Antithrombotic Agent Use in Elderly Patients Sustaining Low-Level Falls

Validation of the cutaneous impact location to predict intracranial lesion among elderly admitted to the Emergency Department after a ground-level fall

INTRODUCTION

In the Emergency Departments, almost one out of two head CT scans are carried out for traumatic brain injuries among elderly victims of ground level-falls. Recently, a new predictive factor for intracranial lesions in this population has been suggested: presence and location of cutaneous impact. The aim of this study was to establish determinants of intracranial lesion among older patients admitted to EDs due to ground-level falls with traumatic brain injury using the head cutaneous impact location.

METHODS

A retrospective, observational and monocentric study of patients admitted to Emergency Department for ground-level falls with traumatic brain injury was carried out between 01 January 2017 and 31 July 2017. The primary outcome was identification of an acute intracranial lesion. A bootstrap procedure was employed to evaluate performance and internal validity of the final model.

RESULTS

Among the 1036 patients included, the mean age was 85.6 (SD 7.6) years and 94/1036 (9.1%, 95% CI 7.4-10.9) patients presented with an acute intracranial lesion. Multivariable analysis adjusted by bootstrap shrinkage showed that compared with temporal-parietal or occipital impact, Odds Ratio of intracranial lesions were 0.61 (95% CI 0.39-0.95, p = 0.03) in patients with frontal impact, 0.27 (95% CI 0.12-0.59, p = 0.001) in patients with facial impact and 0.21 (95% CI 0.06-0.77, p = 0.018) in patients without cutaneous impact. Subcutaneous hematoma (OR 1.97, p = 0.007), loss of consciousness (OR 4.66, p<0.001), fall-related amnesia (OR 2.58, p = 2.6), vomiting (OR 2.62, p = 0.002) and altered Glasgow Score (OR 6.79, p<0.001) were as well associated with high risk of intracranial lesion. Taking antiplatelets or anticoagulants were not associated with an increased risk of intracranial lesions. The model discrimination was adequate (C-statistic 0.79; 95% CI 0.73 - 0.85).

CONCLUSION

Our results establish specific determinants of intracranial lesions among elderly after ground level-falls. The cutaneous impact location may identify patients with high risk of intracranial lesion. Further researches are needed to propose a specific score based on these determinants so as to better target Head CT scan use.

Ground-level falls among nonagenarians: the impact of pre-injury antithrombotic therapy

Among nonagenarians admitted to our emergency department (ED) for ground-level falls, we assessed the impact of pre-injury antithrombotic (AT) treatment on the post-traumatic consequences, and identified risk factors for 1-month mortality. All eligible patients were consecutively included over an 18-month period. Head trauma was attested by reliable medical history, witnesses or recent external signs. Patient characteristics, post-traumatic consequences and outcomes were compared across patients with and without AT. Risk factors for 1-month mortality were assessed using multivariate logistic regression analyses. 1014 consecutive nonagenarians were analysed, 675 (66.6%) with AT and 339 (33.4%) without. Head trauma (n = 429, 42.3%) was significantly more frequent among patients with AT (49.2 vs 28.6%, p < 0.001). Intracranial hemorrhage (ICH, n = 43, 4.2%), mostly subdural hematomas (58%), were more frequently found among patients with AT (p < 0.015). At least one fracture was diagnosed for 23.9% of the population, mostly hip fractures, without any significant association with AT. At 1 month, 103 patients (10.2%) had died. The independent risk factors for 1-month mortality were: ICH associated with head trauma (OR = 5.9, 95% CI 2.5-14), Glasgow coma score ≤ 12 at admission (OR = 10; 95% CI 2.2-46), atrial fibrillation (OR = 2.2, 95% CI 1.4-3.4) and age ≥ 95 years (OR = 1.6, 95% CI 1.0-2.5). Our results support accurate and regular assessment of the benefit/risk ratio for antithrombotic treatment among elderly people at high risk for falls.

Craniotomies following acute traumatic brain injury in Finland-a national study between 1997 and 2018

Background

A number of patients who sustain a traumatic brain injury (TBI) require surgical intervention due to acute intracranial bleeding. The aim of this retrospective study was to assess the national trends of acute craniotomies following TBI in the Finnish adult population.

Methods

The data were collected retrospectively from the Finnish Care Register for Health Care (1997–2018). The study cohort covered all first-time registered craniotomies following TBI in patients aged 18 years or older. A total of 7627 patients (median age = 59 years, men = 72%) were identified.

