1
|
Iddagoda MT, Trevenen M, Meaton C, Etherton-Beer C, Flicker L. Identifying factors predicting outcomes after major trauma in older patients: Prognostic systematic review and meta-analysis. J Trauma Acute Care Surg 2024; 97:478-487. [PMID: 38523141 DOI: 10.1097/ta.0000000000004320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
Abstract
INTRODUCTION Trauma is the most common cause of morbidity and mortality in older people, and it is important to determine the predictors of outcomes after major trauma in older people. METHODS MEDLINE, Embase, and Web of Science were searched, and manual search of relevant papers since 1987 to February 2023 was performed. Random-effects meta-analyses were performed. The primary outcome of interest was mortality, and secondary outcomes were medical complications, length of stay, discharge destination, readmission, and intensive care requirement. RESULTS Among 6,064 studies in the search strategy, 136 studies qualified the inclusion criteria. Forty-three factors, ranging from demographics to patient factors, admission measurements, and injury factors, were identified as potential predictors. Mortality was the commonest outcome investigated, and increasing age was associated with increased risk of in-hospital mortality (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.03-1.07) along with male sex (OR, 1.40; 95% CI, 1.24-1.59). Comorbidities of heart disease (OR, 2.59; 95% CI, 1.41-4.77), renal disease (OR, 2.52; 95% CI, 1.79-3.56), respiratory disease (OR, 1.40; 95% CI, 1.09-1.81), diabetes (OR, 1.35; 95% CI, 1.03-1.77), and neurological disease (OR, 1.42; 95% CI, 0.93-2.18) were also associated with increased in-hospital mortality risk. Each point increase in the Glasgow Coma Scale lowered the risk of in-hospital mortality (OR, 0.85; 95% CI, 0.76-0.95), while each point increase in Injury Severity Score increased the risk of in-hospital mortality (OR, 1.07; 95% CI, 1.04-1.09). There were limited studies and substantial variability in secondary outcome predictors; however, medical comorbidities, frailty, and premorbid living condition appeared predictive for those outcomes. CONCLUSION This review was able to identify potential predictors for older trauma patients. The identification of these factors allows for future development of risk stratification tools for clinicians. LEVEL OF EVIDENCE Systematic Review and Meta-Analysis; Level III.
Collapse
Affiliation(s)
- Mayura Thilanka Iddagoda
- From the Perioperative Service (M.T.I., C.M., C.E.-B., L.F.), Royal Perth Hospital; and University of Western Australia (M.T.I., M.T., C.E.-B., L.F.), Perth, Australia
| | | | | | | | | |
Collapse
|
2
|
Wycech Knight J, Fokin AA, Menzione N, Rabinowitz SR, Viitaniemi SA, Puente I. Are geriatric transfer patients with traumatic brain injury at risk for worse outcomes compared to non-geriatric? Propensity-matched study. Brain Inj 2024; 38:659-667. [PMID: 38568043 DOI: 10.1080/02699052.2024.2337904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 03/28/2024] [Indexed: 05/29/2024]
Abstract
OBJECTIVE To compare outcomes between geriatric and non-geriatric patients with traumatic brain injury (TBI) transferred to trauma center and effects of anticoagulants/antiplatelets (AC/AP) and reversal therapy. METHODS A retrospective review of 1,118 patients with TBI transferred from acute care facilities to level 1 trauma center compared in groups: geriatric versus non-geriatric, geriatric with AC/AP therapy versus without, and geriatric AC/AP with AC/AP reversal therapy versus without. RESULTS Patients with TBI constituted 54.4% of trauma transfers. Mean transfer time was 3.9 h. Propensity matched by Injury Severity Score and Abbreviated Injury Score (AIS) head geriatric compared to non-geriatric patients had more AC/AP use (53.9% vs 8.8%), repeat head computed tomography (93.7% vs 86.1%), intensive care unit (ICU) admissions (57.4% vs 45.7%) and mortality (9.8% vs 3.2%), all p < 0.004. Patients on AC/AP versus without had more ICU admissions (69.1% vs 51.8%, p < 0.001). Patients with AC/AP reversals compared to without reversals had more AIS head 5 (32.0% vs 13.1%), brain surgeries (17.8% vs 3.5%) and ICU admissions (84.8% vs 57.1%), all p < 0.001. CONCLUSION TBI constituted half of trauma transfers and 10% required surgery. Based on higher ICU admissions, mortality, and prevalence of AC/AP therapy requiring reversal, geriatric patients with TBI on anticoagulants/antiplatelets should be considered for direct trauma center admission.
Collapse
Affiliation(s)
- Joanna Wycech Knight
- Delray Medical Center, Division of Trauma and Critical Care Services, Delray Beach, Florida, USA
- Broward Health Medical Center, Division of Trauma and Critical Care Services, Fort Lauderdale, Florida, USA
| | - Alexander A Fokin
- Delray Medical Center, Division of Trauma and Critical Care Services, Delray Beach, Florida, USA
- Charles E. Schmidt College of Medicine, Department of Surgery, Florida Atlantic University, Boca Raton, Florida, USA
| | - Nicholas Menzione
- Delray Medical Center, Division of Trauma and Critical Care Services, Delray Beach, Florida, USA
| | - Sarah R Rabinowitz
- Delray Medical Center, Division of Trauma and Critical Care Services, Delray Beach, Florida, USA
- Charles E. Schmidt College of Medicine, Department of Surgery, Florida Atlantic University, Boca Raton, Florida, USA
| | - Sari A Viitaniemi
- Delray Medical Center, Division of Trauma and Critical Care Services, Delray Beach, Florida, USA
| | - Ivan Puente
- Delray Medical Center, Division of Trauma and Critical Care Services, Delray Beach, Florida, USA
- Broward Health Medical Center, Division of Trauma and Critical Care Services, Fort Lauderdale, Florida, USA
- Charles E. Schmidt College of Medicine, Department of Surgery, Florida Atlantic University, Boca Raton, Florida, USA
- Herbert Wertheim College of Medicine, Department of Surgery, Florida International University, Miami, Florida, USA
| |
Collapse
|
3
|
Pan L, Hu J. Effect of prior anticoagulation therapy on outcomes of traumatic brain injury: A systematic review and meta‑analysis. Exp Ther Med 2024; 27:160. [PMID: 38476913 PMCID: PMC10928994 DOI: 10.3892/etm.2024.12448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 02/02/2024] [Indexed: 03/14/2024] Open
Abstract
Anticoagulants are commonly prescribed for multiple conditions. However, their influence on traumatic brain injury (TBI) outcomes, especially mortality, is not clear. The present study aimed to explore the effect of prior anticoagulation treatment on the outcomes of TBI. PubMed, Embase, Cochrane Central Register of Controlled Trials, Scopus and CINAHL databases were systematically searched for studies on individuals diagnosed with TBI, with a subgroup on prior anticoagulation therapy. Outcomes of interest included overall mortality, in-hospital mortality, length of hospital and intensive care unit stay, need for neurosurgical intervention and discharge rate. Cohort and case-control studies, published up to September 2023, were examined. Analysis was performed using STATA version 14.2 software and the Newcastle Ottawa Scale was used for bias assessment. A total of 22 studies (102,036 participants) were included in the analysis. Patients with TBI with prior anticoagulation treatment showed a statistically higher overall mortality risk [odds ratio (OR): 1.967, 95% confidence interval (CI): 1.481-2.613]. Subgroup analyses revealed age-specific and TBI severity-specific variations. Prior anticoagulation treatment was associated with a 1.860-times higher rate of in-hospital mortality and a significantly increased likelihood of requiring neurosurgical intervention (OR: 1.351, 95%CI: 1.068-1.708). However, no significant difference was noted in lengths of hospital or ICU stays. Patients with TBI and prior anticoagulation therapy are at higher risk of overall and in-hospital mortality and have significantly higher likelihood of needing neurosurgical interventions. The results emphasized the need for tailored therapeutic approach and more comprehensive clinical guidelines. Future investigations on specific anticoagulant types and immediate post-TBI interventions could offer further insights.
Collapse
Affiliation(s)
- Linghong Pan
- Department of Emergency, Huzhou Central Hospital, Affiliated Central Hospital of Huzhou University, Huzhou, Zhejiang 313000, P.R. China
| | - Jiayao Hu
- Department of Emergency, Huzhou Central Hospital, Affiliated Central Hospital of Huzhou University, Huzhou, Zhejiang 313000, P.R. China
| |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
Gallagher SP, Capacio BA, Rooney AS, Schaffer KB, Calvo RY, Sise CB, Krzyzaniak A, Sise MJ, Bansal V, Biffl WL, Martin MJ. Modified Brain Injury Guidelines for preinjury anticoagulation in traumatic brain injury: An opportunity to reduce health care resource utilization. J Trauma Acute Care Surg 2024; 96:240-246. [PMID: 37872672 DOI: 10.1097/ta.0000000000004171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
INTRODUCTION The Brain Injury Guidelines (BIG) stratify patients by traumatic brain injury (TBI) severity to provide management recommendations to reduce health care resource burden but mandates that patients on anticoagulation (AC) are allocated to the most severe tertile (BIG 3). We sought to analyze TBI patients on AC therapy using a modified BIG model to determine if this population can offer further opportunity for safe reductions in health care resource utilization. METHODS Patients 55 years or older on AC with traumatic intracranial hemorrhage (ICH) from two centers were retrospectively stratified into BIG 1 to 3 risk groups using modified BIG criteria excluding AC as a criterion. Intracranial hemorrhage progression, neurosurgical intervention (NSI), death, and worsened discharge status were compared. RESULTS A total of 221 patients were included, with 23%, 29%, and 48% classified as BIG 1, BIG 2, and BIG 3, respectively. The BIG 3 cohort had a higher rate of AC reversal agents administered (66%) compared with the BIG 1 (40%) and BIG 2 (54%) cohorts ( p < 0.01), as well as ICH progression discovered on repeat head computed tomography (56% vs. 38% vs. 26%, respectively; p < 0.001). No patients in the BIG 1 and 2 cohorts required NSI. No patients in BIG 1 and 3% of patients in BIG 2 died secondary to the ICH. In the BIG 3 cohort, 16% of patients required NSI and 26% died. Brain Injury Guidelines 3 patients had 15 times the odds of mortality compared with BIG 1 patients ( p < 0.01). CONCLUSION The AC population had higher rates of ICH progression than the BIG literature, but this did not lead to more NSI or mortality in the lower tertiles of our modified BIG protocol. If the modified BIG used the original tertile management on our population, then NS consultation may have been reduced by up to 52%. These modified criteria may be a safe opportunity for further health care resource and cost savings in the TBI population. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
Collapse
Affiliation(s)
- Shea P Gallagher
- From the Division of Trauma and Acute Care Surgery, Department of Surgery (S.P.G., B.A.C., A.S.R., R.Y.C., C.B.S., A.K., M.J.S., V.B., M.J.M.), Scripps Mercy Hospital, San Diego, California; Division of Trauma and Acute Care Surgery, Department of Surgery (S.P.G., M.J.M.), Los Angeles General Medical Center, Los Angeles, California; and Division of Trauma and Acute Care Surgery, Department of Surgery (K.B.S., W.L.B.), Scripps Memorial Hospital La Jolla, La Jolla, California
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
6
|
Qiu H, Zador Z, Lannon M, Farrokhyar F, Duda T, Sharma S. Identification of clinically relevant patient endotypes in traumatic brain injury using latent class analysis. Sci Rep 2024; 14:1294. [PMID: 38221527 PMCID: PMC10788338 DOI: 10.1038/s41598-024-51474-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 01/05/2024] [Indexed: 01/16/2024] Open
Abstract
Traumatic brain injury (TBI) is a complex condition where heterogeneity impedes the advancement of care. Understanding the diverse presentations of TBI is crucial for personalized medicine. Our study aimed to identify clinically relevant patient endotypes in TBI using latent class analysis based on comorbidity data. We used the Medical Information Mart for Intensive Care III database, which includes 2,629 adult TBI patients. We identified five stable endotypes characterized by specific comorbidity profiles: Heart Failure and Arrhythmia, Healthy, Renal Failure with Hypertension, Alcohol Abuse, and Hypertension. Each endotype had distinct clinical characteristics and outcomes: The Heart Failure and Arrhythmia endotype had lower survival rates than the Renal Failure with Hypertension despite featuring fewer comorbidities overall. Patients in the Hypertension endotype had higher rates of neurosurgical intervention but shorter stays in contrast to the Alcohol Abuse endotype which had lower rates of neurosurgical intervention but significantly longer hospital stays. Both endotypes had high overall survival rates comparable to the Healthy endotype. Logistic regression models showed that endotypes improved the predictability of survival compared to individual comorbidities alone. This study validates clinical endotypes as an approach to addressing heterogeneity in TBI and demonstrates the potential of this methodology in other complex conditions.
