization of the Brain Injury Guideline (BIG) algorithm. Methods An independent literature search was conducted on the BIG, updated versions of BIG, and the prognostic studies of adult mild traumatic brain injury admissions cited by the BIG articles. Evidence resources included the search engines of PubMed, Medline, Ovid, Cochrane Library, and Google Scholar bibliographic databases of items published between 1 January 2010 and 30 December 2021. The evidence focused on BIG and its modified versions, as a potential risk assessment tool for discharging mTBI patients early. Results Studies supporting the BIG algorithm prior to 2019 presented evidence with serious limitations to their findings. These limitations threaten their veracity and fail to support the efficacy or validation of the BIG algorithm's utilization for mTBI patient management. Conclusion The lack of rigor in the BIG algorithm studies suggest the research is currently insufficient to support early discharge and research needs to continue on modified versions of the tool before its widespread use.
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Affiliation(s)
| | - Tarik Wasfie
- Trauma Department, Ascension Genesys, Grand Blanc, MI, USA
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15
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Delayed intracranial hemorrhage after head injury among elderly patients on anticoagulation seen in the emergency department. CAN J EMERG MED 2022; 24:853-861. [PMID: 36242733 DOI: 10.1007/s43678-022-00392-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 09/28/2022] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Elderly patients on oral anticoagulation are commonly seen in emergency departments (EDs). Oral anticoagulation, particularly warfarin, is associated with an increased risk of intracranial hemorrhage after head trauma. Data on delayed bleeds in anticoagulated patients are limited. The objective of this study was to examine risk of delayed intracranial hemorrhage in patients presenting to the ED with a head injury anticoagulated with warfarin or a direct oral anticoagulant, compared to patients not anticoagulated. METHODS Cohort study using administrative data from Ontario of patients ≥ 65 years presenting to the ED with a complaint of head injury between 2016 and 2018. The primary outcome was delayed intracranial hemorrhage, defined as a new ICD-10 code for intracranial hemorrhage within 90 days of the initial ED visit for a head injury where no intracranial hemorrhage was diagnosed. The main exposure variable was oral anticoagulation use, which was a three-level variable (warfarin, direct oral anticoagulants, or no oral anticoagulation). We used multivariable logistic regression to determine the odds of delayed intracranial hemorrhage based on anticoagulation status. RESULTS 69,321 patients were included: 58,233 (84.0%) had not been prescribed oral anticoagulation, 3081 (4.4%) had a warfarin prescription, and 8007 (11.6%) had a direct oral anticoagulant prescription. Overall, 718 (1.0%) patients had a delayed intracranial hemorrhage within 90 days of ED visit for head injury. Among patients not anticoagulated, 586 (1.0%) had a delayed intracranial hemorrhage, 54 (1.8%) patients on warfarin, and 78 (1.0%) patients on a direct oral anticoagulant had a delayed intracranial hemorrhage. There was an increased odds of delayed intracranial hemorrhage with warfarin use compared with no anticoagulation (OR 1.5, 95% CI 1.1-2.1). There was no association between delayed intracranial hemorrhage and direct oral anticoagulant use compared to no anticoagulation (OR 0.9, 95% CI 0.6-1.1). CONCLUSIONS There was an increased odds of delayed intracranial hemorrhage within 90 days in older ED head injured patients prescribed warfarin compared to patients not on anticoagulation. direct oral anticoagulant use was not associated with increased risk of delayed intracranial hemorrhage.
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16
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Perry JJ, Dowlatshahi D, Eagles D. Prolonged observation or routine reimaging in older patients following a head injury is not justified. CAN J EMERG MED 2022; 24:795-796. [PMID: 36481990 DOI: 10.1007/s43678-022-00429-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 11/24/2022] [Indexed: 12/13/2022]
Affiliation(s)
- Jeffrey J Perry
- Department of Emergency Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, ON, Canada. .,School of Epidemiology, Public Health and Preventative Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, ON, Canada. .,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
| | - Dar Dowlatshahi
- Department of Medicine (Neurology), University of Ottawa, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,School of Epidemiology, Public Health and Preventative Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Debra Eagles
- Department of Emergency Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,School of Epidemiology, Public Health and Preventative Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
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17
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ÇATAL Y, GÜNALP M, GENÇ S, OĞUZ AB, KOCA A, POLAT O. Do We Need to Repeat the Initially Normal Head Computerized Tomography for Patients with Mild Head Trauma Using Anticoagulant and/or Antiplatelet Therapy? KONURALP TIP DERGISI 2022. [DOI: 10.18521/ktd.1167329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Objective: Patients using anticoagulant and/or antiplatelet (AC/AP) medications are at an increased risk of intracranial hemorrhage (ICH) subsequent to head trauma and current guidelines recommend a head computed tomography (CT) scan for these patients. There is a lack of consensus about management recommendations for mild head trauma patients on AC/AP treatment who had an initially normal head CT. The aim of this study was to determine the rate of delayed ICH after a 24-hour observation in patients with mild head trauma using AC/AP who had an initially normal head CT.
Method: Patients aged 18 and older, using AC/AP drugs with mild head trauma were included prospectively. Patients underwent head CT for suspected bleeding. A repeat CT scan was performed after a 24-hours observation period for the patients who had an initially normal head CT for detecting delayed intracranial hemorrhage.
Result: A total of 101 patients were included and, 57.4% (n=58) of the patients were female. Delayed ICH was detected in 2.9% (n=3) of the patients after a 24-hour observation. None of the patients with delayed ICH needed surgical treatment or further intervention. Delayed ICH was found in patients who used acetylsalicylic acid (n=1), dabigatran (n=1), and apixaban (n=1).
Conclusion: In patients with mild head trauma using AC/AP, delayed intracranial hemorrhage is rare and may be clinically insignificant. A repeat CT scanning after 24-hour observation may not be necessary for patients with mild head trauma using AC/AP therapy who had initially normal head CT.
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Affiliation(s)
- Yaşar ÇATAL
- Kayseri State Hospital, Department of Emergency Medicine
| | - Müge GÜNALP
- Ankara University School of Medicine, Department of Emergency Medicine
| | - Sinan GENÇ
- Ankara University School of Medicine, Department of Emergency Medicine
| | - Ahmet Burak OĞUZ
- Ankara University School of Medicine, Department of Emergency Medicine
| | - Ayça KOCA
- Ankara University School of Medicine, Department of Emergency Medicine
| | - Onur POLAT
- Ankara University School of Medicine, Department of Emergency Medicine
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18
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Chang W, Yin D, Li C, Weston B, Sohn A, Wanamaker C, Kulzer M, Tragon T, Spearman M, Eisenmenger L, Goldberg M. Increased relative risk of delayed hemorrhage in patients taking anticoagulant/antiplatelet medications with concurrent aspirin therapy: implications for clinical practice based on 3-year retrospective analysis in a large health system. Emerg Radiol 2022; 29:353-358. [PMID: 34988752 DOI: 10.1007/s10140-021-02003-3] [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: 09/21/2021] [Accepted: 11/22/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE The incidence of delayed posttraumatic intracranial hemorrhage (DH) in patients on anticoagulant (AC) and antiplatelet (AP) medications, especially with concurrent aspirin therapy, is not well established, with studies reporting disparate results with between 1-10% risk of DH and 0-3% mortality. The purpose of this 3-year retrospective study is to evaluate the true risk of DH in patients on AP/AC medications with or without concurrent aspirin therapy. METHODS One thousand forty-six patients taking AP and AC medications presenting to network emergency departments with head trauma who had repeat CT to evaluate for DH were included in the study. Repeat examinations were typically performed within 24 h (average follow-up time was 21 h and 99% were within 3 days). Mean time to DH was 20 h. All positive studies were reviewed by two board-certified neuroradiologists. Patients were excluded from the study if hemorrhage was retrospectively identified on the initial examination. Cases were reclassified as negative if hemorrhage on the follow-up examination was thought to be not present or artifactual. Cases were considered positive if the initial examination was negative and the follow-up examination demonstrated new hemorrhage. RESULTS Overall, there was 1.91% incidence (20 patients) of DH and 0.3% overall mortality (3 patients). The group of patients taking warfarin or AP agents demonstrated a significantly higher rate of DH (3.2% compared to 0.9%) and higher mortality (0.9% compared to 0.0%) compared to the DOAC group (p < 0.01). The risk of DH in patients taking AC or AP agents with aspirin (13/20 cases) was significantly higher (RR 3.8, p < 0.01) than that of patients taking AC or AP alone (7/20 cases). CONCLUSION The risk of DH was significantly higher in patients taking aspirin in addition to AC/AP medications. Repeat imaging should be obtained for trauma patients taking AC/AP agents with concurrent aspirin. The rate of DH was also significantly higher in patients taking warfarin or AP agents when compared to patients taking DOACs. Repeat examination should be strongly considered on patients taking warfarin or AP agents without aspirin. Given the relatively low risk of DH in patients taking DOACs alone, repeat imaging could be reserved for patients with external signs of trauma or dangerous mechanism of injury.