Results

The total annual incidence of acute trauma craniotomies decreased by 33%, from 8.6/100,000 in 1997 to 5.7/100,000 in 2018. The decrease was seen in both genders and all age groups, as well as all operation subgroups (subdural hematoma, SDH; epidural hematoma, EDH; intracerebral hematoma, ICH). The greatest incidence rate of 15.4/100,000 was found in patients 70 years or older requiring an acute trauma craniotomy. The majority of surgeries were due to an acute SDH and the patients were more often men. The difference between genders decreased with age (18–39 years = 84% men, 40–69 = 78% men, 70 + years = 55% men). The median age of the patients increased from 58 to 65 years during the 22-year study period.

Conclusions

The number of trauma craniotomies is gradually decreasing; nonetheless, the incidence of TBI-related craniotomies remains high among geriatric patients. Further studies are needed to determine the indications and derive evidence-based guidelines for the neurosurgical care of older adults with TBIs to meet the challenges of the growing elderly population.

The phenomenon of caring for older patients who are dying from traumatic injuries in the emergency department: An interpretive phenomenological study

Purpose

To gain greater understanding of what it means to care for older patients dying from traumatic injuries in the emergency department.

Design

A Heideggerian phenomenological design using the methods of Van Manen.

Methods

In‐depth, face‐to‐face interviews were conducted with five emergency nurses who worked in an emergency department in Australia. Interview data were interpreted using a Heideggerian hermeneutic approach and guided by Van Manen’s lifeworld analysis focusing on the experiential aspects of lived time (temporality) and lived space (spatiality) in the phenomenon.

Findings

The older patient reflects the passage of chronological time. This temporal aspect shaped the participant experience as there was a sudden awareness of the impact of the injuries sustained on the fragile physical condition of the patients. There was an unexpectedness and unpreparedness which was related to a precognitive assumption that the older patient would die from an age‐related comorbid condition. Also of significance was the sacred liminal space in which the nurses worked to facilitate the dying patient transition from life to death.

Conclusions

The existential dimensions of temporality and spatiality revealed new insights into what it means to care for elderly patients dying from traumatic injuries. Temporal aspects were shaped by the longevity of the lives of patients and spatiality explored the liminal space where participants were morally guided to deliver end of life care with dignity and respect for a long‐lived life taken by trauma.

Clinical relevance

The findings may contribute to further understanding of what shapes the experience for emergency nurses delivering EOL care in the ED, with specific relevance and focus on the older patient with traumatic injuries. Hermeneutic research may also encourage clinicians to explore phenomena to reveal new understandings that will inform further dialogue and future research.

Thromboelastography with platelet mapping: Limited predictive ability in detecting preinjury antiplatelet agent use

BACKGROUND

Preinjury antiplatelet agent (APA) use in trauma patients can increase traumatic hemorrhage and worsen outcomes. Thromboelastography with platelet mapping (TEGPM) has characterized platelet function via arachidonic acid (AA) and adenosine diphosphate (ADP) inhibition in nontrauma settings, but limited data exist in the acute trauma population.

METHODS

A prospective observational study of adult trauma patients with suspected preinjury APA use who received TEGPM testing from 2017 to 2020 was performed. Patients on anticoagulants were excluded. Patients were grouped according to preinjury APA regimen: 81 mg or 325 mg of aspirin daily, 81 mg of aspirin and 75 mg of clopidrogrel daily, 75 mg of clopidrogrel daily, or no antiplatelet. Ability of TEGPM to detect APA use was assessed using predictive statistics and area under receiver operating characteristic curves (AUROCs).

RESULTS

A total of 824 patients were included with most patients taking 81 mg of aspirin (n = 558). Patients on no antiplatelet were younger and had higher baseline platelet counts, while patients on 75 mg of clopidrogrel were more likely to be admitted after ground level fall. All other baseline characteristics were balanced. Admission TEG values were similar between groups. Median AA inhibition was higher in patients on aspirin containing regimens (p < 0.0001). Median ADP inhibition was higher in patients on clopidogrel containing regimens and those taking 325 mg of aspirin (p < 0.0001). Arachidonic acid inhibition accurately detected preinjury APA use and aspirin use (AUROC, 0.89 and 0.84, respectively); however, ADP inhibition performed poorly (AUROC, 0.58). Neither AA nor ADP inhibition was able to discern specific APA regimens or rule out APA use entirely.

CONCLUSION

High AA inhibition accurately detects preinjury APA use in trauma patients. High ADP inhibition after trauma is common, limiting its utility to accurately identify preinjury APA use. Further study is needed to identify assays that can reliably detect and further characterize preinjury APA use in trauma populations.

LEVEL OF EVIDENCE

Diagnostic test, level II.