Collapse
Affiliation(s)
- Hongbo Qiu
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada.
| | - Zsolt Zador
- Division of Neurosurgery, McMaster University, Hamilton, ON, Canada
| | - Melissa Lannon
- Division of Neurosurgery, McMaster University, Hamilton, ON, Canada
| | - Forough Farrokhyar
- Department of Health, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Taylor Duda
- Division of Neurosurgery, McMaster University, Hamilton, ON, Canada
| | - Sunjay Sharma
- Division of Neurosurgery, McMaster University, Hamilton, ON, Canada
| |
Collapse
|
7
|
Aziz N, O'Halloran PJ, McKenna GS. Subdural haematoma in the elderly: management and outcomes of a UK Major Trauma Centre. Br J Neurosurg 2023; 37:1604-1612. [PMID: 36218868 DOI: 10.1080/02688697.2022.2122402] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 09/04/2022] [Indexed: 11/02/2022]
Abstract
BACKGROUND An estimated 40% of all traumatic brain injury (TBI) occurs in ≥70-year-olds with a high prevalence of traumatic subdural haematoma (tSDH). It is anticipated that an expanding elderly population will lead to a proportional increase in the incidence of patients with tSDH presenting to UK trauma centres, but the long-term clinical outcomes and factors influencing functional outcomes in this patient group remain poorly understood. AIM To examine the management and clinical outcomes for elderly (≥70 years) patients diagnosed with tSDH. METHODS Patient data for this single-centre, retrospective cohort study were analysed from a Major Trauma Centre (MTC) electronic patient records between January 2013 and December 2019. RESULTS Two hundred and eighty patients were included, 43% aged 70-79, 42% aged 80-89 and 15% >90. In total, 37% underwent a surgical intervention. The 6-month survival in the severe, moderate, and mild TBI groups was 14%, 43%, and 67%, respectively. The 6-month survival in the surgical group was 58%, vs. 60% in the conservatively managed group. Surgical intervention did not significantly impact Extended Glasgow Coma Score (GOS-E) at 6 months, regardless of injury severity. Advanced age (p = 0.04), mixed intracranial injuries (p < 0.0001), craniotomies (p = 0.03), and poor premorbid performance status (p = 0.02) were associated with worse survival and functional outcomes. CONCLUSIONS Our study demonstrated that increasing age, increasing severity of TBI and poorer premorbid performance status were associated with significantly poorer 6-month survival and functional outcomes in elderly patients with tSDH. Burr hole evacuation was associated with better functional outcomes compared to craniotomy, but overall, there was no significant difference in the outcomes of the surgical and non-surgical groups. We identified strong risk factors for death and poor functional outcomes at 6-months which are important to consider when counselling patients and families about the long-term prognosis of elderly patients with tSDH and can help guide clinical decision-making.
Collapse
Affiliation(s)
- Natasha Aziz
- School of Medicine, Queen Mary University of London, London, UK
| | - Philip J O'Halloran
- Department of Neurosurgery, Royal London Hospital, London, UK
- Department of Physiology & Medical Physics, Royal College of Surgeons in Ireland, London, UK
| | | |
Collapse
|
8
|
Sedlák M, Wazir A, Dima A, Gazda J, Morochovič R. Cutaneous Impact Location Predicts Intracranial Injury Among the Elderly Population with Traumatic Brain Injury. Open Access Emerg Med 2023; 15:265-275. [PMID: 37520843 PMCID: PMC10386855 DOI: 10.2147/oaem.s422785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 07/20/2023] [Indexed: 08/01/2023] Open
Abstract
Background Traumatic brain injury (TBI) is one of the most common trauma-related diagnoses among the elderly population treated in emergency departments (ED). Identification of patients with increased or decreased risk of intracranial bleeding is of clinical importance. The objective of this study was to evaluate the implication of cutaneous impact location (CIL) on the prevalence of intracranial injury after suspected or confirmed TBI irrespective of its severity. Methods This was a retrospective, single-center, descriptive observational study of geriatric patients aged 65 years and older treated for suspected or confirmed TBI in a trauma surgery ED. The primary outcome of the study was the assessment of a CIL of the injury and its association with the prevalence of intracranial lesions found on a head computed tomography scan. Results Among 381 patients included in the analysis, the CIL of interest (temporo-parietal and occipital impacts) was present among 178 (46.7%) cases. Thirty-six (9.5%) patients were diagnosed with intracranial bleeding. The prevalence of intracranial bleeding was higher in the CIL of interest group compared with other locations outside (12.9% vs 6.4%; p = 0.030). CIL of interest was a predictor of intracranial bleeding (p = 0.033; OR: 2.17; 95% CI: 1.06 to 4.42). Conclusion The CIL of head injury is a predictor of intracranial lesions among geriatric patients with traumatic brain injury. Physicians should be aware of this association when assessing elderly patients with head injuries. More studies are needed to develop a clinical management tool incorporating CIL to guide the diagnosis of TBI in this population.
Collapse
Affiliation(s)
- Marián Sedlák
- Trauma Surgery Department, Pavol Jozef Safarik University in Kosice, Faculty of Medicine & Louis Pasteur University Hospital, Kosice, Slovakia
- Zachranna Sluzba Kosice, Kosice, Slovakia
| | | | | | - Jakub Gazda
- 2nd Department of Internal Medicine, Pavol Jozef Safarik University in Kosice, Faculty of Medicine & Louis Pasteur University Hospital, Kosice, Slovakia
| | - Radoslav Morochovič
- Trauma Surgery Department, Pavol Jozef Safarik University in Kosice, Faculty of Medicine & Louis Pasteur University Hospital, Kosice, Slovakia
| |
Collapse
|
9
|
Webb AJ, Oetken HJ, Plott AJ, Knapp C, Munger DN, Gibson E, Schreiber M, Barton CA. The impact of low-dose aspirin in the Brain Injury Guidelines on outcomes in traumatic brain injury: A retrospective cohort study. J Trauma Acute Care Surg 2023; 94:320-327. [PMID: 35999660 DOI: 10.1097/ta.0000000000003772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Current Brain Injury Guidelines (BIG) characterize patients with intracranial hemorrhage taking antiplatelet or anticoagulant agents as BIG 3 (the most severe category) regardless of trauma severity. This study assessed the risk of in-hospital mortality or need for neurosurgery in patients taking low-dose aspirin who otherwise would be classified as BIG 1. METHODS This was a retrospective study at an academic level 1 trauma center. Patients were included if they were admitted with traumatic intracerebral hemorrhage and were evaluated by the BIG criteria. Exclusion criteria included indeterminate BIG status or patients with missing primary outcomes documentation. Patients were categorized as BIG 1, BIG 2, BIG 3, or BIG 1 on aspirin (patients with BIG 1 features taking low-dose aspirin). The primary endpoint was a composite of neurosurgical intervention and all-cause in-hospital mortality. Key secondary endpoints include rate of intracranial hemorrhage progression, and intensive care unit- and hospital-free days. RESULTS A total of 1,520 patients met the inclusion criteria. Median initial Glasgow Coma Scale was 14 (interquartile range [IQR], 12-15), Injury Severity Scale score was 17 (IQR, 10-25), and Abbreviated Injury Scale subscore head and neck (AIS Head ) was 3 (IQR, 3-4). The rate of the primary outcome for BIG 1, BIG 1 on aspirin, BIG 2, and BIG 3 was 1%, 2.2%, 1%, and 27%, respectively; the difference between BIG 1 on aspirin and BIG 3 was significant ( p < 0.001). CONCLUSION Patients taking low-dose aspirin with otherwise BIG 1-grade injuries experienced mortality and required neurosurgery significantly less often than other patients categorized as BIG 3. Inclusion of low-dose aspirin in the BIG criteria should be reevaluated. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
Collapse
Affiliation(s)
- Andrew J Webb
- From the Department of Pharmacy (A.J.W., H.J.O., C.A.B.), Oregon Health and Science University, Portland, Oregon; Department of Pharmacy (A.J.W.), Massachusetts General Hospital, Boston, Massachusetts; Department of Pharmacy (A.J.P.), University Hospital, Newark, New Jersey; Department of Surgery (C.K., E.G., M.S.), Oregon Health and Science University; and Department of Neurosurgery (D.N.M.), Oregon Health and Science University, Portland, Oregon
| | | | | | | | | | | | | | | |
Collapse
|
10
|
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.
Collapse
|
11
|
The Impact of Preinjury Antiplatelet and Anticoagulant Use on Elderly Patients with Moderate or Severe Traumatic Brain Injury Following Traumatic Acute Subdural Hematoma. World Neurosurg 2022; 166:e521-e527. [PMID: 35843581 DOI: 10.1016/j.wneu.2022.07.042] [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: 05/01/2022] [Revised: 07/09/2022] [Accepted: 07/09/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Although it is often assumed that preinjury anticoagulant (AC) or antiplatelet (AP) use is associated with poorer outcomes among those with acute subdural hematoma (aSDH), previous studies have had varied results. This study examines the impact of preinjury AC and AP therapy on aSDH thickness, 30-day mortality, and extended Glasgow Outcome Scale at 6 months in elderly patients (aged ≥65). METHODS A level 1 trauma center registry was interrogated to identify consecutive elderly patients who presented with moderate or severe traumatic brain injury (TBI) and associated traumatic aSDH between the first of January 2013 and the first of January 2018. Relevant demographic, clinical, and radiological data were retrieved from institutional medical records. The 3 primary outcome measures were aSDH thickness on initial computed tomography scan, 30-day mortality, and unfavorable outcome at 6 months (extended Glasgow Outcome Scale). RESULTS One hundred thirty-two elderly patients were admitted with moderate or severe TBI and traumatic aSDH. The mean (±SD) age was 78.39 (±7.87) years, and a majority of patients (59.8%, n = 79) were male. There was a statistically significant difference in mean aSDH thickness, but there were no significant differences in 30-day mortality (P = 0.732) and unfavorable outcome between the AP, AC, combined AP and AC, and no antithrombotic exposure groups (P = 0.342). CONCLUSIONS Further studies with larger sample sizes are necessary to confirm these observations, but our findings do not support the preconceived notion in clinical practice that antithrombotic use is associated with poor outcomes in elderly patients with moderate or severe TBI.
Collapse
|
12
|
Cognitive performance in older people after mild traumatic brain injury: Trauma effects and other risk factors. J Int Neuropsychol Soc 2022:1-11. [PMID: 36102332 DOI: 10.1017/s1355617722000674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cognitive symptoms are common in the initial weeks after mTBI, but recovery is generally expected within three months. However, there is limited information about recovery specifically in older age cohorts. Therefore, this study investigated cognitive outcome three months after mTBI in older adults (≥ 65 years) compared to trauma and community age-matched controls and explored risk factors for outcome after traumatic injury. METHODS Older mTBI patients (n = 40) and older adults with mild traumatic injury but without head injury (n = 66) were compared to a noninjured community control group (n = 47). Cognitive assessment included neuropsychological and computerized tests. Group differences were compared on individual tasks and overall cognitive performances using composite scores. Regression analyses identified predictors of outcome for trauma patients and moderator analyses explored possible interactions of mTBI severity with age and cognition. RESULTS As well as lower performances in processing speed and memory, both trauma groups had significantly lower performance on composite neuropsychological (d = .557 and .670) and computerized tasks (d = .783 and .824) compared to noninjured controls. Age, education, and history of depression were direct predictors of cognitive performance after mild traumatic injury (with or without head injury). Further moderation analysis demonstrated that mTBI severity (Glasgow Coma Scale < 15) moderated the impact of older age on computerized assessment (β = -.138). CONCLUSIONS Three months after mild trauma (regardless of head injury), older people demonstrate lower cognition compared to noninjured peers. However, severity of mTBI (Glasgow Coma Scale < 15) can interact with older age to predict poorer cognitive outcomes.
Collapse
|
13
|
van den Brand CL, Foks KA, Lingsma HF, van der Naalt J, Jacobs B, de Jong E, den Boogert HF, Sir Ö, Patka P, Polinder S, Gaakeer MI, Schutte CE, Jie KE, Visee HF, Hunink MG, Reijners E, Braaksma M, Schoonman GG, Steyerberg EW, Dippel DW, Jellema K. Update of the CHIP (CT in Head Injury Patients) decision rule for patients with minor head injury based on a multicenter consecutive case series. Injury 2022; 53:2979-2987. [PMID: 35831208 DOI: 10.1016/j.injury.2022.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 06/23/2022] [Accepted: 07/01/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To update the existing CHIP (CT in Head Injury Patients) decision rule for detection of (intra)cranial findings in adult patients following minor head injury (MHI). METHODS The study is a prospective multicenter cohort study in the Netherlands. Consecutive MHI patients of 16 years and older were included. Primary outcome was any (intra)cranial traumatic finding on computed tomography (CT). Secondary outcomes were any potential neurosurgical lesion and neurosurgical intervention. The CHIP model was validated and subsequently updated and revised. Diagnostic performance was assessed by calculating the c-statistic. RESULTS Among 4557 included patients 3742 received a CT (82%). In 383 patients (8.4%) a traumatic finding was present on CT. A potential neurosurgical lesion was found in 73 patients (1.6%) with 26 (0.6%) patients that actually had neurosurgery or died as a result of traumatic brain injury. The original CHIP underestimated the risk of traumatic (intra)cranial findings in low-predicted-risk groups, while in high-predicted-risk groups the risk was overestimated. The c-statistic of the original CHIP model was 0.72 (95% CI 0.69-0.74) and it would have missed two potential neurosurgical lesions and one patient that underwent neurosurgery. The updated model performed similar to the original model regarding traumatic (intra)cranial findings (c-statistic 0.77 95% CI 0.74-0.79, after crossvalidation c-statistic 0.73). The updated CHIP had the same CT rate as the original CHIP (75%) and a similar sensitivity (92 versus 93%) and specificity (both 27%) for any traumatic (intra)cranial finding. However, the updated CHIP would not have missed any (potential) neurosurgical lesions and had a higher sensitivity for (potential) neurosurgical lesions or death as a result of traumatic brain injury (100% versus 96%). CONCLUSIONS Use of the updated CHIP decision rule is a good alternative to current decision rules for patients with MHI. In contrast to the original CHIP the update identified all patients with (potential) neurosurgical lesions without increasing CT rate.