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Affiliation(s)
- Warren Chang
- Imaging Institute, Allegheny Health Network, 320 E. North Ave, Pittsburgh, PA, 15206, USA.
| | - Danielle Yin
- Imaging Institute, Allegheny Health Network, 320 E. North Ave, Pittsburgh, PA, 15206, USA
| | - Charles Li
- Imaging Institute, Allegheny Health Network, 320 E. North Ave, Pittsburgh, PA, 15206, USA
| | - Brian Weston
- Imaging Institute, Allegheny Health Network, 320 E. North Ave, Pittsburgh, PA, 15206, USA
| | - Albert Sohn
- Imaging Institute, Allegheny Health Network, 320 E. North Ave, Pittsburgh, PA, 15206, USA
| | - Christian Wanamaker
- Imaging Institute, Allegheny Health Network, 320 E. North Ave, Pittsburgh, PA, 15206, USA
| | - Matthew Kulzer
- Imaging Institute, Allegheny Health Network, 320 E. North Ave, Pittsburgh, PA, 15206, USA
| | - Tyson Tragon
- Imaging Institute, Allegheny Health Network, 320 E. North Ave, Pittsburgh, PA, 15206, USA
| | - Michael Spearman
- Imaging Institute, Allegheny Health Network, 320 E. North Ave, Pittsburgh, PA, 15206, USA
| | - Laura Eisenmenger
- School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Michael Goldberg
- Imaging Institute, Allegheny Health Network, 320 E. North Ave, Pittsburgh, PA, 15206, USA
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Low risk of intracranial emergency in patients with minor head injury treated with antiplatelet therapy. Eur J Emerg Med 2021; 28:481-482. [PMID: 34714816 DOI: 10.1097/mej.0000000000000818] [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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Perkins J, Shreffler J, Kamenec D, Bequer A, Ziemba C, O'Brien D, Shoff H, Smith J, Nash N, Huecker M. Short Observation Period and Aggressive Discharge of Patients With Head Injury and Serial CT Scans. Am Surg 2021:31348211063539. [PMID: 34823406 DOI: 10.1177/00031348211063539] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Many patients undergo two head computed tomography (CT) scans after mild traumatic brain injury (TBI). Radiographic progression without clinical deterioration does not usually alter management. Evidence-based guidelines offer potential for limited repeat imaging and safe discharge. This study characterizes patients who had two head CTs in the Emergency Department (ED), determines the change between initial and repeat CTs, and describes timing of repeat scans.Methods: This retrospective series includes all patients with head CTs during the same ED visit at an urban trauma center between May 1st, 2016 and April 30th, 2018. Radiographic interpretation was coded as positive, negative, or equivocal.Results: Of 241 subjects, the number of positive, negative, and equivocal initial CT results were 154, 50, and 37, respectively. On repeat CT, 190 (78.8%) interpretations were congruent with the original scan. Out of the 21.2% of repeat scans that diverged from the original read, 14 (5.8%) showed positive to negative conversion, 1 (.4%) showed positive to equivocal conversion, 2 (.88%) showed negative to positive conversion, 20 (8.3%) showed equivocal to negative conversion, and 14 (5.8%) showed equivocal to positive conversion. Average time between scans was 4.4 hours, and median length of stay was 10.2 hours.Conclusions: In this retrospective review, most repeat CT scans had no new findings. A small percentage converted to positive, rarely altering clinical management. This study demonstrates the need for continued prospective research to update clinical guidelines that could reduce admission and serial CT scanning for mild TBI.
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Affiliation(s)
- Jordan Perkins
- 12254University of Louisville School of Medicine, Louisville, KY, USA
| | - Jacob Shreffler
- Department of Emergency Medicine, 5170University of Louisville, Louisville, KY, USA
| | - Danielle Kamenec
- Department of Emergency Medicine, 5170University of Louisville, Louisville, KY, USA
| | - Alexandra Bequer
- Department of Emergency Medicine, 5170University of Louisville, Louisville, KY, USA
| | - Corey Ziemba
- 12254University of Louisville School of Medicine, Louisville, KY, USA
| | - Dan O'Brien
- Department of Emergency Medicine, 5170University of Louisville, Louisville, KY, USA
| | - Hugh Shoff
- Department of Emergency Medicine, 5170University of Louisville, Louisville, KY, USA
| | - Jason Smith
- Department of Surgery, 5170University of Louisville, Louisville, KY, USA
| | - Nicholas Nash
- Department of Surgery, 5170University of Louisville, Louisville, KY, USA
| | - Martin Huecker
- Department of Emergency Medicine, 5170University of Louisville, Louisville, KY, USA
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Mourad M, Senay A, Kharbutli B. The utility of a second head CT scan after a negative initial CT scan in head trauma patients on new direct oral anticoagulants (DOACs). Injury 2021; 52:2571-2575. [PMID: 34130854 DOI: 10.1016/j.injury.2021.05.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 04/28/2021] [Accepted: 05/21/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND New direct oral anticoagulants (DOACs) are commonly used in the management of atrial fibrillation and VTE. Currently, there is no strong evidence to support the current practice of routinely repeating computed tomography (CT) head in anticoagulated patients within 24 hours after their first negative CT scan to assess for new and delayed intracranial hemorrhage (ICH). Our hypothesis is that the vast majority will not have new CT scan findings of ICH and those who do would not require any further intervention. METHODS This is retrospective cohort study. IRB approval was obtained. Subjects included adults age ≥ 18 taking DOACs who presented to our level III trauma center with confirmed or suspected blunt head trauma between August 2013 and October 2019 and received at least one head CT scans. RESULTS 498 Patient encounters met inclusion criteria. Only 19 patients (3.8%) had positive traumatic ICH on the initial CT head. Those had a higher ISS. 420 out of 479 initial negative CT encounters received a second CT head. Only 2 (0.5%) had delayed positive second CT scan for ICH. 95%CI [0.06%, 1.7%] Patients who developed a new ICH on the second CT head after an initial negative CT scan had a lower Glasgow Coma Scale (GCS) on presentation and a higher ISS. None of those patients required neurosurgical intervention CONCLUSION: Our data suggests that the risk of developing a new or delayed traumatic ICH for patients on DOAC on a second CT head within 24 hours following an initial negative CT is very low and when present did not require neurosurgical intervention and thus does not support routinely obtaining a repeat CT head within 24 hours after a negative initial CT scan. Patients presenting with lower GCS and higher ISS had a higher chance of having a delayed ICH.
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Affiliation(s)
- Maha Mourad
- Department of Surgery, Henry Ford Wyandotte Hospital, Wyandotte, MI, USA.
| | - Ayla Senay
- Department of Surgery, Henry Ford Wyandotte Hospital, Wyandotte, MI, USA.
| | - Bilal Kharbutli
- Department of Surgery, Henry Ford Wyandotte Hospital, Wyandotte, MI, USA.
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Bethard JD, Ainger TJ, Gonciar A, Nyárádi Z. Surviving (but not thriving) after cranial vault trauma: A case study from Transylvania. INTERNATIONAL JOURNAL OF PALEOPATHOLOGY 2021; 34:122-129. [PMID: 34243131 DOI: 10.1016/j.ijpp.2021.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 05/27/2021] [Accepted: 06/20/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To link an antemortem cranial injury on the left parietal bone with potential neurocognitive consequences. MATERIALS The skeleton of a male individual from a Székely archaeological site in Transylvania was examined. The skeleton was radiocarbon dated to Cal AD 1450 and AD 1640 and presented a well-healed antemortem penetrating cranial injury on the left parietal bone. METHODS Macroscopic and radiographic analyses were conducted and the cranium was also archived digitally with a Faro FreeStyle3D scanner. In addition, well-known literature from neuroscience was synthesized in order to better understand the likely neurological consequences of the injury. RESULTS The literature suggests that tasks of attention and working memory, sensory processing, language processing, and vision are affected when the parietal lobe of the brain is injured. CONCLUSIONS Burial 195 did not likely return to a 'normal' life after he survived the cranial injury. SIGNIFICANCE This study demonstrates that bioarcheological interpretations involving antemortem cranial injuries can be enhanced by collaboration with neuroscientists. Bioarcheological interpretations are improved when the consequences of soft tissue injuries are understood. LIMITATIONS This study was limited by a lack of historical documents relevant to the region, time period, and specific case study. In addition, interpretations are cautionary because brain functioning cannot be assessed in vivo in the absence of life. SUGGESTIONS FOR FURTHER RESEARCH Bioarcheologists who study antemortem cranial injuries should continue to collaborate with neuroscientists.
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Affiliation(s)
- Jonathan D Bethard
- University of South Florida, Department of Anthropology, 4202 East Fowler Avenue, SOC107, Tampa, FL 33620, USA.
| | - Timothy J Ainger
- University of Kentucky College of Medicine, Department of Neurology, 740 S. Limestone, Kentucky Clinic J-414, Lexington, KY 40536, USA
| | | | - Zsolt Nyárádi
- Haáz Rezső Múzeum, Strada Beclean 2-6, Odorheiu Secuiesc 535600, Romania
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23
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Mild Head Trauma (MHT) and Antiplatelet Therapy. Reply to Lorenzati et al. Comment on "Savioli et al. Mild Head Trauma: Is Antiplatelet Therapy a Risk Factor for Hemorrhagic Complications? Medicina 2021, 57, 357". MEDICINA-LITHUANIA 2021; 57:medicina57090889. [PMID: 34577811 PMCID: PMC8469365 DOI: 10.3390/medicina57090889] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 08/13/2021] [Accepted: 08/23/2021] [Indexed: 11/17/2022]
Abstract
We read your data with interest, and we truly appreciate the similar experience [...].