Collapse
Affiliation(s)
- Crispijn L van den Brand
- Department of Emergency Medicine, Haaglanden Medical Centre, PO Box 432, 2501 CK The Hague, the Netherlands; Department of Emergency Medicine, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands.
| | - Kelly A Foks
- Department of Public Health, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands; Department of Neurology, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands
| | - Joukje van der Naalt
- Department of Neurology, University of Groningen, University Medical Centre Groningen, PO Box 30001, 9700 RB Groningen, the Netherlands
| | - Bram Jacobs
- Department of Neurology, University of Groningen, University Medical Centre Groningen, PO Box 30001, 9700 RB Groningen, the Netherlands
| | - Eline de Jong
- Department of Emergency Medicine, Haaglanden Medical Centre, PO Box 432, 2501 CK The Hague, the Netherlands
| | - Hugo F den Boogert
- Department of Neurosurgery, Radboud University Medical Centre, PO Box 9101, 6500 HB Nijmegen, the Netherlands
| | - Özcan Sir
- Department of Emergency Medicine, Radboud University Medical Centre, PO Box 9101, 6500 HB Nijmegen, the Netherlands
| | - Peter Patka
- Department of Emergency Medicine, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands
| | - Menno I Gaakeer
- Department of Emergency Medicine, ADRZ, PO Box 15, 4460 AA Goes, the Netherlands
| | - Charlotte E Schutte
- Department of Emergency Medicine, ADRZ, PO Box 15, 4460 AA Goes, the Netherlands
| | - Kim E Jie
- Department of Emergency Medicine, Jeroen Bosch Hospital, PO 90153, 5200 ME 's-Hertogenbosch, the Netherlands
| | - Huib F Visee
- Department of Neurology, Jeroen Bosch Hospital, PO 90153, 5200 ME 's-Hertogenbosch, the Netherlands
| | - Myriam Gm Hunink
- Department of Radiology, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands; Department of Epidemiology, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands; Centre for Health Decision Sciences, Harvard T.H. Chan School of Public Health, Boston, USA
| | - Eef Reijners
- formerly Department of Emergency Medicine, Elisabeth-Tweesteden Hospital, PO Box 90151, 5000 LC Tilburg, the Netherlands
| | - Meriam Braaksma
- Department of Neurology, Bravis Hospital, PO Box 999, 4624 VT Bergen op Zoom, the Netherlands
| | - Guus G Schoonman
- Department of Neurology, Elisabeth-Tweesteden Hospital, PO Box 90151, 5000 LC Tilburg, the Netherlands
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands; Department of Biomedical Data Sciences, Leiden University Medical Centre, PO Box 9600, 2300 RC Leiden, the Netherlands
| | - Diederik Wj Dippel
- Department of Neurology, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands
| | - Korné Jellema
- Department of Neurology, Haaglanden Medical Centre, PO Box 432, 2501 CK The Hague, the Netherlands
| |
Collapse
|
14
|
Vervoordt SM, Hamze MK, Dell KC, Staph J, Hillary FG. Effects of preexisting stroke on acute hospital outcomes for older adults admitted with neurotrauma and orthopedic injury. Brain Inj 2022; 36:1109-1117. [PMID: 35996331 DOI: 10.1080/02699052.2022.2109742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
OBJECTIVE We aimed to examine acute trauma outcomes, specifically among those with neurotrauma (NT), in patients with preexisting cerebrovascular accident (CVA). METHODS We identified patients treated for neurotrauma or orthopedic trauma at hospitals in Pennsylvania with and without an identified history of stroke with residual deficits, aged 50-99 across four groups of N = 11,648 each. We assessed mortality, craniotomy, and total hospital, ICU, step-down, and ventilator days, functional status at discharge (FSD), and discharge destination. RESULTS Stroke history did not influence mortality but was predictive of patients undergoing craniotomy (OR = 1.25, p = 0.008). There was a moderate group effect on total ICU days, with the CVA+NT group in the ICU the longest (η2 = 0.10, p < 0.001). Patients with stroke history were less likely to be discharged to home (OR = 0.65, p < 0.001) and had poorer FSD scores across the various domains assessed. CONCLUSIONS Trauma patients with preexisting CVA were found to have poorer outcomes on a number of different metrics when compared to those without stroke history. While it is possible that functional differences pre-injury influenced FSD and discharge destination, given these results, clinicians should assess for possible comorbidities that may influence treatment.
Collapse
Affiliation(s)
- Samantha M Vervoordt
- Department of Psychology, The Pennsylvania State University, University Park, PA, USA
| | - Mohamad K Hamze
- Larner College of Medicine, The University of Vermont, Burlington, VT, USA
| | - Kristine C Dell
- Department of Psychology, The Pennsylvania State University, University Park, PA, USA
| | - Jason Staph
- Department of Psychology, The Pennsylvania State University, University Park, PA, USA
| | - Frank G Hillary
- Department of Psychology, The Pennsylvania State University, University Park, PA, USA
| |
Collapse
|
15
|
Mathieu F, Malhotra AK, Ku JC, Zeiler FA, Wilson JR, Pirouzmand F, Scales DC. Pre-Injury Antiplatelet Therapy and Risk of Adverse Outcomes after Traumatic Brain Injury: A Systematic Review and Meta-Analysis. Neurotrauma Rep 2022; 3:308-320. [PMID: 36060453 PMCID: PMC9438446 DOI: 10.1089/neur.2022.0042] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
There is an increasing number of trauma patients presenting on pre-injury antiplatelet (AP) agents attributable to an aging population and expanding cardio- or cerebrovascular indications for antithrombotic therapy. The effects of different AP regimens on outcomes after traumatic brain injury (TBI) have yet to be elucidated, despite the implications on patient/family counseling and the potential need for better reversal strategies. The goal of this systematic review and meta-analysis was to assess the impact of different pre-injury AP regimens on outcomes after TBI. In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, the OVID Medline, Embase, BIOSIS, Scopus, and Cochrane databases were searched from inception to February 2022 using a combination of terms pertaining to TBI and use of AP agents. Baseline demographics and study characteristics as well as outcome data pertaining to intracerebral hematoma (ICH) progression, need for neurosurgical intervention, hospital length of stay, mortality, and functional outcome were extracted. Pooled odds ratios (ORs) and mean differences comparing groups were calculated using random-effects models. Thirteen observational studies, totaling 1244 patients receiving single AP therapy with acetylsalicylic acid or clopidogrel, 413 patients on dual AP therapy, and 3027 non-AP users were included. No randomized controlled trials were identified. There were significant associations between dual AP use and ICH progression (OR, 2.81; 95% confidence interval [CI], 1.19–6.61; I2, 85%; p = 0.02) and need for neurosurgical intervention post-TBI (OR, 1.61; 95% CI, 1.15–2.28; I2, 15%; p = 0.006) compared to non-users, but not between single AP therapy and non-users. There were no associations between AP use and hospital length of stay or mortality after trauma. Pre-injury dual AP use, but not single AP use, is associated with higher rates of ICH progression and neurosurgical intervention post-TBI. However, the overall quality of studies was low, and this association should be further investigated in larger studies.
Collapse
Affiliation(s)
- François Mathieu
- Division of Neurosurgery, Department of Surgery, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Address correspondence to: François Mathieu, MD, MPhil, FRCSC, Division of Neurosurgery, Department of Surgery, University of Toronto, 399 Bathurst Street, Toronto, Ontario, Canada, M5T 2S8.
| | - Armaan K. Malhotra
- Division of Neurosurgery, Department of Surgery, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Jerry C. Ku
- Division of Neurosurgery, Department of Surgery, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Frederick A. Zeiler
- Department of Human Anatomy and Cell Science, University of Manitoba, Winnipeg, Manitoba, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
- Centre on Aging, University of Manitoba, Winnipeg, Manitoba, Canada
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Jefferson R. Wilson
- Division of Neurosurgery, Department of Surgery, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Neurosurgery, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Farhad Pirouzmand
- Division of Neurosurgery, Department of Surgery, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Damon C. Scales
- Interdepartmental Division of Critical Care Medicine, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
16
|
Abstract
OBJECTIVE Older age is often identified as a risk factor for poor outcome from traumatic brain injury (TBI). However, this relates predominantly to mortality following moderate-severe TBI. It remains unclear whether increasing age exerts risk on the expected recovery from mild TBI (mTBI). In this systematic review of mTBI in older age (60+ years), a focus was to identify outcome through several domains - cognition, psychological health, and life participation. METHODS Fourteen studies were identified for review, using PRISMA guidelines. Narrative synthesis is provided for all outcomes, from acute to long-term time points, and a meta-analysis was conducted for data investigating life participation. RESULTS By 3-month follow-up, preliminary findings indicate that older adults continue to experience selective cognitive difficulties, but given the data it is possible these difficulties are due to generalised trauma or preexisting cognitive impairment. In contrast, there is stronger evidence across time points that older adults do not experience elevated levels of psychological distress following injury and endorse fewer psychological symptoms than younger adults. Meta-analysis, based on the Glasgow Outcome Scale at 6 months+ post-injury, indicates that a large proportion (67%; 95% CI 0.569, 0.761) of older adults can achieve good functional recovery, similar to younger adults. Nevertheless, individual studies using alternative life participation measures suggest more mixed rates of recovery. CONCLUSIONS Although our initial review suggests some optimism in recovery from mTBI in older age, there is an urgent need for more investigations in this under-researched but growing demographic. This is critical for ensuring adequate health service provision, if needed.
Collapse
|
17
|
Posti JP, Ruuskanen JO, Sipilä JOT, Luoto TM, Rautava P, Kytö V. Effect of Oral Anticoagulation and Adenosine Diphosphate Inhibitor Therapies on Short-term Outcome of Traumatic Brain Injury. Neurology 2022; 99:e1122-e1130. [PMID: 35764401 DOI: 10.1212/wnl.0000000000200834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 04/22/2022] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Usage of oral anticoagulants (OAC) or adenosine diphosphate inhibitors (ADPi) is known to increase the risk of bleeding. We aimed to investigate the impact of OAC and ADPi therapies on short-term outcomes after traumatic brain injury (TBI). METHODS All adult patients hospitalized for TBI in Finland during 2005-2018 were retrospectively studied using a combination of national registries. Usage of pharmacy-purchased OACs and ADPis at the time of TBI was analyzed with the pill-counting method (Social Insurance Institution of Finland). The primary outcome was 30-day case-fatality (Finnish Cause of Death Registry). The secondary outcomes were acute neurosurgical operation (ANO) and admission duration (Finnish Care Register for Health Care). Baseline characteristics were adjusted with multivariable regression including age, sex, comorbidities, skull or facial fracture, OAC/ADPi treatment, initial admission location, and the year of TBI admission. RESULTS The study population included 57,056 persons (mean age 66 years) of whom 0.9% used direct oral anticoagulants (DOAC), 7.1% Vitamin K antagonists (VKA), and 2.3% ADPis. Patients with VKAs had higher case-fatality than patients without OAC (15.4% vs. 7.1%; adjHR 1.35, CI 1.23-1.48; p<0.0001). Case-fatality was lower with DOACs (8.4%) than with VKAs (adjHR 0.62, CI 0.44-0.87; p=0.005) and was not different from patients without OACs (adjHR 0.93, CI 0.69-1.26; p=0.634). VKA usage was associated with higher neurosurgical operation rate compared to non-OAC patients (9.1% vs. 8.3%; adjOR 1.33, CI 1.17-1.52; p<0.0001). There was no difference in operation rate between DOAC and VKA. ADPi was not associated with case-fatality or operation rate in the adjusted analyses. VKAs and DOACs were not associated with longer admission length compared with the non-OAC group, whereas the admissions were longer in the ADPi group compared with the non-ADPi group. CONCLUSION Preinjury use of VKA is associated with increases in short-term mortality and in need for ANOs after TBI. DOACs are associated with lower fatality than VKAs after TBI. ADPis were not independently associated with the outcomes studied. These results point to relative safety of DOACs or ADPis in patients at risk of head trauma and encourage to choose DOACs when oral anticoagulation is required. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that among adults with TBI, mortality was significantly increased in those using VKAs but not in those using DOACs or ADPis.
Collapse
Affiliation(s)
- Jussi P Posti
- Neurocenter, Department of Neurosurgery and Turku Brain Injury Center, Turku University Hospital and University of Turku, Finland
| | - Jori O Ruuskanen
- Neurocenter, Department of Neurology, Turku University Hospital and University of Turku, Finland
| | - Jussi O T Sipilä
- Clinical neurosciences, University of Turku, Turku, Finland; Department of Neurology, Siun sote, North Karelia Central Hospital, Joensuu, Finland
| | - Teemu M Luoto
- Department of Neurosurgery, Tampere University Hospital and Tampere University, Tampere, Finland
| | - Päivi Rautava
- Clinical Research Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Ville Kytö
- Heart Centre and Center for Population Health Research, Turku University Hospital and University of Turku, Turku, Finland.,Research Center of Applied and Preventive Cardiovascular Medicine, University of Turku, Turku, Finland.,Administrative Center, Hospital District of Southwest Finland, Turku, Finland.,Department of Public Health, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| |
Collapse
|
18
|
Application of a TEG-Platelet Mapping Algorithm to Guide Reversal of Antiplatelet Agents in Adults with Mild-to-Moderate Traumatic Brain Injury: An Observational Pilot Study. Neurocrit Care 2022; 37:638-648. [PMID: 35705826 DOI: 10.1007/s12028-022-01535-x] [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: 09/27/2021] [Accepted: 05/13/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Traumatic intracranial hemorrhages expand in one third of cases, and antiplatelet medications may exacerbate hematoma expansion. However, the reversal of an antiplatelet effect with platelet transfusion has been associated with harm. We sought to determine whether a thromboelastography platelet mapping (TEG-PM)-guided algorithm could limit platelet transfusion in patients with hemorrhagic traumatic brain injury (TBI) prescribed antiplatelet medications without a resultant clinically significant increase in hemorrhage volume, late hemostatic treatments, or delayed operative intervention. METHODS A total of 175 consecutive patients with TBI were admitted to our university-affiliated, level I trauma center between March 2016 and December 2019: 54 preintervention patients (control) and 121 patients with TEG-PM (study). After exclusion for anticoagulant administration, availability of neuroimaging and emergent neurosurgery, 62 study patients and 37 control patients remained. Intervention consisted of administration of desmopressin (DDAVP) for nonsurgical patients with significant inhibition at the arachidonic acid or adenosine diphosphate receptor sites. For surgical patients with significant inhibition, dual therapy with DDAVP and platelet transfusion was employed. Study patients were compared with a group of historical controls, which were identified from a prospectively maintained registry and typically treated with empiric platelet transfusion. RESULTS Median age was 75 years (interquartile range 85-67) and 77 years (interquartile range 81-65) in the TEG-PM and control patient groups, respectively. Admission hemorrhage volumes were similar (10.7 cm3 [20.1] in patients with TEG-PM vs. 14.1 cm3 [19.7] in controls; p = 0.41). There were no significant differences in admission Glasgow Coma Scale, mechanism of trauma, or baseline comorbidities. A total of 57% of controls versus 10% of patients with TEG-PM (p < 0.001) were transfused platelets; 52% of intervention patients and 0% controls were treated with DDAVP. Expansion hemorrhage volumes were not significantly different (14.0 cm3 [20.2] patients with TEG-PM versus 13.6 cm3 [23.7] controls; p = 0.93). There was no significant difference in rates of clinical deterioration, delayed neurosurgical intervention, or late platelet transfusion between groups. CONCLUSIONS Among patients with hemorrhagic TBI prescribed preinjury antiplatelet therapy, our study suggests that the use of a TEG-PM algorithm may reduce platelet transfusions without a concurrent increase in clinically significant hematoma expansion. Further study is required to prove a causative relationship.
Collapse
|
19
|
Cheng L, Cui G, Yang R. The Impact of Preinjury Use of Antiplatelet Drugs on Outcomes of Traumatic Brain Injury: A Systematic Review and Meta-Analysis. Front Neurol 2022; 13:724641. [PMID: 35197919 PMCID: PMC8858945 DOI: 10.3389/fneur.2022.724641] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 01/12/2022] [Indexed: 11/15/2022] Open
Abstract
Objective The study aimed to compare outcomes of traumatic brain injury (TBI) in patients on pre-injury antiplatelet drugs vs. those, not on any antiplatelet or anticoagulant drugs. Methods PubMed, Embase, and Google Scholar databases were searched up to 15th May 2021. All cohort studies comparing outcomes of TBI between antiplatelet users vs. non-users were included. Results Twenty studies were included. On comparison of data of 2,447 patients on pre-injury antiplatelet drugs with 4,814 controls, our analysis revealed no statistically significant difference in early mortality between the two groups (OR: 1.30 95% CI: 0.85, 1.98 I2 = 80% p = 0.23). Meta-analysis of adjusted data also revealed no statistically significant difference in early mortality between antiplatelet users vs. controls (OR: 1.24 95% CI: 0.93, 1.65 I2 = 41% p = 0.14). Results were similar for subgroup analysis of aspirin users and clopidogrel users. Data on functional outcomes was scarce and only descriptive analysis could be carried out. For the need for surgical intervention, pooled analysis did not demonstrate any statistically significant difference between the two groups (OR: 1.11 95% CI: 0.83, 1.48 I2 = 55% p = 0.50). Length of hospital stay (LOS) was also not found to be significantly different between antiplatelet users vs. non-users (MD: −1.00 95% CI: −2.17, 0.17 I2 = 97% p = 0.09). Conclusion Our results demonstrate that patients on pre-injury antiplatelet drugs do not have worse early mortality rates as compared to patients, not on any antiplatelet or anticoagulant drugs. The use of antiplatelets is not associated with an increased need for neurosurgical intervention and prolonged LOS.
Collapse
|
20
|
Kobeissy F, Mallah K, Zibara K, Dakroub F, Dalloul Z, Nasser M, Nasrallah L, Mallah Z, El-Achkar GA, Ramadan N, Mohamed W, Mondello S, Hamade E, Habib A. The effect of clopidogrel and aspirin on the severity of traumatic brain injury in a rat model. Neurochem Int 2022; 154:105301. [PMID: 35121011 DOI: 10.1016/j.neuint.2022.105301] [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: 10/10/2021] [Revised: 01/07/2022] [Accepted: 01/31/2022] [Indexed: 10/19/2022]
Abstract
Traumatic Brain Injury (TBI) is one of the leading causes of death and disability worldwide. Aspirin (ASA) and clopidogrel (CLOP) are antiplatelet agents that inhibit platelet aggregation. They are implicated in worsening the intracerebral haemorrhage (ICH) risk post-TBI. However, antiplatelet drugs may also exert a neuroprotective effect post-injury. We determined the impact of aspirin and clopidogrel treatment, alone or in combination, on ICH and brain damage in an experimental rat TBI model. We assessed changes in platelet aggregation and measured serum thromboxane by enzyme immune assay. We also explored a panel of brain damage and apoptosis biomarkers by immunoblotting. Rats were treated with aspirin and/or clopidogrel for 48 h prior to TBI and sacrificed 48 h post-injury. In rats treated with antiplatelet agents prior to TBI, platelet aggregation was completely inhibited, and serum thromboxane was significantly decreased, compared to the TBI group without treatment. TBI increases UCHL-1 and GFAP, but decreases hexokinase expression compared to the non-injured controls. All groups treated with antiplatelet drugs prior to TBI had decreased UCH-L1 and GFAP serum levels compared to the TBI untreated group. Furthermore, the ASA and CLOP single treatments increased the hexokinase serum levels. We confirmed that αII-spectrin cleavage increased post-TBI, with the highest cleavage detected in CLOP-treated rats. Aspirin and/or clopidogrel treatment prior to TBI is a double-edged sword that exerts a dual effect post-injury. On one hand, ASA and CLOP single treatments increase the post-TBI ICH risk, with a further detrimental effect from the ASA + CLOP treatment. On the other hand, ASA and/or CLOP treatments are neuroprotective and result in a favourable profile of TBI injury markers. The ICH risk and the neuroprotection benefits from antiplatelet therapy should be weighed against each other to ameliorate the management of TBI patients.
Collapse
Affiliation(s)
- Firas Kobeissy
- Department of Biochemistry and Molecular Genetics, Faculty of Medicine, American University of Beirut, Beirut, Lebanon.
| | - Khalil Mallah
- Department of Biochemistry and Molecular Genetics, Faculty of Medicine, American University of Beirut, Beirut, Lebanon; Department of Microbiology and Immunology, Medical University of South Carolina, 173 Ashley Avenue, BSB 204, MSC 504, Charleston, SC, 29425, USA
| | - Kazem Zibara
- ER045, Laboratory of Stem Cells, DSST, PRASE, Lebanese University, Beirut, Lebanon; Department of Biology, Faculty of Sciences-I, Lebanese University, Beirut, Lebanon
| | - Fatima Dakroub
- Department of Biochemistry and Molecular Genetics, Faculty of Medicine, American University of Beirut, Beirut, Lebanon; Molecular Biology and Cancer Immunology Laboratory, Faculty of Sciences-I, Lebanese University, Beirut, Lebanon
| | - Zeinab Dalloul
- Department of Biochemistry and Molecular Genetics, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Mohammad Nasser
- Department of Biochemistry and Molecular Genetics, Faculty of Medicine, American University of Beirut, Beirut, Lebanon; Molecular Biology and Cancer Immunology Laboratory, Faculty of Sciences-I, Lebanese University, Beirut, Lebanon
| | - Leila Nasrallah
- Department of Biochemistry and Molecular Genetics, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Zahraa Mallah
- Department of Biochemistry and Molecular Genetics, Faculty of Medicine, American University of Beirut, Beirut, Lebanon; Molecular Biology and Cancer Immunology Laboratory, Faculty of Sciences-I, Lebanese University, Beirut, Lebanon
| | - Ghewa A El-Achkar
- Department of Biochemistry and Molecular Genetics, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Naify Ramadan
- Department of Biochemistry and Molecular Genetics, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Wael Mohamed
- Clinical Pharmacology Department, Menoufia Medical School, Menoufia University, AlMinufya, Egypt; Basic Medical Science Department, Kulliyyah of Medicine, International Islamic University Malaysia, Kuantan, Pahang, Malaysia
| | | | - Eva Hamade
- Molecular Biology and Cancer Immunology Laboratory, Faculty of Sciences-I, Lebanese University, Beirut, Lebanon; Department of Biochemistry, Faculty of Sciences-I, Lebanese University, Beirut, Lebanon.
| | - Aida Habib
- Department of Basic Medical Sciences, QU Health, Qatar University, Doha, Qatar.
| |
Collapse
|
21
|
Serviá L, Llompart-Pou JA, Chico-Fernández M, Montserrat N, Badia M, Barea-Mendoza JA, Ballesteros-Sanz MÁ, Trujillano J. Development of a new score for early mortality prediction in trauma ICU patients: RETRASCORE. Crit Care 2021; 25:420. [PMID: 34876199 PMCID: PMC8650319 DOI: 10.1186/s13054-021-03845-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 11/26/2021] [Indexed: 11/20/2022] Open
Abstract
Background Severity scores are commonly used for outcome adjustment and benchmarking of trauma care provided. No specific models performed only with critically ill patients are available. Our objective was to develop a new score for early mortality prediction in trauma ICU patients. Methods This is a retrospective study using the Spanish Trauma ICU registry (RETRAUCI) 2015–2019. Patients were divided and analysed into the derivation (2015–2017) and validation sets (2018–2019). We used as candidate variables to be associated with mortality those available in RETRAUCI that could be collected in the first 24 h after ICU admission. Using logistic regression methodology, a simple score (RETRASCORE) was created with points assigned to each selected variable. The performance of the model was carried out according to global measures, discrimination and calibration. Results The analysis included 9465 patients: derivation set 5976 and validation set 3489. Thirty-day mortality was 12.2%. The predicted probability of 30-day mortality was determined by the following equation: 1/(1 + exp (− y)), where y = 0.598 (Age 50–65) + 1.239 (Age 66–75) + 2.198 (Age > 75) + 0.349 (PRECOAG) + 0.336 (Pre-hospital intubation) + 0.662 (High-risk mechanism) + 0.950 (unilateral mydriasis) + 3.217 (bilateral mydriasis) + 0.841 (Glasgow ≤ 8) + 0.495 (MAIS-Head) − 0.271 (MAIS-Thorax) + 1.148 (Haemodynamic failure) + 0.708 (Respiratory failure) + 0.567 (Coagulopathy) + 0.580 (Mechanical ventilation) + 0.452 (Massive haemorrhage) − 5.432. The AUROC was 0.913 (0.903–0.923) in the derivation set and 0.929 (0.918–0.940) in the validation set. Conclusions The newly developed RETRASCORE is an early, easy-to-calculate and specific score to predict in-hospital mortality in trauma ICU patients. Although it has achieved adequate internal validation, it must be externally validated. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03845-6.
Collapse
Affiliation(s)
- Luis Serviá
- Servei de Medicina Intensiva, Hospital Universitari Arnau de Vilanova, Universitat de Lleida, IRBLleida, Lleida, Spain
| | - Juan Antonio Llompart-Pou
- Servei de Medicina Intensiva, Hospital Universitari Son Espases, Institut d'Investigació Sanitària Illes Balears (IdISBa), Palma de Mallorca, Spain
| | - Mario Chico-Fernández
- UCI de Trauma y Emergencias, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Neus Montserrat
- Servei de Medicina Intensiva, Hospital Universitari Arnau de Vilanova, Universitat de Lleida, IRBLleida, Lleida, Spain
| | - Mariona Badia
- Servei de Medicina Intensiva, Hospital Universitari Arnau de Vilanova, Universitat de Lleida, IRBLleida, Lleida, Spain
| | - Jesús Abelardo Barea-Mendoza
- UCI de Trauma y Emergencias, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | - Javier Trujillano
- Servei de Medicina Intensiva, Hospital Universitari Arnau de Vilanova, Universitat de Lleida, IRBLleida, Lleida, Spain. .,Intensive Care Unit, Hospital Universitario Arnau de Vilanova, Avda Rovira Roure 80, 25198, Lleida, Spain.
| | | |
Collapse
|
22
|
Factors Affecting Outcomes in Geriatric Traumatic Subdural Hematoma in a Neurosurgical Intensive Care Unit. World Neurosurg 2021; 158:e441-e450. [PMID: 34767994 DOI: 10.1016/j.wneu.2021.11.004] [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: 09/02/2021] [Revised: 10/31/2021] [Accepted: 11/01/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND OBJECTIVE Geriatric patients (age ≥65 years) who sustain a traumatic brain injury have an increased risk of poor outcomes and higher mortality compared with younger cohorts. We aimed to evaluate the risk factors for discharge outcomes in a geriatric traumatic subdural hematoma population, stratified by age and pretraumatic medical comorbidities. This was a single-center retrospective cohort study of geriatric patients (N = 207). METHODS Patient charts were evaluated for factors including patient characteristics, comorbidities, injury-related and seizure-related factors, neurosurgical intervention, and patient disposition on discharge. RESULTS Bivariate and multivariate analyses showed that age was nonpredictive of patient outcomes. Underlying vasculopathic comorbidities were the primary determinant of posttraumatic seizure, surgical, and discharge outcomes. Multifactor analysis showed that patients who went on to develop status epilepticus (n = 11) had a higher frequency of vasculopathic comorbidities with strong predictive power in poor patient outcomes. CONCLUSIONS Our findings suggest a need to establish unique prognostic risk factors based on patient outcomes that guide medical and surgical treatment in geriatric patients.
Collapse
|
23
|
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 [...].
Collapse
|
24
|
Hofmann V, Deininger C, Döbele S, Konrads C, Wichlas F. Mild Traumatic Brain Injury in Older Adults: Are Routine Second cCT Scans Necessary? J Clin Med 2021; 10:jcm10173794. [PMID: 34501243 PMCID: PMC8432134 DOI: 10.3390/jcm10173794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 08/13/2021] [Accepted: 08/16/2021] [Indexed: 11/24/2022] Open
Abstract
Fall-related hospitalizations among older adults have been increasing in recent decades. One of the most common reasons for this is minimal or mild traumatic brain injury (mTBI) in older individuals taking anticoagulant medication. In this study, we analyzed all inpatient stays from January 2017 to December 2019 of patients aged > 75 years with a mTBI on anticoagulant therapy who received at least two cranial computer tomography (cCT) scans. Of 1477 inpatient stays, 39 had primary cranial bleeding, and in 1438 the results of initial scans were negative for cranial bleeding. Of these 1438 cases, 6 suffered secondary bleeding from the control cCT scan. There was no significance for bleeding related to the type of anticoagulation. We conclude that geriatric patients under anticoagulant medication don’t need a second cCT scan if the primary cCT was negative for intracranial bleeding and the patient shows no clinical signs of bleeding. These patients can be dismissed but require an evaluation for need of home care or protective measures to prevent recurrent falls. The type of anticoagulant medication does not affect the risk of bleeding.