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Incidence of delayed bleeding in patients on antiplatelet therapy after mild traumatic brain injury: a systematic review and meta-analysis. Scand J Trauma Resusc Emerg Med 2021; 29:123. [PMID: 34425865 PMCID: PMC8381571 DOI: 10.1186/s13049-021-00936-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 08/12/2021] [Indexed: 11/13/2022] Open
Abstract
Background The scientific evidence regarding the risk of delayed intracranial bleeding (DB) after mild traumatic brain injury (MTBI) in patients administered an antiplatelet agent (APA) is scant and incomplete. In addition, no consensus exists on the utility of a routine repeated head computed tomography (CT) scan in these patients. Objective The aim of this study was to evaluate the risk of DB after MTBI in patients administered an APA. Methods A systematic review and meta-analysis of prospective and retrospective observational studies enrolling adult patients with MTBI administered an APA and who had a second CT scan performed or a clinical follow-up to detect any DB after a first negative head CT scan were conducted. The primary outcome was the risk of DB in MTBI patients administered an APA. The secondary outcome was the risk of clinically relevant DB (defined as any DB leading to neurosurgical intervention or death). Results Sixteen studies comprising 2930 patients were included in this meta-analysis. The pooled absolute risk for DB was 0.77% (95% CI 0.23–1.52%), ranging from 0 to 4%, with substantial heterogeneity (I2 = 61%). The pooled incidence of clinically relevant DB was 0.18%. The subgroup of patients on dual antiplatelet therapy (DAPT) had an increased DB risk, compared to the acetylsalicylic acid (ASA)-only patients (2.64% vs. 0.22%; p = 0.04). Conclusion Our systematic review showed a very low risk of DB in MTBI patients on antiplatelet therapy. We believe that such a low rate of DB could not justify routine repeated CT scans in MTBI patients administered a single APA. We speculate that in the case of clinically stable patients, a repeated head CT scan could be useful for select high-risk patients and for patients on DAPT before discharge. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-021-00936-9.
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25
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Eichinger M, Robb HDP, Scurr C, Tucker H, Heschl S, Peck G. Challenges in the PREHOSPITAL emergency management of geriatric trauma patients - a scoping review. Scand J Trauma Resusc Emerg Med 2021; 29:100. [PMID: 34301281 PMCID: PMC8305876 DOI: 10.1186/s13049-021-00922-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 07/14/2021] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Despite a widely acknowledged increase in older people presenting with traumatic injury in western populations there remains a lack of research into the optimal prehospital management of this vulnerable patient group. Research into this cohort faces many uniqu1e challenges, such as inconsistent definitions, variable physiology, non-linear presentation and multi-morbidity. This scoping review sought to summarise the main challenges in providing prehospital care to older trauma patients to improve the care for this vulnerable group. METHODS AND FINDINGS A scoping review was performed searching Google Scholar, PubMed and Medline from 2000 until 2020 for literature in English addressing the management of older trauma patients in both the prehospital arena and Emergency Department. A thematic analysis and narrative synthesis was conducted on the included 131 studies. Age-threshold was confirmed by a descriptive analysis from all included studies. The majority of the studies assessed triage and found that recognition and undertriage presented a significant challenge, with adverse effects on mortality. We identified six key challenges in the prehospital field that were summarised in this review. CONCLUSIONS Trauma in older people is common and challenges prehospital care providers in numerous ways that are difficult to address. Undertriage and the potential for age bias remain prevalent. In this Scoping Review, we identified and discussed six major challenges that are unique to the prehospital environment. More high-quality evidence is needed to investigate this issue further.
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Affiliation(s)
- Michael Eichinger
- Major Trauma and Cutrale Perioperative and Ageing Group, Imperial College Healthcare NHS Trust, London, UK
| | - Henry Douglas Pow Robb
- Academic Clinical Fellow in General Surgery, Imperial College Healthcare NHS Trust, London, UK
| | - Cosmo Scurr
- Department of Anaesthesia, Imperial College Healthcare NHS Trust, London, UK
| | | | - Stefan Heschl
- Department of Cardiac, Thoracic and Vascular Anaesthesiology and Intensive Care, Medical University Hospital, Graz, Austria
| | - George Peck
- Cutrale Peri-operative and Ageing Group, Imperial College London, London, UK
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26
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Hughes PG, Alter SM, Greaves SW, Mazer BA, Solano JJ, Shih RD, Clayton LM, Trinh NQ, Lottenberg L, Hughes MJ. Acute and Delayed Intracranial Hemorrhage in Head-Injured Patients on Warfarin versus Direct Oral Anticoagulant Therapy. J Emerg Trauma Shock 2021; 14:123-127. [PMID: 34759629 PMCID: PMC8527063 DOI: 10.4103/jets.jets_139_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 11/24/2020] [Accepted: 12/22/2020] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Direct oral anticoagulant (DOAC) use for thrombosis treatment and prophylaxis is a popular alternative to warfarin. This study compares rates of traumatic intracranial hemorrhage (ICH) for patients on anticoagulant therapies and the effect of combined anticoagulant and antiplatelet therapies. METHODS A retrospective observational study of trauma patients was conducted at two level I trauma centers. Patients aged ≥18 years with preinjury use of an anticoagulant (warfarin, rivaroxaban, apixaban, or dabigatran) who sustained a blunt head injury within the past day were included. Patients were evaluated by head CT to evaluate for ICH. RESULTS Three hundred and eighty-eight patients were included (140 on warfarin, 149 on a DOAC, and 99 on combined anticoagulant and antiplatelet therapies). Seventy-nine patients (20.4%) had an acute ICH, while 16 patients (4.1%) had a delayed ICH found on routine repeat CT. Those on combination therapy were not at increased risk of acute ICH (relative risk [RR] 0.90, confidence interval [CI]: 0.56-1.44; P > 0.5) or delayed ICH (RR 2.19, CI: 0.84-5.69; P = 0.10) compared to anticoagulant use only. Those on warfarin were at increased risk of acute ICH (RR 1.75, CI: 1.10-2.78, P = 0.015), but not delayed ICH (RR 0.99, CI 0.27-3.59, P > 0.5), compared to those on DOACs. No delayed ICH patients died or required neurosurgical intervention. CONCLUSION Patients on warfarin had a higher rate of acute ICH, but not delayed ICH, compared to those on DOACs. Given the low rate of delayed ICH with no resultant morbidity or mortality, routine observation and repeat head CT on patients with no acute ICH may not be necessary.
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Affiliation(s)
- Patrick G. Hughes
- Division of Emergency Medicine, Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, FL, USA
| | - Scott M. Alter
- Division of Emergency Medicine, Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, FL, USA
| | - Spencer W. Greaves
- Division of Emergency Medicine, Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, FL, USA
| | - Benjamin A. Mazer
- Division of Emergency Medicine, Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, FL, USA
| | - Joshua J. Solano
- Division of Emergency Medicine, Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, FL, USA
| | - Richard D. Shih
- Division of Emergency Medicine, Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, FL, USA
| | - Lisa M. Clayton
- Division of Emergency Medicine, Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, FL, USA
| | - Nhat Q. Trinh
- Department of Emergency Medicine, Sparrow Hospital, Lansing, MI, USA
| | - Lawrence Lottenberg
- Department of Surgery, Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, MI, USA
- St. Mary’s Medical Center, West Palm Beach, FL, USA
| | - Mary J. Hughes
- Department of Osteopathic Medical Specialties, Michigan State University College of Osteopathic Medicine, East Lansing, MI, USA
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Valiuddin H, Calice M, Alam A, Millard J, Boehm K, Valiuddin Y, Laforest D, Ricardi R, Kaakaji R, Keyes D. Incidence of Traumatic Delayed Intracranial Hemorrhage Among Patients Using Direct Oral Anticoagulants. J Emerg Med 2021; 61:489-498. [PMID: 34175191 DOI: 10.1016/j.jemermed.2021.04.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 04/16/2021] [Accepted: 04/26/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Emergency department visits due to head injury in the United States have increased significantly over the past decade, and parallel the increasing use of direct oral anticoagulants (DOACs). OBJECTIVE We investigated the incidence of delayed intracranial hemorrhage (DICH) in patients with head injury who were taking DOACs. METHODS We conducted a single-center retrospective study at a level II trauma center. All patients with head injury and using DOACs with an initial negative head computed tomography (HCT) scan from March 1, 2014 to December 31, 2017 were included. DICH was identified as a positive finding on repeat HCT performed within 24 h. Each case of DICH underwent blinded review by two additional neuroradiologists. Demographic data were collected; independent t-tests were used to compare group means and linear regression for variable correlations. RESULTS Two hundred and eighty-seven patients with mean age of 80 years (interquartile range 14 years) met inclusion criteria. Repeat HCT was performed in 224 study participants (78%). Five (1.7%) resulted in DICH, three of which might have been present on initial HCT, with an incidence rate ranging from 0.7% to 1.7%. Only two initial HCTs were read as negative by all three neuroradiologists; 60% disagreed on the initial read. Independent t-test procedures showed an association between DICH and higher Injury Severity Score (ISS). CONCLUSIONS We found a DICH incidence rate of 0.7-1.7%. ISS was statistically significant between the two groups. It is possible that in patients with a subjective estimation of low injury severity, a low mechanism of injury and reasonable outpatient follow-up, patients can be discharged home with standard head injury precautions and no repeat HCT, but further prospective studies are needed.
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Affiliation(s)
| | | | | | | | - Kevin Boehm
- Broward Health Medical Center, Fort Lauderdale, Florida
| | | | - Daniel Laforest
- Sparrow Hospital Michigan State University, Lansing, Michigan
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Vedin T, Bergenfeldt H, Holmström E, Lundager-Forberg J, Edelhamre M. Microwave scan and brain biomarkers to rule out intracranial hemorrhage: study protocol of a planned prospective study (MBI01). Eur J Trauma Emerg Surg 2021; 48:1335-1342. [PMID: 33944977 PMCID: PMC9001545 DOI: 10.1007/s00068-021-01671-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 04/12/2021] [Indexed: 11/25/2022]
Abstract
Purpose The aim of this planned study is to evaluate the ability of a cranial microwave scanner in conjunction with nine brain biomarkers (Aβ40, Aβ42, GFAP, H-FABP, S100B, NF-L, NSE, UCH-L1 and IL-10) to detect and rule out traumatic intracranial hemorrhage in an emergency department setting. Traumatic brain injury is a world-wide topic of interest for researchers and clinicians. It affects 2% of the population per annum and presents challenges for physicians as patients’ initial signs and symptoms do not always correlate with the extent of brain injury. The gold standard for diagnosis of intracranial hemorrhage is head computerized tomography (CT) with the drawbacks of high cost and radiation exposure. A fast, secure way of diagnosing without these drawbacks has potential to make care more effective and reduce cost. Methods Study will be prospective and enroll adult, consenting patients with head trauma who seek emergency department care. Only patients where the treating physician prescribes a head-CT will be included. The microwave scan and blood sampling will be performed in close temporal proximity to the CT scan. Results will be analyzed with sensitivity, specificity and receiver operator characteristics analysis to provide the best combination of a number of biomarkers and the microwave scan. Conclusion This study will explore the diagnostic accuracy of a head microwave scanner in combination with biomarkers in ruling out intracranial hemorrhage in traumatic brain injury patients presenting to the emergency department. Potentially, this combined diagnostic approach could achieve both high sensitivity and high specificity, thereby reducing the need of CT-head scans when managing these patients. Clinicaltrials.gov identifier: NCT04666766. Registered December 11, 2020.
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Affiliation(s)
- Tomas Vedin
- Clinical Sciences, Lund University, Svartbrödragränden 3-5, 251 87 Helsingborg, Sweden
| | - Henrik Bergenfeldt
- Clinical Sciences, Lund University, Svartbrödragränden 3-5, 251 87 Helsingborg, Sweden
| | - Emanuel Holmström
- Clinical Sciences, Lund University, Svartbrödragränden 3-5, 251 87 Helsingborg, Sweden
| | | | - Marcus Edelhamre
- Clinical Sciences, Lund University, Svartbrödragränden 3-5, 251 87 Helsingborg, Sweden
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29
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Shih RY, Burns J, Ajam AA, Broder JS, Chakraborty S, Kendi AT, Lacy ME, Ledbetter LN, Lee RK, Liebeskind DS, Pollock JM, Prall JA, Ptak T, Raksin PB, Shaines MD, Tsiouris AJ, Utukuri PS, Wang LL, Corey AS. ACR Appropriateness Criteria® Head Trauma: 2021 Update. J Am Coll Radiol 2021; 18:S13-S36. [PMID: 33958108 DOI: 10.1016/j.jacr.2021.01.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 01/14/2021] [Indexed: 12/13/2022]
Abstract
Head trauma (ie, head injury) is a significant public health concern and is a leading cause of morbidity and mortality in children and young adults. Neuroimaging plays an important role in the management of head and brain injury, which can be separated into acute (0-7 days), subacute (<3 months), then chronic (>3 months) phases. Over 75% of acute head trauma is classified as mild, of which over 75% have a normal Glasgow Coma Scale score of 15, therefore clinical practice guidelines universally recommend selective CT scanning in this patient population, which is often based on clinical decision rules. While CT is considered the first-line imaging modality for suspected intracranial injury, MRI is useful when there are persistent neurologic deficits that remain unexplained after CT, especially in the subacute or chronic phase. Regardless of time frame, head trauma with suspected vascular injury or suspected cerebrospinal fluid leak should also be evaluated with CT angiography or thin-section CT imaging of the skull base, respectively. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Judah Burns
- Panel Chair, Montefiore Medical Center, Bronx, New York
| | | | - Joshua S Broder
- Duke University School of Medicine, Durham, North Carolina, American College of Emergency Physicians, Residency Program Director for Emergency Medicine, Vice Chief for Education, Division of Emergency Medicine, Department of Surgery, Duke University School of Medicine
| | - Santanu Chakraborty
- Ottawa Hospital Research Institute and the Department of Radiology, The University of Ottawa, Ottawa, Ontario, Canada, Canadian Association of Radiologists, CAR representative in ACR Quality Commission
| | - A Tuba Kendi
- Mayo Clinic, Rochester, Minnesota, Head of Nuclear Medicine Therapies at Mayo Clinic
| | - Mary E Lacy
- University of New Mexico, Albuquerque, New Mexico, American College of Physicians
| | | | - Ryan K Lee
- Einstein Healthcare Network, Philadelphia, Pennsylvania
| | - David S Liebeskind
- University of California Los Angeles, Los Angeles, California, American Academy of Neurology, President of SVIN
| | - Jeffrey M Pollock
- Oregon Health and Science University, Portland, Oregon, Editor, ACR Case in Point; Functional MRI Director, Oregon Health and Science University
| | - J Adair Prall
- Littleton Adventist Hospital, Littleton, Colorado, Neurosurgery expert, Chair, Guidelines Committee, Joint Section for Trauma and Critical Care
| | - Thomas Ptak
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland, Vice Chair of Community Radiology, University of Maryland Medical Center, Chief of Emergency and Trauma Imaging, R Adams Cowley Shock Trauma Center
| | - P B Raksin
- John H. Stroger Jr Hospital of Cook County, Chicago, Illinois, Neurosurgery expert, Chair Elect, American Association of Neurological Surgeons/Congress of Neurological Surgeons Section on Neurotrauma & Neurocritical Care; Vice Chair, American Association of Neurological Surgeons/Congress of Neurological Surgeons Joint Guidelines Review Committee; Director, Neurosurgery ICU
| | - Matthew D Shaines
- Albert Einstein College of Medicine Montefiore Medical Center, Bronx, New York, Internal Medicine Physician, Associate Program Director for the Moses-Weiler Internal Medicine Residency Program, Albert Einstein College of Medicine; Associate Chief, Division of Hospital Medicine
| | | | | | - Lily L Wang
- University of Cincinnati Medical Center, Cincinnati, Ohio, Neuroradiology Fellowship Program Director
| | - Amanda S Corey
- Specialty Chair, Atlanta VA Health Care System and Emory University, Atlanta, Georgia
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30
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Borst J, Godat LN, Berndtson AE, Kobayashi L, Doucet JJ, Costantini TW. Repeat head computed tomography for anticoagulated patients with an initial negative scan is not cost-effective. Surgery 2021; 170:623-627. [PMID: 33781587 DOI: 10.1016/j.surg.2021.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 01/17/2021] [Accepted: 02/08/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Patients on antithrombotic medications presenting with blunt trauma are at risk for delayed intracranial hemorrhage. We hypothesized that clinically significant delayed intracranial hemorrhage is rare in patients presenting on antithrombotic medications and therefore routine, repeat head computed tomography imaging is not a cost-effective practice to monitor for delayed intracranial hemorrhage. METHODS Patients presenting to our institution on antithrombotic (anticoagulant and antiplatelet) medications during a 5-y period from January 2014 through March 2019 who underwent a head computed tomography for blunt trauma were identified in our trauma registry. Patients with an initial negative head computed tomography underwent repeat imaging 6 h after their initial head computed tomography. Patient demographics, antithrombotic medication, international normalized ratio, Glasgow Coma Score, clinical change in neurologic status, and need for neurosurgical intervention were collected. RESULTS Our institution evaluated 1,676 patients on antithrombotic therapy with blunt trauma. The initial head computed tomography was negative in 1,377 patients (82.0%). Of those with an initial negative head computed tomography, 12 patients (0.9%) developed an intracranial hemorrhage that was identified on the second head computed tomography. Delayed intracranial hemorrhage included 6 patients with intraventricular hemorrhage, 3 with subdural hematoma, 2 with subarachnoid hemorrhage, and 1 with an intraparenchymal hemorrhage. None of the patients with delayed intracranial hemorrhage developed a change in neurologic status, required an intracranial pressure monitor, or underwent neurosurgical intervention. The estimated total direct cost of the negative head computed tomography scans was $926,247. CONCLUSION Clinically significant delayed intracranial hemorrhage is rare in trauma patients on antithrombotic therapy, with an initial negative head computed tomography. Routine repeat head computed tomography imaging in patients with a negative scan on admission is not cost-effective.
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Affiliation(s)
- Johanna Borst
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, UC San Diego School of Medicine, San Diego, CA. https://twitter.com/BorstJohanna
| | - Laura N Godat
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, UC San Diego School of Medicine, San Diego, CA. https://twitter.com/godat_l
| | - Allison E Berndtson
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, UC San Diego School of Medicine, San Diego, CA. https://twitter.com/ABerndtson
| | - Leslie Kobayashi
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, UC San Diego School of Medicine, San Diego, CA
| | - Jay J Doucet
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, UC San Diego School of Medicine, San Diego, CA. https://twitter.com/jaydoucet
| | - Todd W Costantini
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, UC San Diego School of Medicine, San Diego, CA.