Collapse
Affiliation(s)
- Valeska Hofmann
- BG Trauma Centre, Department of Trauma and Reconstructive Surgery, University of Tübingen, 72076 Tübingen, Germany; (S.D.); (C.K.)
- Correspondence:
| | - Christian Deininger
- Department of Orthopedics and Traumatology, University Hospital Salzburg, 5020 Salzburg, Austria; (C.D.); (F.W.)
| | - Stefan Döbele
- BG Trauma Centre, Department of Trauma and Reconstructive Surgery, University of Tübingen, 72076 Tübingen, Germany; (S.D.); (C.K.)
| | - Christian Konrads
- BG Trauma Centre, Department of Trauma and Reconstructive Surgery, University of Tübingen, 72076 Tübingen, Germany; (S.D.); (C.K.)
| | - Florian Wichlas
- Department of Orthopedics and Traumatology, University Hospital Salzburg, 5020 Salzburg, Austria; (C.D.); (F.W.)
| |
Collapse
|
25
|
Platelet dysfunction in patients with traumatic intracranial hemorrhage: Do desmopressin and platelet therapy help or harm? Am J Surg 2021; 223:131-136. [PMID: 34446216 DOI: 10.1016/j.amjsurg.2021.07.050] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 07/27/2021] [Accepted: 07/28/2021] [Indexed: 01/15/2023]
Abstract
BACKGROUND Pre-injury anti-platelet use has been associated with increased risk of progression of traumatic intracranial hemorrhage (TICH) and worse outcomes. VerifyNow® assays assess platelet inhibition due to aspirin/clopidogrel. This study assesses the outcomes of patients with TICH and platelet dysfunction treated with desmopressin and/or platelets. METHODS We performed a retrospective chart review of patients with mild TICH at a level 1 trauma center 1/1/2013-6/1/2016. Patients with documented platelet dysfunction who received desmopressin and/or platelets were compared to those who were untreated. Primary outcomes were progression of TICH and neurologic outcomes at discharge. RESULTS Of 565 patients with a mild TICH, 200 patients had evidence of platelet dysfunction (a positive VerifyNow® assay). Patients had similar baseline demographics, injury characteristics, and rate of TICH progression; but patients who received desmopressin and/or platelets had worse Glasgow Outcomes Score at discharge. CONCLUSION Treatment of patients with mild TICH and platelet dysfunction with desmopressin and/or platelets did not affect TICH progression but correlated with worse neurologic status at discharge.
Collapse
|
26
|
Ziegenhain F, Scherer J, Kalbas Y, Neuhaus V, Lefering R, Teuben M, Sprengel K, Pape HC, Jensen KO. Age-Dependent Patient and Trauma Characteristics and Hospital Resource Requirements-Can Improvement Be Made? An Analysis from the German Trauma Registry. ACTA ACUST UNITED AC 2021; 57:medicina57040330. [PMID: 33915888 PMCID: PMC8066778 DOI: 10.3390/medicina57040330] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 03/13/2021] [Accepted: 03/27/2021] [Indexed: 01/07/2023]
Abstract
Background and objectives: The burden of geriatric trauma patients continues to rise in Western society. Injury patterns and outcomes differ from those seen in younger adults. Getting a better understanding of these differences helps medical staff to provide a better care for the elderly. The aim of this study was to determine epidemiological differences between geriatric trauma patients and their younger counterparts. To do so, we used data of polytraumatized patients from the TraumaRegister DGU®. Materials and Methods: All adult patients that were admitted between 1 January 2013 and 31 December 2017 were included from the TraumaRegister DGU®. Patients aged 55 and above were defined as the elderly patient group. Patients aged 18–54 were included as control group. Patient and trauma characteristics, as well as treatment and outcome were compared between groups. Results: A total of 114,169 severely injured trauma patients were included, of whom 55,404 were considered as elderly patients and 58,765 younger patients were selected for group 2. Older patients were more likely to be admitted to a Level II or III trauma center. Older age was associated with a higher occurrence of low energy trauma and isolated traumatic brain injury. More restricted utilization of CT-imaging at admission was observed in older patients. While the mean Injury Severity Score (ISS) throughout the age groups stayed consistent, mortality rates increased with age: the overall mortality in young trauma patients was 7.0%, and a mortality rate of 40.2% was found in patients >90 years of age. Conclusions: This study shows that geriatric trauma patients are more frequently injured due to low energy trauma, and more often diagnosed with isolated craniocerebral injuries than younger patients. Furthermore, utilization of diagnostic tools as well as outcome differ between both groups. Given the aging society in Western Europe, upcoming studies should focus on the right application of resources and optimizing trauma care for the geriatric trauma patient.
Collapse
Affiliation(s)
- Franziska Ziegenhain
- Department of Trauma, University Hospital Zurich, 8091 Zurich, Switzerland; (J.S.); (Y.K.); (V.N.); (M.T.); (K.S.); (H.-C.P.); (K.O.J.)
- Correspondence:
| | - Julian Scherer
- Department of Trauma, University Hospital Zurich, 8091 Zurich, Switzerland; (J.S.); (Y.K.); (V.N.); (M.T.); (K.S.); (H.-C.P.); (K.O.J.)
| | - Yannik Kalbas
- Department of Trauma, University Hospital Zurich, 8091 Zurich, Switzerland; (J.S.); (Y.K.); (V.N.); (M.T.); (K.S.); (H.-C.P.); (K.O.J.)
| | - Valentin Neuhaus
- Department of Trauma, University Hospital Zurich, 8091 Zurich, Switzerland; (J.S.); (Y.K.); (V.N.); (M.T.); (K.S.); (H.-C.P.); (K.O.J.)
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, 51109 Cologne, Germany;
| | - Michel Teuben
- Department of Trauma, University Hospital Zurich, 8091 Zurich, Switzerland; (J.S.); (Y.K.); (V.N.); (M.T.); (K.S.); (H.-C.P.); (K.O.J.)
| | - Kai Sprengel
- Department of Trauma, University Hospital Zurich, 8091 Zurich, Switzerland; (J.S.); (Y.K.); (V.N.); (M.T.); (K.S.); (H.-C.P.); (K.O.J.)
| | - Hans-Christoph Pape
- Department of Trauma, University Hospital Zurich, 8091 Zurich, Switzerland; (J.S.); (Y.K.); (V.N.); (M.T.); (K.S.); (H.-C.P.); (K.O.J.)
| | - Kai Oliver Jensen
- Department of Trauma, University Hospital Zurich, 8091 Zurich, Switzerland; (J.S.); (Y.K.); (V.N.); (M.T.); (K.S.); (H.-C.P.); (K.O.J.)
| | - The TraumaRegister DGU
- Committee on Emergency Medicine, Intensive Care and Trauma Management (Sektion NIS) of the German Trauma Society (DGU), 10623 Berlin, Germany
| |
Collapse
|
27
|
Eastman DK, Spilman SK, Tang K, Sidwell RA, Pelaez CA. Platelet Reactivity Testing for Aspirin Patients Who Sustain Traumatic Intracranial Hemorrhage. J Surg Res 2021; 263:186-192. [PMID: 33677146 DOI: 10.1016/j.jss.2021.01.039] [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: 03/06/2020] [Revised: 11/12/2020] [Accepted: 01/15/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patients who take aspirin and sustain traumatic intracranial hemorrhage (tICH) are often transfused platelets in an effort to prevent bleeding progression. The efficacy of platelet transfusion is questionable, however, and some medical societies recommend that platelet reactivity testing (PRT) should guide transfusion decisions. The study hypothesis was that utilization of PRT to guide platelet transfusion for tICH patients suspected of taking aspirin would safely identify patients who did not require platelet transfusion. METHODS This was a retrospective study of patients with blunt tICH who received PRT for known or suspected aspirin use between June 2014 and December 2017 at a level I trauma center. Chart abstraction was conducted to determine home aspirin status, and PRT values were used to classify patients as therapeutic or nontherapeutic on aspirin. Differences were assessed with Kruskal-Wallis and chi-square tests. RESULTS 157 patients met study inclusion criteria, and 118 (75%) patients had documented prior aspirin use. PRT results were available approximately 1.7 h (IQR: 0.9, 3.2) after arrival. Upon initial PRT, 70% of patients were considered inhibited and 88% of those patients had aspirin documented as a home medication. Conversely, 18% of patients with home aspirin use had normal platelet reactivity. Clinically significant worsening of the tICH did not significantly differ when comparing those who received platelet transfusion with those who did not (8% versus 7%, P = 0.87). CONCLUSIONS Platelet reactivity testing can detect platelet inhibition related to aspirin and should guide transfusion decisions for head injured patients in the initial hours after trauma.
Collapse
Affiliation(s)
- Darla K Eastman
- Drake University, College of Pharmacy and Health Sciences, Des Moines, Iowa.
| | | | - Kelly Tang
- Osteopathic Medicine Program, Des Moines University, Des Moines, Iowa
| | - Richard A Sidwell
- Trauma Services, UnityPoint Health, Des Moines, Iowa; Trauma Surgery, The Iowa Clinic, Des Moines, Iowa
| | - Carlos A Pelaez
- Trauma Services, UnityPoint Health, Des Moines, Iowa; Trauma Surgery, The Iowa Clinic, Des Moines, Iowa
| |
Collapse
|
28
|
Beyer-Westendorf J. Direct Oral Anticoagulants in Atrial Fibrillation: Practical Considerations and Remaining Issues. Hamostaseologie 2021; 41:35-41. [PMID: 33588453 DOI: 10.1055/a-1329-2430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Preventing thromboembolic events, while minimizing bleeding risks, remains challenging when managing patients with atrial fibrillation. Despite large and successful trial programs, several clinical concerns remain which commonly relate to fears of over- or underexposure to drugs and unfavorable outcomes. After a short summary of the main phase III trial findings, this short review discusses the evidence and clinical relevance of common clinical concerns (correct direct oral anticoagulant [DOAC] dosing; DOAC in moderate-to-severe renal impairment; and the relevance of fasting, nasogastric tube feeding, or high body mass index) on DOAC plasma levels. Finally, the need for specific DOAC antidotes will be addressed.
Collapse
Affiliation(s)
- Jan Beyer-Westendorf
- Thrombosis Research Unit, Department of Medicine I, Division Hematology, University Hospital "Carl Gustav Carus" Dresden, Dresden, Germany
| |
Collapse
|
29
|
Riojas CM, Ekaney ML, Ross SW, Cunningham KW, Furay EJ, Brown CVR, Evans SL. Platelet Dysfunction after Traumatic Brain Injury: A Review. J Neurotrauma 2021; 38:819-829. [PMID: 33143502 DOI: 10.1089/neu.2020.7301] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Coagulopathy is a known sequela of traumatic brain injury (TBI) and can lead to increased morbidity and mortality. Platelet dysfunction has been identified as one of several etiologies of coagulopathy following TBI and has been associated with poor outcomes. Regardless of whether the platelet dysfunction occurs as a direct consequence of the injury or because of pre-existing medical comorbidities or medication use, accurate detection and monitoring of response to therapy is key to optimal patient care. Platelet transfusion has been proposed as a potential therapeutic intervention to treat platelet dysfunction, with several studies using platelet function assays to monitor response. The development of increasingly precise diagnostic testing is providing enhanced understanding of the specific derangement in the hemostatic process, allowing clinicians to provide patient-specific treatment plans. There is wide variability in the currently available literature on the incidence and clinical significance of platelet dysfunction following TBI, which creates challenges with developing evidence-based management guidelines. The relatively high prevalence of platelet inhibitor therapy serves as an additional confounding factor. In addition, the data are largely retrospective in nature. We performed a literature review to provide clarity on this clinical issue. We reviewed 348 abstracts, and included 97 manuscripts in our final literature review. Based on the currently available research, platelet dysfunction has been consistently demonstrated in patients with moderate-severe TBI. We recommend the use of platelet functional assays to evaluate patients with TBI. Platelet transfusion directed at platelet dysfunction may lead to improved clinical outcome. A randomized trial guided by implementation science could improve the applicability of these practices.
Collapse
Affiliation(s)
- Christina M Riojas
- FH "Sammy" Ross Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Michael L Ekaney
- FH "Sammy" Ross Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Samuel W Ross
- FH "Sammy" Ross Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Kyle W Cunningham
- FH "Sammy" Ross Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Elisa J Furay
- Dell Medical School, University of Texas at Austin, Austin, Texas, USA
| | - Carlos V R Brown
- Dell Medical School, University of Texas at Austin, Austin, Texas, USA
| | - Susan L Evans
- FH "Sammy" Ross Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| |
Collapse
|
30
|
Lim XT, Ang E, Lee ZX, Hajibandeh S, Hajibandeh S. Prognostic significance of preinjury anticoagulation in patients with traumatic brain injury: A systematic review and meta-analysis. J Trauma Acute Care Surg 2021; 90:191-201. [PMID: 33048909 DOI: 10.1097/ta.0000000000002976] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a leading cause of injury-related deaths and neurological disability globally. Considering the widespread anticoagulant use among the aging population, we aimed to perform a systematic review and meta-analysis to evaluate the prognostic significance of preinjury anticoagulation in TBI patients. METHODS This systematic review was conducted according to a predefined protocol (International Prospective Register of Systematic Reviews CRD42020192323). In compliance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-Analysis of Observational Studies in Epidemiology standards, a structured electronic database search was undertaken to identify all observational studies comparing preinjury anticoagulation with no preinjury anticoagulation in TBI patients. The primary outcome measure was overall mortality. The secondary outcome measures comprised in-hospital mortality, length of hospital stay, length of intensive care unit stay, need for neurosurgical procedure, and number of patients discharged home. All outcome data were analyzed using random effects modeling. RESULTS Twelve comparative studies enrolling a total of 4,417 patients were included. Preinjury anticoagulation was associated with higher risk of overall mortality (odds ratio [OR], 2.39; 95% confidence interval [CI], 1.63-3.50, p < 0.00001), in-hospital mortality (OR, 2.47; 95% CI, 1.56-3.93, p = 0.0001), and longer length of intensive care unit stay (mean difference, 1.06; 95% CI, 0.54-1.57; p < 0.0001) compared with no preinjury anticoagulation. No statistical difference was observed in length of hospital stay (mean difference, -2.15; 95% CI, -5.36 to 1.05, p = 0.19), need for neurosurgical procedure (OR, 1.30; 95% CI, 0.70-2.44; p = 0.41), and discharged home (OR, 0.76; 95% CI, 0.55-1.04; p = 0.09) between the two groups. CONCLUSION Preinjury anticoagulation is a powerful prognosticator of mortality in TBI patients. This highlights the need for dedicated triage and trauma team activation protocols considering earlier intervention and more aggressive imaging in all anticoagulated patients. Future studies should focus on strategies that can potentially reduce the risk of mortality in this population. The prognostic significance of direct oral anticoagulants versus warfarin remains unanswered. LEVEL OF EVIDENCE Systematic review and meta-analysis of observational studies, level III.