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Puzio TJ, Murphy PB, Kregel HR, Ellis RC, Holder T, Wandling MW, Wade CE, Kao LS, McNutt MK, Harvin JA. Delayed Intracranial Hemorrhage after Blunt Head Trauma while on Direct Oral Anticoagulant: Systematic Review and Meta-Analysis. J Am Coll Surg 2021; 232:1007-1016.e5. [PMID: 33766725 DOI: 10.1016/j.jamcollsurg.2021.02.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 02/16/2021] [Accepted: 02/17/2021] [Indexed: 12/26/2022]
Affiliation(s)
| | | | | | - Ryan C Ellis
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Travis Holder
- Houston Academy of Medicine-Texas Medical Center Library, Houston, TX
| | | | - Charles E Wade
- University of Texas Medical Center at Houston, Houston, TX
| | - Lillian S Kao
- University of Texas Medical Center at Houston, Houston, TX
| | | | - John A Harvin
- University of Texas Medical Center at Houston, Houston, TX
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Marrone F, Zavatto L, Allevi M, Di Vitantonio H, Millimaggi DF, Dehcordi SR, Ricci A, Taddei G. Management of Mild Brain Trauma in the Elderly: Literature Review. Asian J Neurosurg 2021; 15:809-820. [PMID: 33708648 PMCID: PMC7869288 DOI: 10.4103/ajns.ajns_205_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 06/14/2020] [Accepted: 07/03/2020] [Indexed: 11/04/2022] Open
Abstract
Purpose The world population is aging. As direct consequence, geriatric trauma is increasing both in absolute number and in the proportion of annual admissions causing a challenge for the health-care system worldwide. The aim of this review is to delineate the specific and practice rules for the management of mild brain trauma in the elderly. Methods Systematic review of the last 15 years literature on mild traumatic brain injury (nTBI) in elderly patients. Results A total of 68 articles met all eligibility criteria and were selected for the systematic review. We collected 29% high-quality studies and 71% low-quality studies. Conclusion Clinical advices for a comprehensive management are provided. Current outcome data from mTBIs in the elderly show a condition that cannot be sustained in the future by families, society, and health-care systems. There is a strong need for more research on geriatric mild brain trauma addressed to prevent falls, to reduce the impact of polypharmacy, and to define specific management strategies.
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Affiliation(s)
- Federica Marrone
- Department of Neurosurgery, San Salvatore Hospital, University of L'Aquila, L'Aquila, Italy.,Department of Life, Health and Environmental Sciences (MESVA), University of L'Aquila, L'Aquila, Italy
| | - Luca Zavatto
- Department of Neurosurgery, San Salvatore Hospital, University of L'Aquila, L'Aquila, Italy.,Department of Life, Health and Environmental Sciences (MESVA), University of L'Aquila, L'Aquila, Italy
| | - Mario Allevi
- Department of Neurosurgery, San Salvatore Hospital, University of L'Aquila, L'Aquila, Italy.,Department of Life, Health and Environmental Sciences (MESVA), University of L'Aquila, L'Aquila, Italy
| | - Hambra Di Vitantonio
- Department of Neurosurgery, San Salvatore Hospital, University of L'Aquila, L'Aquila, Italy
| | | | - Soheila Raysi Dehcordi
- Department of Neurosurgery, San Salvatore Hospital, University of L'Aquila, L'Aquila, Italy
| | - Alessandro Ricci
- Department of Neurosurgery, San Salvatore Hospital, University of L'Aquila, L'Aquila, Italy
| | - Graziano Taddei
- Department of Neurosurgery, San Salvatore Hospital, University of L'Aquila, L'Aquila, Italy
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33
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Mitra B, Ruggles T, Seah J, Miller C, Fitzgerald MC. Delayed intracranial hemorrhage after trauma. Brain Inj 2021; 35:484-489. [PMID: 33606557 DOI: 10.1080/02699052.2021.1887520] [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: 10/22/2022]
Abstract
Introduction: Delayed Intracranial Hemorrhage (D-ICH), defined as finding of ICH on subsequent imaging after a normal computed tomography of the brain (CTB), is a feared complication after head trauma. The aim of this study was to determine the incidence and severity of D-ICH.Methods: This retrospective cohort study included patients that presented directly from the scene of injury to an adult major trauma center from Jan 2013 to Dec 2018.Results: There were 6536 patients who had an initial normal CTB and 23 (0.3%; 95%CI: 0.20-0.47) had D-ICH. There were 653 patients who had a repeat CTB (incidence of D-ICH 3.5%; 95%CI: 2.2-5.2). There was no significant association of D-ICH with age>65 years (OR 1.33; 95%CI: 0.54-3.29), presenting GCS <15 (OR 1.21; 95% CI: 0.52-2.80) and anti-platelet medications (OR 0.68; 95%CI: 0.26-1.74). Exposure to anti-coagulant medications was associated with lower odds of D-ICH (OR 0.23; 95%CI: 0.05-0.99). All cases of D-ICH were diffuse injury type II lesions on the Marshall classification. There were no cases that underwent neurosurgical intervention and no deaths were attributed to D-ICH.Conclusions: These results question observation of patients with head injury in hospital after a normal CTB for the sole purpose of excluding D-ICH.
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Affiliation(s)
- Biswadev Mitra
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia.,School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia.,National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia
| | - Tomi Ruggles
- School of Nursing & Midwifery, La Trobe University, Melbourne, Australia
| | - Jarrel Seah
- Department of Radiology, Alfred Health, Melbourne, Australia
| | - Charne Miller
- School of Nursing & Midwifery, La Trobe University, Melbourne, Australia
| | - Mark C Fitzgerald
- National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia.,Central Clinical School, Monash University, Melbourne, Australia.,Trauma Service, The Alfred Hospital, Melbourne, Australia
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Ethridge M, Keller J, Edhayan E. Risk of delayed intracranial hemorrhage in patients on anticoagulation with negative initial imaging. Am J Surg 2021; 221:606-608. [PMID: 33485622 DOI: 10.1016/j.amjsurg.2021.01.011] [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: 07/07/2020] [Revised: 12/30/2020] [Accepted: 01/05/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Many institutions obtain a delayed head CT in patients presenting after a ground level fall while on anticoagulation. This study evaluates their risk of delayed ICH. METHODS Retrospective chart review of 635 patients on anticoagulation who sustained a ground level fall with a negative initial head CT and a GCS above eight. Patients underwent a repeat head CT within 48 h. The ISS was calculated for all patients. RESULTS Five patients had a delayed ICH. All survived and none required neurosurgical intervention. Patient variables did not have any correlation with development of ICH. Patients with a delayed ICH had a significantly higher ISS. CONCLUSION Patients on anticoagulation presenting to the hospital after a ground level fall, with a GCS above eight and an initial negative head CT, do not need to undergo repeat imaging. ISS could be used to stratify patients who are at higher risk of delayed ICH.
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Affiliation(s)
- Meryl Ethridge
- Department of Surgery, Ascension St. John Hospital, USA.
| | - Joseph Keller
- Department of Surgery, Ascension St. John Hospital, USA.
| | - Elango Edhayan
- Department of Surgery, Ascension St. John Hospital, USA.
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Hickey S, Hickman ZL, Conway J, Giwa A. The Effect of Direct Oral Anti-Coagulants on Delayed Traumatic Intracranial Hemorrhage After Mild Traumatic Brain Injury: A Systematic Review. J Emerg Med 2021; 60:321-330. [PMID: 33390300 DOI: 10.1016/j.jemermed.2020.10.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 10/08/2020] [Accepted: 10/19/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND The use of anticoagulant medications leads to a higher risk of developing traumatic intracranial hemorrhage (tICH) after a mild traumatic brain injury (mTBI). The management of anticoagulated patients can be difficult to determine when the initial head computed tomography is negative for tICH. There has been limited research on the risk of delayed tICH in patients taking direct oral anticoagulant (DOAC) medications. OBJECTIVE Our aim was to determine the risk of delayed tICH for patients anticoagulated with DOACs after mTBI. METHODS We conducted a systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and searched several medical databases to examine the risk of delayed tICH in patients on DOACs. RESULTS There were 1252 nonduplicate studies that were identified through an initial database search, 15 of which met our inclusion and exclusion criteria and were included in our analysis after full-text review. A total of 1375 subjects were combined among the 15 studies, with 20 instances of delayed tICH after mTBI. Nineteen of the 20 patients with a delayed tICH were discharged without any neurosurgical intervention, and 1 patient on apixaban died due to a delayed tICH. CONCLUSIONS This systematic review confirms that delayed tICH after mTBI in patients on DOACs is uncommon. However, large, multicenter, prospective studies are needed to confirm the true incidence of clinically significant delayed tICH after DOAC use. Due to the limited data, we recommend using shared decision-making for patients who are candidates for discharge.
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Affiliation(s)
- Sean Hickey
- Department of Emergency Medicine, Icahn School of Medicine at the Mount Sinai Hospital, New York, New York
| | - Zachary L Hickman
- Department of Neurosurgery, Icahn School of Medicine at the Mount Sinai Hospital, New York, New York; Department of Neurosurgery, NYC Health + Hospitals/Elmhurst, Queens, New York
| | - John Conway
- Department of Emergency Medicine, Icahn School of Medicine at the Mount Sinai Hospital, New York, New York
| | - Al Giwa
- Department of Emergency Medicine, Icahn School of Medicine at the Mount Sinai Hospital, New York, New York; Neurotrauma Consortium, Inc., Elmhurst, New York
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Alter SM, Mazer BA, Solano JJ, Shih RD, Hughes MJ, Clayton LM, Greaves SW, Trinh NQ, Hughes PG. Antiplatelet therapy is associated with a high rate of intracranial hemorrhage in patients with head injuries. Trauma Surg Acute Care Open 2020; 5:e000520. [PMID: 33294625 PMCID: PMC7689589 DOI: 10.1136/tsaco-2020-000520] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 09/17/2020] [Accepted: 10/25/2020] [Indexed: 01/25/2023] Open
Abstract
Background Antiplatelet agents are increasingly used in cardiovascular treatment. Limited research has been performed into risks of acute and delayed traumatic intracranial hemorrhage (ICH) in these patients who sustain head injuries. Our goal was to assess the overall odds and identify factors associated with ICH in patients on antiplatelet therapy. Methods A retrospective observational study was conducted at two level I trauma centers. Adult patients with head injuries on antiplatelet agents were enrolled from the hospitals’ trauma registries. Acute ICH was diagnosed by head CT. Observation and repeat CT to evaluate for delayed ICH was performed at clinicians’ discretion. Patients were stratified by antiplatelet type and analyzed by ICH outcome. Results Of 327 patients on antiplatelets who presented with blunt head trauma, 133 (40.7%) had acute ICH. Three (0.9%) had delayed ICH on repeat CT, were asymptomatic and did not require neurosurgical intervention. One with delayed ICH was on clopidogrel and two were on both clopidogrel and aspirin. Patients with delayed ICH compared with no ICH were older (94 vs 74 years) with higher injury severity scores (15.7 vs 4.4) and trended towards lower platelet counts (141 vs 216). Patients on aspirin had a higher acute ICH rate compared with patients on P2Y12 inhibitors (48% vs 30%, 18% difference, 95% CI 4 to 33; OR 2.18, 95% CI 1.15 to 4.13). No other group comparison had significant differences in ICH rate. Conclusions Patients on antiplatelet agents with head trauma have a high rate of ICH. Routine head CT is recommended. Patients infrequently developed delayed ICH. Routine repeat CT imaging does not appear to be necessary for all patients. Level of evidence Level III, prognostic.
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Affiliation(s)
- Scott M Alter
- Division of Emergency Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, Florida, USA.,Department of Emergency Medicine, Delray Medical Center, Delray Beach, Florida, USA.,Department of Emergency Medicine, Bethesda Hospital East, Boynton Beach, Florida, USA
| | - Benjamin A Mazer
- Division of Emergency Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, Florida, USA
| | - Joshua J Solano
- Division of Emergency Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, Florida, USA.,Department of Emergency Medicine, Delray Medical Center, Delray Beach, Florida, USA.,Department of Emergency Medicine, Bethesda Hospital East, Boynton Beach, Florida, USA
| | - Richard D Shih
- Division of Emergency Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, Florida, USA.,Department of Emergency Medicine, Delray Medical Center, Delray Beach, Florida, USA
| | - Mary J Hughes
- Department of Osteopathic Medical Specialties, Michigan State University College of Osteopathic Medicine, East Lansing, Michigan, USA
| | - Lisa M Clayton
- Division of Emergency Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, Florida, USA.,Department of Emergency Medicine, Delray Medical Center, Delray Beach, Florida, USA.,Department of Emergency Medicine, Bethesda Hospital East, Boynton Beach, Florida, USA
| | - Spencer W Greaves
- Division of Emergency Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, Florida, USA
| | - Nhat Q Trinh
- Emergency Medicine Residency-Lansing, Sparrow Hospital, Lansing, Michigan, USA
| | - Patrick G Hughes
- Division of Emergency Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, Florida, USA.,Department of Emergency Medicine, Delray Medical Center, Delray Beach, Florida, USA.,Department of Emergency Medicine, Bethesda Hospital East, Boynton Beach, Florida, USA
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Repeat computed tomography head scan is not indicated in trauma patients taking novel anticoagulation: A multicenter study. J Trauma Acute Care Surg 2020; 89:301-310. [DOI: 10.1097/ta.0000000000002760] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Savioli G, Ceresa IF, Luzzi S, Gragnaniello C, Giotta Lucifero A, Del Maestro M, Marasco S, Manzoni F, Ciceri L, Gelfi E, Ricevuti G, Bressan MA. Rates of Intracranial Hemorrhage in Mild Head Trauma Patients Presenting to Emergency Department and Their Management: A Comparison of Direct Oral Anticoagulant Drugs with Vitamin K Antagonists. MEDICINA (KAUNAS, LITHUANIA) 2020; 56:E308. [PMID: 32585829 PMCID: PMC7353902 DOI: 10.3390/medicina56060308] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 06/17/2020] [Accepted: 06/19/2020] [Indexed: 12/18/2022]
Abstract
Background and objectives: Anticoagulants are thought to increase the risks of traumatic intracranial injury and poor clinical outcomes after blunt head trauma. The safety of using direct oral anticoagulants (DOACs) compared to vitamin K antagonists (VKAs) after intracranial hemorrhage (ICH) is unclear. This study aims to compare the incidence of post-traumatic ICH following mild head injury (MHI) and to assess the need for surgery, mortality rates, emergency department (ED) revisit rates, and the volume of ICH. Materials and Methods: This is a retrospective, single-center observational study on all patients admitted to our emergency department for mild head trauma from 1 January 2016, to 31 December 2018. We enrolled 234 anticoagulated patients, of which 156 were on VKAs and 78 on DOACs. Patients underwent computed tomography (CT) scans on arrival (T0) and after 24 h (T24). The control group consisted of patients not taking anticoagulants, had no clotting disorders, and who reported an MHI in the same period. About 54% in the control group had CTs performed. Results: The anticoagulated groups were comparable in baseline parameters. Patients on VKA developed ICH more frequently than patients on DOACs and the control group at 17%, 5.13%, and 7.5%, respectively. No significant difference between the two groups was noted in terms of surgery, intrahospital mortality rates, ED revisit rates, and the volume of ICH. Conclusions: Patients with mild head trauma on DOAC therapy had a similar prevalence of ICH to that of the control group. Meanwhile, patients on VKA therapy had about twice the ICH prevalence than that on the control group or patients on DOAC, which remained after correcting for age. No significant difference in the need for surgery was determined; however, this result must take into account the very small number of patients needing surgery.
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Affiliation(s)
- Gabriele Savioli
- Emergency Department, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (I.F.C.); (L.C.); (E.G.); (M.A.B.)
- Department of Clinical-Surgical, PhD School in Experimental Medicine, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy;
| | - Iride Francesca Ceresa
- Emergency Department, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (I.F.C.); (L.C.); (E.G.); (M.A.B.)
| | - Sabino Luzzi
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy; (S.L.); (A.G.L.); (S.M.)
- Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Cristian Gragnaniello
- Department of Neurological Surgery, University of Illinois at Chicago, Chicago, IL 60656, USA;
| | - Alice Giotta Lucifero
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy; (S.L.); (A.G.L.); (S.M.)
| | - Mattia Del Maestro
- Department of Clinical-Surgical, PhD School in Experimental Medicine, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy;
- Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Stefano Marasco
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy; (S.L.); (A.G.L.); (S.M.)
| | - Federica Manzoni
- Clinical Epidemiology and Biometry Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy;
| | - Luca Ciceri
- Emergency Department, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (I.F.C.); (L.C.); (E.G.); (M.A.B.)
| | - Elia Gelfi
- Emergency Department, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (I.F.C.); (L.C.); (E.G.); (M.A.B.)
| | - Giovanni Ricevuti
- Department of Drug Science, University of Pavia, Italy, -Saint Camillus International University of Health Sciences-Rome-Italy, 27100 Pavia, Italy;
| | - Maria Antonietta Bressan
- Emergency Department, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (I.F.C.); (L.C.); (E.G.); (M.A.B.)
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Cohan CM, Beattie G, Dominguez DA, Glass M, Palmer B, Victorino GP. Routine Repeat Head CT Does Not Change Management in Trauma Patients on Novel Anticoagulants. J Surg Res 2020; 249:114-120. [DOI: 10.1016/j.jss.2019.11.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 10/23/2019] [Accepted: 11/02/2019] [Indexed: 02/02/2023]
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40
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Valiuddin H, Alam A, Calice M, Boehm K, Millard J, Laforest D, Valiuddin Y, Ricardi R, Kaakaji R, Koch S, Oweis T, Keyes D. Utility of INR For Prediction of Delayed Intracranial Hemorrhage Among Warfarin Users with Head Injury. J Emerg Med 2020; 58:183-190. [DOI: 10.1016/j.jemermed.2020.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 12/31/2019] [Accepted: 01/09/2020] [Indexed: 01/24/2023]
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Probst MA, Gupta M, Hendey GW, Rodriguez RM, Winkel G, Loo GT, Mower WR. Prevalence of Intracranial Injury in Adult Patients With Blunt Head Trauma With and Without Anticoagulant or Antiplatelet Use. Ann Emerg Med 2020; 75:354-364. [PMID: 31959538 DOI: 10.1016/j.annemergmed.2019.10.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 09/09/2019] [Accepted: 10/02/2019] [Indexed: 12/27/2022]
Abstract
STUDY OBJECTIVE We determine the prevalence of significant intracranial injury among adults with blunt head trauma who are receiving preinjury anticoagulant or antiplatelet medications. METHODS This was a multicenter, prospective, observational study conducted from December 2007 to December 2015. Patients were enrolled in 3 emergency departments (EDs) in the United States. Adults with blunt head trauma who underwent neuroimaging in the ED were included. Use of preinjury aspirin, clopidogrel, and warfarin was recorded. Data on direct oral anticoagulants were not specifically recorded. The primary outcome was prevalence of significant intracranial injury on neuroimaging. The secondary outcome was receipt of neurosurgical intervention. RESULTS Among 9,070 patients enrolled in this study, the median age was 53.8 years (interquartile range 34.7 to 74.3 years) and 60.7% were men. A total of 1,323 patients (14.6%) were receiving antiplatelet medications or warfarin, including 635 receiving aspirin alone, 109 clopidogrel alone, and 406 warfarin alone. Compared with that of patients without any coagulopathy, the relative risk of significant intracranial injury was 1.29 (95% confidence interval [CI] 0.88 to 1.87) for patients receiving aspirin alone, 0.75 (95% CI 0.24 to 2.30) for those receiving clopidogrel alone, and 1.88 (95% CI 1.28 to 2.75) for those receiving warfarin alone. The relative risk of significant intracranial injury was 2.88 (95% CI 1.53 to 5.42) for patients receiving aspirin and clopidogrel in combination. CONCLUSION Patients receiving preinjury warfarin or a combination of aspirin and clopidogrel were at increased risk for significant intracranial injury, but not those receiving aspirin alone. Clinicians should have a low threshold for neuroimaging when evaluating patients receiving warfarin or a combination of aspirin and clopidogrel.