Collapse
Affiliation(s)
- Xin Tian Lim
- From the Wrexham Maelor Hospital (X.T.L., E.A., Z.X.L.), Betsi Cadwaladr University Health Board, Wrexham; Department of General Surgery (Shahin.H.), Sandwell and West Birmingham Hospitals NHS Trust, Birmingham; and Department of General Surgery (Shahab.H.), Glan Clwyd Hospital, Betsi Cadwaladr University Health Board, Rhyl, United Kingdom
| | | | | | | | | |
Collapse
|
31
|
Liu C, Xie J, Xiao X, Li T, Li H, Bai X, Li Z, Wang W. Clinical predictors of prognosis in patients with traumatic brain injury combined with extracranial trauma. Int J Med Sci 2021; 18:1639-1647. [PMID: 33746580 PMCID: PMC7976565 DOI: 10.7150/ijms.54913] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 01/04/2021] [Indexed: 12/20/2022] Open
Abstract
Objective: The purpose of this study was to investigate whether routine blood tests on admission and clinical characteristics can predict prognosis in patients with traumatic brain injury (TBI) combined with extracranial trauma. Methods: Clinical data of 182 patients with TBI combined with extracranial trauma from April 2018 to December 2019 were retrospectively collected and analyzed. Based on GOSE score one month after discharge, the patients were divided into a favorable group (GOSE 1-4) and unfavorable group (GOSE 5-8). Routine blood tests on admission and clinical characteristics were recorded. Results: Overall, there were 48 (26.4%) patients with unfavorable outcome and 134 (73.6%) patients with favorable outcome. Based on multivariate analysis, independent risk factors associated with unfavorable outcome were age (odds ratio [OR], 1.070; 95% confidence interval [CI], 1.018-1.124; p<0.01), admission Glasgow Coma Scale (GCS) score (OR, 0.807; 95% CI, 0.675-0.965; p<0.05), heart rate (OR, 1.035; 95% CI, 1.004-1.067; p<0.05), platelets count (OR, 0.982; 95% CI, 0.967-0.997; p<0.05), and tracheotomy (OR, 15.201; 95% CI, 4.121-56.078; p<0.001). Areas under the curve (AUC) of age, admission GCS, heart rate, tracheotomy, and platelets count were 0.678 (95% CI, 0.584-0.771), 0.799 (95% CI, 0.723-0.875), 0.652 (95% CI, 0.553-0.751), 0.776 (95% CI, 0.692-0.859), and 0.688 (95% CI, 0.606-0.770), respectively. Conclusions: Age, admission GCS score, heart rate, tracheotomy, and platelets count can be recognized as independent predictors of clinical prognosis in patients with severe TBI combined with extracranial trauma.
Collapse
Affiliation(s)
- Chengli Liu
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, P.R. China
| | - Jie Xie
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, P.R. China
| | - Xinshuang Xiao
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, P.R. China
| | - Tianyu Li
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, P.R. China
| | - Hui Li
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, P.R. China
| | - Xiangjun Bai
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, P.R. China
| | - Zhanfei Li
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, P.R. China
| | - Wei Wang
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, P.R. China
| |
Collapse
|
32
|
Lumas SG, Hsiang W, Becher RD, Maung AA, Davis KA, Schuster KM. Choosing the Best Approach to Warfarin Reversal After Traumatic Intracranial Hemorrhage. J Surg Res 2020; 260:369-376. [PMID: 33388533 DOI: 10.1016/j.jss.2020.12.004] [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: 08/02/2020] [Revised: 11/17/2020] [Accepted: 12/08/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patients on warfarin with traumatic intracranial hemorrhage often have the warfarin effects pharmacologically reversed. We compared outcomes among patients who received 4-factor prothrombin complex concentrate (PCC), fresh frozen plasma (FFP), or no reversal to assess the real-world impact of PCC on elderly patients with traumatic intracranial hemorrhage (ICH). MATERIALS AND METHODS This was a retrospective analysis of 150 patients on preinjury warfarin. Data were manually abstracted from the electronic medical record of an academic level 1 trauma center for patients admitted between January 2013 and December 2018. Outcomes were ICH progression on follow-up computed tomography scan, mortality, need for surgical intervention, and trends in the use of reversal agents. RESULTS Of 150 patients eligible for analysis, 41 received FFP, 60 PCC, and 49 were not reversed. On multivariable analysis, patients not reversed [OR 0.25 95% CI (0.31-0.85)] and women [OR 0.38 95% CI (0.17-0.88)] were less likely to experience progression of their initial bleed on follow-up computed tomography while subdural hemorrhage increased the risk [OR 3.69 95% CI (1.27-10.73)]. There was no difference between groups in terms of mortality or need for surgery. Over time use of reversal with PCC increased while use of FFP and not reversing warfarin declined (P < 0.001). CONCLUSIONS Male gender and using a reversal agent were associated with progression of ICH. Choice of reversal did not impact the need for surgery, hospital length of stay, or mortality. Some ICH patients may not require warfarin reversal and may bias studies, especially retrospective studies of warfarin reversal.
Collapse
Affiliation(s)
- Shunella G Lumas
- Division of General Surgery, Department of Surgery, Trauma, and Surgical Critical Care, Yale School of Medicine, New Haven, Connecticut
| | - Walter Hsiang
- Division of General Surgery, Department of Surgery, Trauma, and Surgical Critical Care, Yale School of Medicine, New Haven, Connecticut
| | - Robert D Becher
- Division of General Surgery, Department of Surgery, Trauma, and Surgical Critical Care, Yale School of Medicine, New Haven, Connecticut
| | - Adrian A Maung
- Division of General Surgery, Department of Surgery, Trauma, and Surgical Critical Care, Yale School of Medicine, New Haven, Connecticut
| | - Kimberly A Davis
- Division of General Surgery, Department of Surgery, Trauma, and Surgical Critical Care, Yale School of Medicine, New Haven, Connecticut
| | - Kevin M Schuster
- Division of General Surgery, Department of Surgery, Trauma, and Surgical Critical Care, Yale School of Medicine, New Haven, Connecticut.
| |
Collapse
|
33
|
Meade MJ, Tumati A, Chantachote C, Huang EC, Rutigliano DN, Rubano JA, Vosswinkel JA, Jawa RS. Antithrombotic Agent Use in Elderly Patients Sustaining Low-Level Falls. J Surg Res 2020; 258:216-223. [PMID: 33032140 DOI: 10.1016/j.jss.2020.08.047] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 08/19/2020] [Accepted: 08/25/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Elderly patients who are injured from a low-level fall comprise an increasing percentage of trauma admissions. We sought to evaluate the prevalence of antithrombotic (anticoagulant or antiplatelet) agent use, injury patterns, and outcomes in this population, focusing on intracranial hemorrhage (ICH). METHODS We retrospectively reviewed the trauma registry at an American College of Surgeons-verified Level I trauma center for all patients aged 65 y or older admitted between 2007 and 2016 following a low-level fall. Medical records of patients on antithrombotic agents were examined in detail. Patients were divided into four groups based on the presence/absence of ICH and presence/absence of preadmission antithrombotic medication use. RESULTS There were 4074 elderly patients admitted after a low-level fall, of which 1153 (28.3%) had a traumatic ICH, and 1238 (30.4%) were on antithrombotic agents. Notably, 35.9% of patients on antithrombotics had an ICH, as compared to 25.0% of 2836 patients not on antithrombotics other than aspirin (P < 0.001). The overall distribution of antithrombotic agent use differed significantly between the ICH and non-ICH groups; the ICH group had more coumadin usage. The mortality rate was significantly different across groups, with the group having ICH and a history of antithrombotics having the highest mortality at 14.2% (P < 0.001). Excluding the 27.8% of patients who were transferred into our hospital demonstrated that significantly more admissions on antithrombotics had ICH (22.4%) versus ICH admissions not on antithrombotics (14.7%, P < 0.001). The mortality rate was significantly different across groups, with the group having ICH and a history of antithrombotics having the highest mortality at 12.0% (P < 0.001). On multivariable analysis, anticoagulants, antiplatelets, and aspirin were all significantly associated with ICH; but only anticoagulants were significantly associated with mortality. CONCLUSIONS Antithrombotic agent use was common in admitted elderly patients sustaining a low-level fall and is associated with an elevated rate of ICH. Anticoagulants were also associated with increased mortality.
Collapse
Affiliation(s)
- Michael J Meade
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, New York
| | - Abhinay Tumati
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, New York
| | - Chanak Chantachote
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, New York
| | - Emily C Huang
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, New York
| | - Daniel N Rutigliano
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, New York
| | - Jerry A Rubano
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, New York
| | - James A Vosswinkel
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, New York
| | - Randeep S Jawa
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, New York.
| |
Collapse
|
34
|
Stranjalis G, Komaitis S, Kalyvas AV, Drosos E, Stavrinou LC, Koutsarnakis C, Kalamatianos T. Recent trends (2010-2018) in traumatic brain injury in Greece: Results on 2042 patients. Injury 2020; 51:2033-2039. [PMID: 32536530 DOI: 10.1016/j.injury.2020.05.045] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 05/10/2020] [Accepted: 05/29/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Recent analysis on the epidemiology of traumatic brain injury (TBI) within Europe indicates an increase in fall-related injuries and in the incidence of hospitalization among older adults as well as a decrease in contribution of road traffic accidents (RTA). Given the paucity of recent national data, we analyzed TBI-related admissions from the Athens Head Trauma Registry during the largest part of the past decade (2010-2018), a period marked by a profound national socioeconomic crisis. METHODS Demographic and clinical data of admitted TBI patients were collected and analyzed statistically. RESULTS The mean age of patients (N=2042, 68% men) was 59 years (median 64 years). Patient age showed an upward trend across the study period. Most cases were mild, while moderate and severe injuries were indicated in, 11% and 20%, respectively. Falls were the predominant cause of injury (46% of cases), followed by RTA (38%). An upward trend in the frequency of fall-related injury was apparent across the study period; RTA-related injury frequency displayed a downward trend during the second part of the study period. Assault-related injury accounted for 6%. Surgery took place in 11% of cases. In-hospital mortality (IHM) was 21%. Fall-related mortality contributed to 56% of total IHM; RTA-related mortality contributed to 30%. The mean length of hospital stay was 13 days (median: 5 days). CONCLUSIONS The present findings suggest a shift in the epidemiologic profile of TBI patients in Greece with a rise in the proportion of elderly patients, a concomitant increase in fall-related injuries and a reduction in RTA-related injury. They also highlight fall-related injury as the predominant cause of IHM. Our results point towards the urgent need for the intensification of fall prevention strategies, continuing medical education as well as public information campaigns on the risks of geriatric fall-related injury.
Collapse
Affiliation(s)
- George Stranjalis
- Department of Neurosurgery, Evangelismos Hospital, National and Kapodistrian University of Athens, Ypsilantou 45-47, Athens 10676, Greece
| | - Spyridon Komaitis
- Department of Neurosurgery, Evangelismos Hospital, National and Kapodistrian University of Athens, Ypsilantou 45-47, Athens 10676, Greece
| | - Aristotelis V Kalyvas
- Department of Neurosurgery, Evangelismos Hospital, National and Kapodistrian University of Athens, Ypsilantou 45-47, Athens 10676, Greece
| | - Evangelos Drosos
- Department of Neurosurgery, Evangelismos Hospital, National and Kapodistrian University of Athens, Ypsilantou 45-47, Athens 10676, Greece
| | - Lampis C Stavrinou
- Department of Neurosurgery, Evangelismos Hospital, National and Kapodistrian University of Athens, Ypsilantou 45-47, Athens 10676, Greece
| | - Christos Koutsarnakis
- Department of Neurosurgery, Evangelismos Hospital, National and Kapodistrian University of Athens, Ypsilantou 45-47, Athens 10676, Greece
| | - Theodosis Kalamatianos
- Department of Neurosurgery, Evangelismos Hospital, National and Kapodistrian University of Athens, Ypsilantou 45-47, Athens 10676, Greece.
| |
Collapse
|
35
|
Scotti P, Séguin C, Lo BWY, de Guise E, Troquet JM, Marcoux J. Antithrombotic agents and traumatic brain injury in the elderly population: hemorrhage patterns and outcomes. J Neurosurg 2020; 133:486-495. [PMID: 31277068 DOI: 10.3171/2019.4.jns19252] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 04/08/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Among the elderly, use of antithrombotics (ATs), antiplatelets (APs; aspirin, clopidogrel), and/or anticoagulants (ACs; warfarin, direct oral ACs [DOACs; dabigatran, rivaroxaban, apixaban]) to prevent thromboembolic events must be carefully weighed against the risk of intracranial hemorrhage (ICH) with trauma. The goal of this study was to assess the risk of sustaining a traumatic brain injury (TBI), ICH, and poorer outcomes in relation to AT use among all patients 65 years or older presenting to a single institution with head trauma. METHODS Data were collected from all head trauma patients 65 years or older presenting to the authors' supraregional tertiary trauma center over a 24-month period and included age, sex, injury mechanism, medical history, international normalized ratio, Glasgow Coma Scale (GCS) score, ICH presence and type, hospital admission, reversal therapy, surgery, discharge destination, Extended Glasgow Outcome Scale (GOSE) score at discharge, and mortality. RESULTS A total of 1365 head trauma patients 65 years or older were included; 724 were on AT therapy (413 on APs, 151 on ACs, 59 on DOACs, 48 on 2 APs, 38 on AP+AC, and 15 on AP+DOAC) and 641 were not. Among all head trauma patients, the risk of sustaining a TBI was associated with AP use after adjusting for covariates. Of the 731 TBI patients, those using ATs had higher rates of ICH (p <0.0001), functional dependency at discharge (GOSE score ≤ 4; p < 0.0001), and mortality (p < 0.0001). Elevated rates of ICH progression on follow-up CT scanning were observed in patients in the warfarin monotherapy (OR 5.30, p < 0.0001) and warfarin + AP (OR 6.15, p = 0.0011). Risk of mortality was not associated with single antiplatelet use but was notably high with 2 APs (OR 4.66, p = 0.0056), warfarin (OR 5.18, p = 0.0003), and DOAC use (OR 5.09, p = 0.0149). CONCLUSIONS Elderly trauma patients on ATs, especially combination therapy, are at elevated risk of ICH and poor outcomes compared with those not on AT therapy. While both AP and warfarin use alone and in combination were associated with significantly elevated odds of sustaining an ICH among TBI patients, only warfarin use was a predictor of hemorrhage progression on follow-up scans. The use of a single AP was not associated with mortality; however, the combination of both aspirin and clopidogrel was. Warfarin and DOAC users had comparable mortality rates; however, DOAC users had lower rates of ICH progression, and fewer survivors were functionally dependent at discharge than were warfarin users. DOACs are an overall safer alternative to warfarin for patients at high risk of falls.