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Affiliation(s)
- Marc A Probst
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Malkeet Gupta
- UCLA Department of Emergency Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA; Antelope Valley Hospital Emergency Department, Lancaster, CA
| | - Gregory W Hendey
- UCLA Department of Emergency Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA; UCSF Fresno, Community Regional Medical Center, Fresno, CA
| | - Robert M Rodriguez
- Zuckerberg San Francisco General Hospital, Department of Emergency Medicine, UCSF School of Medicine, San Francisco, CA
| | - Gary Winkel
- Department of Oncological Sciences, Mount Sinai School of Medicine, New York, NY
| | - George T Loo
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - William R Mower
- UCLA Department of Emergency Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA
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Delayed Intracranial Hemorrhage in Patients with Head Trauma and Antithrombotic Therapy. J Clin Med 2019; 8:jcm8111780. [PMID: 31731421 PMCID: PMC6912196 DOI: 10.3390/jcm8111780] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 10/09/2019] [Accepted: 10/23/2019] [Indexed: 12/20/2022] Open
Abstract
Background: Delayed intracranial hemorrhage can occur up to several weeks after head trauma and was reported more frequently in patients with antithrombotic therapy. Due to the risk of delayed intracranial hemorrhage, some hospitals follow extensive observation and cranial computed tomography (CT) protocols for patients with head trauma, while others discharge asymptomatic patients after negative CT. Methods: We retrospectively analyzed data on patients with head trauma and antithrombotic therapy without pathologies on their initial CT. During the observation period, we followed a protocol of routine repeat CT before discharge for patients using vitamin K antagonists, clopidogrel or direct oral anticoagulants. Results: 793 patients fulfilled the inclusion criteria. Acetylsalicylic acid (ASA) was the most common antithrombotic therapy (46.4%), followed by vitamin K antagonists (VKA) (32.2%) and Clopidogrel (10.8%). We observed 11 delayed hemorrhages (1.2%) in total. The group of 390 patients receiving routine repeat CT showed nine delayed hemorrhages (2.3%). VKA were used in 6 of these 11 patients. One patient needed an urgent decompressive craniectomy while the other patients were discharged after an extended observation period. The patient requiring surgical intervention due to delayed hemorrhage showed neurological deterioration during the observation period. Conclusions: Routine repeat CT scans without neurological deterioration are not necessary if patients are observed in a clinical setting. Patients using ASA as single antithrombotic therapy do not require in-hospital observation after a negative CT scan.
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Huang GS, Dunham CM, Chance EA, Hileman BM. Detecting delayed intracranial hemorrhage with repeat head imaging in trauma patients on antithrombotics with no hemorrhage on the initial image: A retrospective chart review and meta-analysis. Am J Surg 2019; 220:55-61. [PMID: 31619376 DOI: 10.1016/j.amjsurg.2019.10.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 09/10/2019] [Accepted: 10/01/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND There is debate regarding routine repeat head computed tomography (CT) in blunt trauma patients on a pre-injury antithrombotic when the initial CT is negative for intracranial hemorrhage (ICH). DATA SOURCES Retrospective chart review and systematic literature review with meta-analysis. CONCLUSIONS In the chart review, 32.1% did not have a repeat head CT and 67.9% did. The delayed ICH incidence between those with and without a repeat head CT was similar (1.7% vs 0, p = .3101). The current study was combined with the identified 24 studies. Delayed ICH with or without routine repeat CT was similar between antiplatelet and anticoagulant categories (1.4% vs. 1.3%, p = .5322). Delayed ICH was lower for patients without routine repeat CT compared to those with routine repeat CT (0.8% vs 1.7%, p = .0008). For this patient population, repeat scans should be discretionary. Routine repeat CT may identify a larger proportion of minor delayed ICH.
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Affiliation(s)
- Gregory S Huang
- Trauma/ Critical Care/ General Surgery, St Elizabeth Youngstown Hospital, 1044 Belmont Ave, Youngstown, OH, 44501, USA.
| | - C Michael Dunham
- Trauma/ Critical Care/ General Surgery, St Elizabeth Youngstown Hospital, 1044 Belmont Ave, Youngstown, OH, 44501, USA
| | - Elisha A Chance
- Trauma/ Neuroscience Research, St Elizabeth Youngstown Hospital, 1044 Belmont Ave, Youngstown, OH, 44501, USA
| | - Barbara M Hileman
- Trauma/ Neuroscience Research, St Elizabeth Youngstown Hospital, 1044 Belmont Ave, Youngstown, OH, 44501, USA
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Using Lean Six Sigma to Improve Delayed Intracranial Hemorrhage Screening in a Geriatric Trauma Population. Qual Manag Health Care 2019; 27:199-203. [PMID: 30260926 DOI: 10.1097/qmh.0000000000000186] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Geriatric trauma patients taking preinjury anticoagulant or antiplatelet (ACAP) medications are at greater risk for delayed intracranial hemorrhage (DICH), a rare but potentially life-threatening condition. Routine repeat head computed tomography (RRHCT) scans can identify DICH. Our objective was to decrease the rate of missed RRHCT in a level 1 Midwest trauma center geriatric minor trauma population on preinjury ACAP medications. OBJECTIVE The objective of the quality improvement project was to identify the root cause of the missed RRHCTs and to implement a comprehensive solution to reduce rates of missed RRHCTs. METHODS Medical records from before and after the intervention were evaluated. Frequencies and percentages were calculated. In addition, χ and logistic regression were utilized. The Lean Six Sigma (LSS) DMAIC (Define, Measure, Analyze, Improve, and Control) process was used to drive process improvement. RESULTS At baseline, 15% (41 of 267) of RRHCTs were missed. After solution implementation, missed RRHCTs dropped to 4% (2 of 50). Of the 2 that were missed, zero were clinically inappropriate misses, making the postimplementation rate effectively 0%. CONCLUSION The LSS DMAIC process helped health care professional to facilitate improved adherence to the department's practice guideline with respect to RRHCT. Adherence with this guideline can help providers identify patients with DICH, a potentially life-threatening condition.
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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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Suehiro E, Fujiyama Y, Kiyohira M, Haji K, Ishihara H, Nomura S, Suzuki M. Risk of Deterioration of Geriatric Traumatic Brain Injury in Patients Treated with Antithrombotic Drugs. World Neurosurg 2019; 127:e1221-e1227. [PMID: 31009773 DOI: 10.1016/j.wneu.2019.04.108] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 04/10/2019] [Accepted: 04/11/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Developed countries have rapidly aging populations and the use of antithrombotic drugs is increasing. We investigated the effects of antithrombotic drugs and reversal of these drugs in patients with geriatric traumatic brain injury (TBI). METHODS Age, sex, mechanism of injury, Glasgow Coma Scale on admission, head computed tomography findings, antithrombotic therapy, acute exacerbation, and outcomes at discharge were examined in 711 patients with geriatric TBI, complicated with traumatic intracranial hemorrhage using data from the Japan Neurotrauma Data Bank Project 2015 (JNTDB P2015). These items were compared between patients who did and did not receive antithrombotic therapy. We also conducted a questionnaire survey of reversal of antithrombotic therapy at hospitals participating in the JNTDB P2015. Acute exacerbation was compared in hospitals that did and did not regularly use reversal of this therapy. RESULTS The major cause of injury was a fall. In head computed tomography, acute subdural hematoma was found in 65.7% of the subjects. Antithrombotic therapy was performed in 30.4% of subjects, and these subjects were significantly older than those who did not receive this therapy; many had a fall as the mechanism of injury, and the level of consciousness was significantly exacerbated with this therapy. In hospitals that performed regular reversal, late exacerbation of the level of consciousness was suppressed. CONCLUSIONS Patients with geriatric TBI who are given antithrombotic drugs have a risk for late exacerbation, even if initially diagnosed with mild TBI. Therefore, there is a possibility that reversal of antithrombotic drugs is important to suppress the risk of deterioration of patients with TBI.
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Affiliation(s)
- Eiichi Suehiro
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Yamaguchi, Japan; Japan Neurotrauma Data Bank Committee, The Japan Society of Neurotraumatology, Tokyo, Japan.
| | - Yuichi Fujiyama
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Yamaguchi, Japan
| | - Miwa Kiyohira
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Yamaguchi, Japan
| | - Kouhei Haji
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Yamaguchi, Japan
| | - Hideyuki Ishihara
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Yamaguchi, Japan
| | - Sadahiro Nomura
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Yamaguchi, Japan
| | - Michiyasu Suzuki
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Yamaguchi, Japan; Japan Neurotrauma Data Bank Committee, The Japan Society of Neurotraumatology, Tokyo, Japan
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- Japan Neurotrauma Data Bank Committee, The Japan Society of Neurotraumatology, Tokyo, Japan
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Spahn DR, Bouillon B, Cerny V, Duranteau J, Filipescu D, Hunt BJ, Komadina R, Maegele M, Nardi G, Riddez L, Samama CM, Vincent JL, Rossaint R. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care 2019; 23:98. [PMID: 30917843 PMCID: PMC6436241 DOI: 10.1186/s13054-019-2347-3] [Citation(s) in RCA: 688] [Impact Index Per Article: 137.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 02/06/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources. METHODS The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. RESULTS Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group's belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms. CONCLUSIONS A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient.
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Affiliation(s)
- Donat R. Spahn
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - Bertil Bouillon
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Vladimir Cerny
- Department of Anaesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Socialni pece 3316/12A, CZ-40113 Usti nad Labem, Czech Republic
- Centre for Research and Development, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic, Sokolska 581, CZ-50005 Hradec Kralove, Czech Republic
- Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine in Hradec Kralove, Charles University, Simkova 870, CZ-50003 Hradec Kralove, Czech Republic
- Department of Anaesthesia, Pain Management and Perioperative Medicine, QE II Health Sciences Centre, Dalhousie University, Halifax, 10 West Victoria, 1276 South Park St, Halifax, NS B3H 2Y9 Canada
| | - Jacques Duranteau
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud, University of Paris XI, Faculté de Médecine Paris-Sud, 78 rue du Général Leclerc, F-94275 Le Kremlin-Bicêtre Cedex, France
| | - Daniela Filipescu
- Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases, Sos Fundeni 256-258, RO-022328 Bucharest, Romania
| | - Beverley J. Hunt
- King’s College and Departments of Haematology and Pathology, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Radko Komadina
- Department of Traumatology, General and Teaching Hospital Celje, Medical Faculty Ljubljana University, SI-3000 Celje, Slovenia
| | - Marc Maegele
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Giuseppe Nardi
- Department of Anaesthesia and ICU, AUSL della Romagna, Infermi Hospital Rimini, Viale Settembrini, 2, I-47924 Rimini, Italy
| | - Louis Riddez
- Department of Surgery and Trauma, Karolinska University Hospital, S-171 76 Solna, Sweden
| | - Charles-Marc Samama
- Hotel-Dieu University Hospital, 1, place du Parvis de Notre-Dame, F-75181 Paris Cedex 04, France
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070 Brussels, Belgium
| | - Rolf Rossaint
- Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstrasse 30, D-52074 Aachen, Germany
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Hon S, Gaona SD, Faul M, Holmes JF, Nishijima DK. How Well Do EMS Providers Predict Intracranial Hemorrhage in Head-Injured Older Adults? PREHOSP EMERG CARE 2019; 24:8-14. [PMID: 30895835 DOI: 10.1080/10903127.2019.1597954] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective: To evaluate the accuracy of emergency medical services (EMS) provider judgment for traumatic intracranial hemorrhage (tICH) in older patients following head trauma in the field. We also compared EMS provider judgment with other sets of field triage criteria. Methods: This was a prospective observational cohort study conducted with five EMS agencies and 11 hospitals in Northern California. Patients 55 years and older who experienced blunt head trauma were transported by EMS between August 1, 2015 and September 30, 2016, and received an initial cranial computed tomography (CT) imaging, were eligible. EMS providers were asked, "What is your suspicion for the patient having intracranial hemorrhage (bleeding in the brain)?" Responses were recorded as ordinal categories (<1%, 1-5%, >5-10%, >10-50%, or >50%) and the incidences of tICH were recorded for each category. The accuracy of EMS provider judgment was compared to other sets of triage criteria, including current field triage criteria, current field triage criteria plus multivariate logistical regression risk factors, and actual transport. Results: Among the 673 patients enrolled, 319 (47.0%) were male and the median age was 75 years (interquartile range 64-85). Seventy-six (11.3%) patients had tICH on initial cranial CT imaging. The increase in EMS provider judgment correlated with an increase in the incidence of tICH. EMS provider judgment had a sensitivity of 77.6% (95% CI 67.1-85.5%) and a specificity of 41.5% (37.7-45.5%) when using a threshold of 1% or higher suspicion for tICH. Current field triage criteria (Steps 1-3) was poorly sensitive (26.3%, 95% CI 17.7-37.2%) in identifying tICH and current field trial criteria plus multivariate logistical regression risk factors was sensitive (97.4%, 95% CI 90.9-99.3%) but poorly specific (12.9%, 95% CI 10.4-15.8%). Actual transport was comparable to EMS provider judgment (sensitivity 71.1%, 95% CI 60.0-80.0%; specificity 35.3%, 95% CI 31.6-38.3%). Conclusions: As EMS provider judgment for tICH increased, the incidence for tICH also increased. EMS provider judgment, using a threshold of 1% or higher suspicion for tICH, was more accurate than current field triage criteria, with and without additional risk factors included.
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Barmparas G, Kobayashi L, Dhillon NK, Patel KA, Ley EJ, Coimbra R, Margulies DR. The risk of delayed intracranial hemorrhage with direct acting oral anticoagulants after trauma: A two-center study. Am J Surg 2018; 217:1051-1054. [PMID: 30336936 DOI: 10.1016/j.amjsurg.2018.10.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 10/09/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND The aim of this study was to characterize the risk of a delayed intracranial hemorrhage (ICH) in trauma patients on direct-acting oral anticoagulants (DOACs). METHODS Patients on DOACs admitted to two Level I Trauma Centers between 2014 and 2017 were reviewed. Only patients with a negative admission CT brain were included. The primary outcome was a delayed ICH. RESULTS Overall, 249 patients were included. The median age was 81 years with 82% undergoing a repeat CT. Three patients developed a delayed ICH (1.2%). One developed an ICH after receiving tissue plasminogen activator for a cerebrovascular accident after two negative CTs. Excluding this patient, the incidence dropped to 0.8%. None required neurosurgical intervention. CONCLUSION For patients at risk for a TBI who are on DOACs, repeat cross-sectional imaging of the brain when the initial imaging is negative is not necessary. A period of clinical observation may be warranted.
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Affiliation(s)
- Galinos Barmparas
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Leslie Kobayashi
- Department of Surgery, Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, University of California, San Diego, CA, USA
| | - Navpreet K Dhillon
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Kavita A Patel
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Eric J Ley
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Raul Coimbra
- Department of Surgery, Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, University of California, San Diego, CA, USA
| | - Daniel R Margulies
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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50
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Mann N, Welch K, Martin A, Subichin M, Wietecha K, Birmingham LE, Marchand TD, George RL. Delayed intracranial hemorrhage in elderly anticoagulated patients sustaining a minor fall. BMC Emerg Med 2018; 18:27. [PMID: 30142999 PMCID: PMC6109349 DOI: 10.1186/s12873-018-0179-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 08/10/2018] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Falls are a common cause of hospitalization, morbidity, and mortality among the elderly in the United States. Evidence-based imaging recommendations for evaluation of delayed intracranial hemorrhage (DICH) are not generally agreed upon. The purpose of this project was to evaluate the incidence of DICH detected by head computer tomography (CT) among an elderly population on pre-injury anticoagulant or antiplatelet (ACAP) therapy. METHODS Data from a Level 1 Trauma Center trauma registry was used to assess the incidence of DICH in an elderly population of patients (≥65 years) who sustained a minor fall while on pre-injury ACAP medications. Counts and percentages are reported. RESULTS Data on 1076 elderly trauma patients were downloaded, of which 838 sustained a minor fall and 513 were found to be using a pre-injury ACAP medication. One patient (0.46%) with a DICH was identified out of 218 patients who received a routine repeat head CT. Aspirin and warfarin were the most common pre-injury ACAP medications and 19.27% (42/218) of patients were found to be using multiple ACAP medications. CONCLUSIONS Universal screening protocols promote immediate-term patient safety, but do so at a great expense with respect to health expenditures and increased radiation exposure. This analysis highlights the need for an effective risk assessment tool for DICH that would reduce the burden of unnecessary screenings while still identifying life-threatening intracranial hemorrhages in affected patients.
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Affiliation(s)
- Nolan Mann
- Summa Health System- Department of Surgery, Akron Campus, Akron, OH, USA
| | - Kellen Welch
- Summa Health System- Department of Surgery, Akron Campus, Akron, OH, USA
| | - Andrew Martin
- Summa Health System- Department of Surgery, Akron Campus, Akron, OH, USA
| | - Michael Subichin
- Summa Health System- Department of Surgery, Akron Campus, Akron, OH, USA
| | - Katherine Wietecha
- Summa Health System- Department of Surgery, Division of Trauma Akron Campus, Akron Ohio, USA Northeast Ohio Medical University, Rootstown, OH, USA
| | | | - Tiffany D Marchand
- Summa Health System- Department of Surgery, Akron Campus, Akron, OH, USA
| | - Richard L George
- Summa Health System- Department of Surgery, Akron Campus, Akron, OH, USA
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