Collapse
Affiliation(s)
| | | | | | - Elaine de Guise
- 3Department of Psychology, University of Montreal, Quebec, Canada
| | - Jean-Marc Troquet
- 4Emergency Medicine, McGill University Health Centre, Montreal, Quebec; and
| | | |
Collapse
|
36
|
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.
Collapse
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.)
| |
Collapse
|
37
|
Alvikas J, Myers SP, Wessel CB, Okonkwo DO, Joseph B, Pelaez C, Dosberstein C, Guillotte AR, Rosengart MR, Neal MD. A systematic review and meta-analysis of traumatic intracranial hemorrhage in patients taking prehospital antiplatelet therapy: Is there a role for platelet transfusions? J Trauma Acute Care Surg 2020; 88:847-854. [PMID: 32118818 PMCID: PMC7431190 DOI: 10.1097/ta.0000000000002640] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Platelet transfusion has been utilized to reverse platelet dysfunction in patients on preinjury antiplatelets who have sustained a traumatic intracranial hemorrhage (tICH); however, there is little evidence to substantiate this practice. The objective of this study was to perform a systematic review on the impact of platelet transfusion on survival, hemorrhage progression and need for neurosurgical intervention in patients with tICH on prehospital antiplatelet medication. METHODS Controlled, observational and randomized, prospective and retrospective studies describing tICH, preinjury antiplatelet use, and platelet transfusion reported in PubMed, Embase, Cochrane Reviews, Cochrane Trials and Cochrane DARE databases between January 1987 and March 2019 were included. Investigations of concomitant anticoagulant use were excluded. Risk of bias was assessed using the Newcastle-Ottawa scale. We calculated pooled estimates of relative effect of platelet transfusion on the risk of death, hemorrhage progression and need for neurosurgical intervention using the methods of Dersimonian-Laird random-effects meta-analysis. Sensitivity analysis established whether study size contributed to heterogeneity. Subgroup analyses determined whether antiplatelet type, additional blood products/reversal agents, or platelet function assays impacted effect size using meta-regression. RESULTS Twelve of 18,609 screened references were applicable to our questions and were qualitatively and quantitatively analyzed. We found no association between platelet transfusion and the risk of death in patients with tICH taking prehospital antiplatelets (odds ratio [OR], 1.29; 95% confidence interval [CI], 0.76-2.18; p = 0.346; I = 32.5%). There was no significant reduction in hemorrhage progression (OR, 0.88; 95% CI, 0.34-2.28; p = 0.788; I = 78.1%). There was no significant reduction in the need for neurosurgical intervention (OR, 1.00; 95% CI, 0.53-1.90, p = 0.996; I = 59.1%; p = 0.032). CONCLUSION Current evidence does not support the use of platelet transfusion in patients with tICH on prehospital antiplatelets, highlighting the need for a prospective evaluation of this practice. LEVEL OF EVIDENCE Systematic Reviews and Meta-Analyses, Level III.
Collapse
Affiliation(s)
- Jurgis Alvikas
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Sara P. Myers
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Charles B. Wessel
- University of Pittsburgh Health Sciences Library System, Pittsburgh, PA
| | - David O. Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Bellal Joseph
- Department of Surgery, University of Arizona, Tucson, AZ
| | | | - Cody Dosberstein
- Warren Alpert Medical School of Brown University, Providence, RI
| | - Andrew R. Guillotte
- Division of Neurological Surgery, University of Missouri School of Medicine, Columbia, MO
| | - Matthew R. Rosengart
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Matthew D. Neal
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| |
Collapse
|
38
|
Cuevas-Østrem M, Røise O, Wisborg T, Jeppesen E. Geriatric Trauma - A Rising Tide. Assessing Patient Safety Challenges in a Vulnerable Population Using Norwegian Trauma Registry Data and Focus Group Interviews: Protocol for a Mixed Methods Study. JMIR Res Protoc 2020; 9:e15722. [PMID: 32352386 PMCID: PMC7226039 DOI: 10.2196/15722] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 11/27/2019] [Accepted: 12/17/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Elderly trauma patients constitute a vulnerable group, with a substantial risk of morbidity and mortality even after low-energy falls. As the world's elderly population continues to increase, the number of elderly trauma patients is expected to increase. Limited data are available about the possible patient safety challenges that elderly trauma patients face. The outcomes and characteristics of the Norwegian geriatric trauma population are not described on a national level. OBJECTIVE The aim of this project is to investigate whether patient safety challenges exist for geriatric trauma patients in Norway. An important objective of the study is to identify risk areas that will facilitate further work to safeguard and promote quality and safety in the Norwegian trauma system. METHODS This is a population-based mixed methods project divided into 4 parts: 3 quantitative retrospective cohort studies and 1 qualitative interview study. The quantitative studies will compare adult (aged 16-64 years) and elderly (aged ≥65 years) trauma patients captured in the Norwegian Trauma Registry (NTR) with a date of injury from January 1, 2015, to December 31, 2018. Descriptive statistics and relevant statistical methods to compare groups will be applied. The qualitative study will comprise focus group interviews with doctors responsible for trauma care, and data will be analyzed using a thematic analysis to identify important themes. RESULTS The project received funding in January 2019 and was approved by the Oslo University Hospital data protection officer (No. 19/16593). Registry data have been extracted for 33,344 patients, and the analysis of these data has begun. Focus group interviews will be conducted from spring 2020. Results from this project are expected to be ready for publication from fall 2020. CONCLUSIONS By combining data from the NTR with interviews with doctors responsible for treatment and transfer of elderly trauma patients, we will provide increased knowledge about trauma in Norwegian geriatric patients on a national level that will form the basis for further research aiming at developing interventions that hopefully will make the trauma system better equipped to manage the rising tide of geriatric trauma. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/15722.
Collapse
Affiliation(s)
- Mathias Cuevas-Østrem
- Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway
- Norwegian Trauma Registry, Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Olav Røise
- Norwegian Trauma Registry, Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Torben Wisborg
- Norwegian National Advisory Unit on Trauma, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
- Anaesthesia and Critical Care Research Group, Faculty of Health Sciences, University of Tromsø - The Arctic University of Norway, Tromsø, Norway
| | - Elisabeth Jeppesen
- Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway
- Norwegian Trauma Registry, Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| |
Collapse
|
39
|
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.
Collapse
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
| |
Collapse
|
40
|
The Role of Desmopressin on Hematoma Expansion in Patients with Mild Traumatic Brain Injury Prescribed Pre-injury Antiplatelet Medications. Neurocrit Care 2020; 33:405-413. [DOI: 10.1007/s12028-019-00899-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
|
41
|
Effects of anticoagulant and antiplatelet agents in severe traumatic brain injury in an asian population – A matched case-control study. J Clin Neurosci 2019; 70:61-66. [DOI: 10.1016/j.jocn.2019.08.087] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 08/10/2019] [Accepted: 08/17/2019] [Indexed: 11/18/2022]
|
42
|
Fernando SM, Mok G, Rochwerg B, English SW, Thavorn K, McCredie VA, Dowlatshahi D, Perry JJ, Wijdicks EFM, Reardon PM, Tanuseputro P, Kyeremanteng K. Preadmission Antiplatelet Use and Associated Outcomes and Costs Among ICU Patients With Intracranial Hemorrhage. J Intensive Care Med 2019; 36:70-79. [PMID: 31741418 DOI: 10.1177/0885066619885347] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Patients with intracranial hemorrhage (including intracerebral hemorrhage, subarachnoid hemorrhage, and traumatic hemorrhage) are commonly admitted to the intensive care unit (ICU). Although indications for oral antiplatelet agents are increasing, the impact of preadmission use on outcomes in patients with intracranial hemorrhage admitted to the ICU is unknown. We sought to evaluate the association between preadmission oral antiplatelet use, in-hospital mortality, resource utilization, and costs among ICU patients with intracranial hemorrhage. METHODS We retrospectively analyzed a prospectively collected registry (2011-2016) and included consecutive adult patients from 2 hospitals admitted to ICU with intracranial hemorrhage. Patients were categorized on the basis of preadmission oral antiplatelet use. We excluded patients with preadmission anticoagulant use. The primary outcome was in-hospital mortality and was analyzed using a multivariable logistic regression model. Contributors to total hospital cost were analyzed using a generalized linear model with log link and gamma distribution. RESULTS Of 720 included patients with intracranial hemorrhage, 107 (14.9%) had been using an oral antiplatelet agent at the time of ICU admission. Oral antiplatelet use was not associated with in-hospital mortality (adjusted odds ratio: 1.31 [95% confidence interval [CI]: 0.93-2.22]). Evaluation of total costs also revealed no association with oral antiplatelet use (adjusted ratio of means [aROM]: 0.92 [95% CI: 0.82-1.02, P = .10]). Total cost among patients with intracranial hemorrhage was driven by illness severity (aROM: 1.96 [95% CI: 1.94-1.98], P < .001), increasing ICU length of stay (aROM: 1.05 [95% CI: 1.05-1.06], P < .001), and use of invasive mechanical ventilation (aROM: 1.76 [95% CI: 1.68-1.86], P < .001). CONCLUSIONS Among ICU patients admitted with intracranial hemorrhage, preadmission oral antiplatelet use was not associated with increased in-hospital mortality or hospital costs. These findings have important prognostic implications for clinicians who care for patients with intracranial hemorrhage.
Collapse
Affiliation(s)
- Shannon M Fernando
- Division of Critical Care, Department of Medicine, 6363University of Ottawa, Ottawa, Ontario, Canada.,Department of Emergency Medicine, 6363University of Ottawa, Ottawa, Ontario, Canada
| | - Garrick Mok
- Department of Emergency Medicine, 6363University of Ottawa, Ottawa, Ontario, Canada
| | - Bram Rochwerg
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Shane W English
- Division of Critical Care, Department of Medicine, 6363University of Ottawa, Ottawa, Ontario, Canada.,School of Epidemiology and Public Health, 6363University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Kednapa Thavorn
- School of Epidemiology and Public Health, 6363University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Victoria A McCredie
- Interdepartmental Division of Critical Care Medicine, 7938University of Toronto, Toronto, Ontario, Canada.,Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Dar Dowlatshahi
- School of Epidemiology and Public Health, 6363University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Division of Neurology, Department of Medicine, 6363University of Ottawa, Ottawa, Ontario, Canada
| | - Jeffrey J Perry
- Department of Emergency Medicine, 6363University of Ottawa, Ottawa, Ontario, Canada.,School of Epidemiology and Public Health, 6363University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Eelco F M Wijdicks
- Division of Neurocritical Care and Hospital Neurology, Department of Neurology, 6915Mayo Clinic, Rochester, MN, USA
| | - Peter M Reardon
- Division of Critical Care, Department of Medicine, 6363University of Ottawa, Ottawa, Ontario, Canada.,Department of Emergency Medicine, 6363University of Ottawa, Ottawa, Ontario, Canada
| | - Peter Tanuseputro
- School of Epidemiology and Public Health, 6363University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Division of Palliative Care, Department of Medicine, 6363University of Ottawa, Ottawa, Ontario, Canada
| | - Kwadwo Kyeremanteng
- Division of Critical Care, Department of Medicine, 6363University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Division of Palliative Care, Department of Medicine, 6363University of Ottawa, Ottawa, Ontario, Canada
| |
Collapse
|
43
|
Chenoweth JA, Gaona SD, Faul M, Holmes JF, Nishijima DK. Incidence of Delayed Intracranial Hemorrhage in Older Patients After Blunt Head Trauma. JAMA Surg 2019; 153:570-575. [PMID: 29450470 DOI: 10.1001/jamasurg.2017.6159] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Current guidelines conflict on the management of older adults who have blunt head trauma taking anticoagulant and antiplatelet medications. This is partially due to the limited data comparing patients who are taking these medications with those who are not. Objective To investigate the incidence of delayed traumatic intracranial hemorrhage in older adults with head trauma, including those taking anticoagulant and antiplatelet medications. Design, Setting, and Participants This prospective observational cohort study included patients 55 years and older who had blunt head trauma and were transported via emergency medical services between August 1, 2015, and September 30, 2016. The setting was a multicenter study conducted at 11 hospitals in northern California. Patients were excluded if they had traumatic intracranial hemorrhage on the initial cranial computed tomographic scan, did not have a cranial computed tomographic scan performed at the initial emergency department visit, refused consent for a follow-up telephone call, or did not have reliable means of follow-up. Main Outcome and Measure The primary outcome of this study was the incidence of delayed traumatic intracranial hemorrhage within 14 days of injury. Results Among 859 patients enrolled in the study, the median age was 75 years (interquartile range, 64-85 years), and 389 (45.3%) were male. A total of 343 patients (39.9%) were taking an anticoagulant or antiplatelet medication. Three patients (0.3%; 95% CI, 0.1%-1.0%) had a delayed traumatic intracranial hemorrhage. Of the 3 patients, 1 of 75 patients (1.3%; 95% CI, 0.0%-7.2%) who were taking warfarin sodium alone and 2 of 516 patients (0.4%; 95% CI, 0.1%-1.4%) who were not taking any anticoagulant or antiplatelet medication had a delayed traumatic intracranial hemorrhage. Thirty-nine patients (4.5%; 95% CI, 3.2%-6.2%) were lost to follow-up. Conclusions and Relevance Overall, the incidence of delayed intracranial hemorrhage in older adults who have blunt head trauma is low, including patients taking an anticoagulant or antiplatelet medication. These findings suggest that routine observation and serial cranial computed tomography may not be necessary in these patients.
Collapse
Affiliation(s)
- James A Chenoweth
- Department of Emergency Medicine, University of California, Davis, School of Medicine, Sacramento
| | - Samuel D Gaona
- Department of Emergency Medicine, University of California, Davis, School of Medicine, Sacramento
| | - Mark Faul
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - James F Holmes
- Department of Emergency Medicine, University of California, Davis, School of Medicine, Sacramento
| | - Daniel K Nishijima
- Department of Emergency Medicine, University of California, Davis, School of Medicine, Sacramento
| | | |
Collapse
|
44
|
Abdelmalik PA, Draghic N, Ling GSF. Management of moderate and severe traumatic brain injury. Transfusion 2019; 59:1529-1538. [PMID: 30980755 DOI: 10.1111/trf.15171] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 10/12/2018] [Accepted: 10/13/2018] [Indexed: 12/28/2022]
Abstract
Traumatic brain injury (TBI) is a common disorder with high morbidity and mortality, accounting for one in every three deaths due to injury. Older adults are especially vulnerable. They have the highest rates of TBI-related hospitalization and death. There are about 2.5 to 6.5 million US citizens living with TBI-related disabilities. The cost of care is very high. Aside from prevention, little can be done for the initial primary injury of neurotrauma. The tissue damage incurred directly from the inciting event, for example, a blow to the head or bullet penetration, is largely complete by the time medical care can be instituted. However, this event will give rise to secondary injury, which consists of a cascade of changes on a cellular and molecular level, including cellular swelling, loss of membrane gradients, influx of immune and inflammatory mediators, excitotoxic transmitter release, and changes in calcium dynamics. Clinicians can intercede with interventions to improve outcome in the mitigating secondary injury. The fundamental concepts in critical care management of moderate and severe TBI focus on alleviating intracranial pressure and avoiding hypotension and hypoxia. In addition to these important considerations, mechanical ventilation, appropriate transfusion of blood products, management of paroxysmal sympathetic hyperactivity, using nutrition as a therapy, and, of course, venous thromboembolism and seizure prevention are all essential in the management of moderate to severe TBI patients. These concepts will be reviewed using the recent 2016 Brain Trauma Foundation Guidelines to discuss best practices and identify future research priorities.
Collapse
Affiliation(s)
| | - Nicole Draghic
- Department of Clinical Neurosciences, Inova Fairfax Hospital, Falls Church, Virginia
| | - Geoffrey S F Ling
- Department of Clinical Neurosciences, Inova Fairfax Hospital, Falls Church, Virginia.,Neurosciences Critical Care, Departments of Neurology, Neurosurgery and Anesthesiology-Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| |
Collapse
|
45
|
Management of Head Trauma in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
|
46
|
Williams SE, Nelson R, Kashif R, Goff T, Simon L, Janse M. Demographic variation in the injury patterns of adult cyclists admitted to a large US healthcare network: A five-year review. TRAUMA-ENGLAND 2019. [DOI: 10.1177/1460408617740903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Shanna E Williams
- Department of Biomedical Sciences, University of South Carolina School of Medicine Greenville, Greenville, SC, USA
| | - Rachel Nelson
- Department of Biomedical Sciences, University of South Carolina School of Medicine Greenville, Greenville, SC, USA
| | - Reema Kashif
- Department of Biomedical Sciences, University of South Carolina School of Medicine Greenville, Greenville, SC, USA
| | - Tyler Goff
- Department of Biomedical Sciences, University of South Carolina School of Medicine Greenville, Greenville, SC, USA
| | - Laura Simon
- Department of Biomedical Sciences, University of South Carolina School of Medicine Greenville, Greenville, SC, USA
| | - Melissa Janse
- Department of Emergency Medicine, Greenville Health System, Greenville, SC, USA
| |
Collapse
|
47
|
Hwang P, Ong AW, Muller A, Mcnicholas A, Martin A, Sigal A, Fernandez FB. Geriatric Patients on Antithrombotic Agents who Fall: Does Trauma Team Activation Improve Outcomes? Am Surg 2019. [DOI: 10.1177/000313481908500730] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Despite the incorporation of anticoagulant and antiplatelet (ACAP) drugs in our trauma triage criteria, it is unclear whether trauma team activation (TTA) impacts outcomes in geriatric patients on ACAP drugs sustaining falls. We hypothesized that TTA in this cohort was associated with improved outcomes. The hospital electronic database was queried to identify normotensive, awake patients aged ≥65 years on ACAP agent from 2014 to 2018 presenting to the emergency department after falls. The outcome was in-hospital mortality. The association between TTA and mortality was examined using logistic regression analysis and 1:1 propensity score matching analysis. In this study, 4540 patients on ACAP drugs were analyzed, with TTA occurring in 500 (11%). TTA occurred in younger but more severely injured patients with lower Glasgow Coma Score. Logistic regression revealed that TTA was not associated with mortality (odds ratio [95% confidence intervals], 2.04 [0.89–4.25]). The 1:1 propensity score analysis revealed similar mortality for the matched groups (non-TTA, 1.6% vs TTA, 2.2%, P = 0.64). In the elderly patients on ACAP agents, the current triage criteria resulted in the appropriate use of TTA for more severely injured patients. The lack of outcome benefit suggests that ACAP drug use as a criterion for TTA should be re-evaluated.
Collapse
Affiliation(s)
- Peter Hwang
- Department of Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia Pennsylvania
| | - Adrian W. Ong
- Department of Surgery, Reading Hospital, Tower Health System, Reading, Pennsylvania; and
| | - Alison Muller
- Department of Surgery, Reading Hospital, Tower Health System, Reading, Pennsylvania; and
| | - Amanda Mcnicholas
- Department of Surgery, Reading Hospital, Tower Health System, Reading, Pennsylvania; and
| | - Anthony Martin
- Department of Surgery, Reading Hospital, Tower Health System, Reading, Pennsylvania; and
| | - Adam Sigal
- Department of Emergency Medicine, Reading Hospital, Tower Health System, Reading, Pennsylvania
| | - Forrest B. Fernandez
- Department of Surgery, Reading Hospital, Tower Health System, Reading, Pennsylvania; and
| |
Collapse
|
48
|
Scantling D, Kucejko R, Williamson J, Galvez A, Teichman A, Gruner R, Serniak N, McCracken B. Worsening head bleeds in elderly blunt head trauma patients taking antithrombotics: Delayed CT head fails to change management. Injury 2019; 50:54-60. [PMID: 30078628 DOI: 10.1016/j.injury.2018.07.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Revised: 06/30/2018] [Accepted: 07/24/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Most elderly trauma patients suffer blunt head injury and many utilize antithrombotic (AT) medications. The utility of delayed CT-head (D-CTH) in neurologically intact elderly patients using AT who have an intracranial hemorrhage (ICH) on presentation is unknown. We hypothesized that D-CTH would not alter clinical management and aimed to evaluate the role of D-CTH in this population. METHODS A retrospective cohort study was performed. Patients ≥65 years sustaining blunt head injuries from January 2010 to July 2017 were identified using our level 1 trauma center database. AT-patients presenting with ICH who underwent D-CTH were included. Patients with worsened ICH were compared to those with stable to improved ICH on D-CTH. AT-patients were compared to a cohort of non-AT patients. Fisher's Exact and Mann-Whitney U tests were utilized and a power analysis conducted. RESULTS 137 A T and 34 non-AT patients were identified. There was no difference in hemorrhage progression or appearance of new ICH. No patient had a change in management from D-CTH in either cohort. AT-patients were slightly older (p < 0.001), but cohorts were otherwise similar. 50 AT-patients with worsened ICH were compared to 87 with stable ICH. There was no difference in cohort demographics. Hemorrhage progression did not vary with type of AT used but did increase if multiple types of synchronous ICH were present (p < 0.001). CONCLUSIONS Our data supports abstaining from routine D-CTH of elderly ICH patients with an intact neurologic examination who are utilizing aspirin, clopidogrel or warfarin. Conclusions cannot be drawn regarding new oral anticoagulants (NOACs) given low enrollment. Further multicenter study is required to provide adequate power and detect small levels of management change.
Collapse
Affiliation(s)
- Dane Scantling
- Hahnemann University Hospital, PA 19102, United States; The Drexel University College of Medicine Philadelphia, PA 19102, United States.
| | - Robert Kucejko
- Hahnemann University Hospital, PA 19102, United States; The Drexel University College of Medicine Philadelphia, PA 19102, United States
| | - John Williamson
- Hahnemann University Hospital, PA 19102, United States; The Drexel University College of Medicine Philadelphia, PA 19102, United States
| | - Alvaro Galvez
- Hahnemann University Hospital, PA 19102, United States; The Drexel University College of Medicine Philadelphia, PA 19102, United States
| | - Amanda Teichman
- Hahnemann University Hospital, PA 19102, United States; The Drexel University College of Medicine Philadelphia, PA 19102, United States
| | - Ryan Gruner
- Hahnemann University Hospital, PA 19102, United States; The Drexel University College of Medicine Philadelphia, PA 19102, United States
| | - Nicholas Serniak
- Hahnemann University Hospital, PA 19102, United States; The Drexel University College of Medicine Philadelphia, PA 19102, United States
| | - Brendan McCracken
- Hahnemann University Hospital, PA 19102, United States; The Drexel University College of Medicine Philadelphia, PA 19102, United States
| |
Collapse
|
49
|
Glass NE, Vadlamani A, Hwang F, Sifri ZC, Kunac A, Bonne S, Pentakota SR, Yonclas P, Mosenthal AC, Livingston DH, Albrecht JS. Bleeding and Thromboembolism After Traumatic Brain Injury in the Elderly: A Real Conundrum. J Surg Res 2018; 235:615-620. [PMID: 30691850 DOI: 10.1016/j.jss.2018.10.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 08/22/2018] [Accepted: 10/16/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Elderly patients presenting with a traumatic brain injury (TBI) often have comorbidities that increase risk of thromboembolic (TE) disease and recurrent TBI. A significant number are on anticoagulant therapy at the time of injury and studies suggest that continuing anticoagulation can prevent TE events. Understanding bleeding, recurrent TBI, and TE risk after TBI can help to guide therapy. Our objectives were to 1) evaluate the incidence of bleeding, recurrent TBI, and TE events after an initial TBI in older adults and 2) identify which factors contribute to this risk. METHODS Retrospective analysis of Medicare claims between May 30, 2006 and December 31, 2009 for patients hospitalized with TBI was performed. We defined TBI for the index admission, and hemorrhage (gastrointestinal bleeding or hemorrhagic stroke), recurrent TBI, and TE events (stroke, myocardial infarction, deep venous thrombosis, or pulmonary embolism) over the following year using ICD-9 codes. Unadjusted incidence rates and 95% confidence intervals (CIs) were calculated. Risk factors of these events were identified using logistic regression. RESULTS Among beneficiaries hospitalized with TBI, incidence of TE events (58.6 events/1000 person-years; 95% CI 56.2, 60.8) was significantly higher than bleeding (23.6 events/1000 person-years; 95% CI 22.2, 25.1) and recurrent TBI events (26.0 events/1000 person-years; 95% CI 24.5, 27.6). Several common factors predisposed to bleeding, recurrent TBI, and TE outcomes. CONCLUSIONS Among Medicare patients hospitalized with TBI, the incidence of TE was significantly higher than that of bleeding or recurrent TBI. Specific risk factors of bleeding and TE events were identified which may guide care of older adults after TBI.
Collapse
Affiliation(s)
- Nina E Glass
- Division of Trauma and Critical Care, Department of Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey.
| | - Aparna Vadlamani
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
| | - Franchesca Hwang
- Division of Trauma and Critical Care, Department of Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey
| | - Ziad C Sifri
- Division of Trauma and Critical Care, Department of Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey
| | - Anastasia Kunac
- Division of Trauma and Critical Care, Department of Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey
| | - Stephanie Bonne
- Division of Trauma and Critical Care, Department of Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey
| | - Sri Ram Pentakota
- Division of Trauma and Critical Care, Department of Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey
| | - Peter Yonclas
- Division of Trauma and Critical Care, Department of Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey
| | - Anne C Mosenthal
- Division of Trauma and Critical Care, Department of Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey
| | - David H Livingston
- Division of Trauma and Critical Care, Department of Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey
| | - Jennifer S Albrecht
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
| |
Collapse
|
50
|
Lamb M, Reveal C, Muertos K, Sciarretta JD. Double Trouble: Intracranial Hemorrhage Risk with Antithrombotic Use and Underlying Thrombocytopenia. Am Surg 2018. [DOI: 10.1177/000313481808401201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Matthew Lamb
- Grand Strand Medical Center University of South Carolina Myrtle Beach, South Carolina
| | - Caitlin Reveal
- Grand Strand Medical Center University of South Carolina Myrtle Beach, South Carolina
| | - Keely Muertos
- Grand Strand Medical Center University of South Carolina Myrtle Beach, South Carolina
| | - Jason D. Sciarretta
- Grand Strand Medical Center University of South Carolina Myrtle Beach, South Carolina
| |
Collapse
|