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Sharp V, Bazzi R, Hecht JP. Clinical outcomes for patients on antiplatelet and anticoagulants in thoracoabdominal trauma. Surg Open Sci 2023; 16:44-48. [PMID: 37808423 PMCID: PMC10550756 DOI: 10.1016/j.sopen.2023.09.019] [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: 05/23/2023] [Revised: 08/01/2023] [Accepted: 09/17/2023] [Indexed: 10/10/2023] Open
Abstract
Introduction Trauma outcomes can be greatly affected by antiplatelet and anticoagulant (AP/AC) use. The goal of this study was to compare outcomes in trauma patients on AP/AC undergoing emergent surgery for thoracoabdominal trauma at 35 level 1 and 2 trauma centers from 2014 to 2021. Methods This was a retrospective cohort study of 2460 adult patients with a chest, abdomen, or pelvis abbreviated injury score (AIS) of 2 or more who underwent surgery within 24 h of admission. These patients were segregated into four main cohorts based on antiplatelet/anticoagulation use: those not on AP/AC, those taking direct-acting oral anticoagulants (DOACs), those taking clopidogrel, and those taking warfarin. Patients were excluded if they had surgery >24 h after presentation, were dead on arrival, or had any other body system AIS score of 3 or higher. Results The mean injury severity score (ISS) in all four groups ranged from 16.3 to 18.6 (p = 0.834) with a mean time to operating room from 208 to 478 min (p < 0.001). Laparotomy was performed in 60 to 71 % (p > 0.01) of patients, regardless of AP/AC status, and thoracic procedures were performed in 3.1 to 9.3 % (p = 0.42) of patients. In-hospital mortality and hospice rates were highest in the clopidogrel group at 21.9 %, followed by warfarin at 13 %, DOACs at 15 %, and no AP/AC at 7.63 % (p = 0.008). Serious complications occurred in 61 % of patients on warfarin, 50 % of those on DOACs, and 44 % of those on clopidogrel. All of these groups demonstrated significantly higher complication rates than patients in the no AP/AC control group at 25 % (p < 0.001). Total transfusion of packed red blood cells and fresh frozen plasma did not differ significantly between the groups; however, 24-h platelet transfusion did. Patients on clopidogrel received 14 packs of platelets, while those on warfarin and DOACs received 8 and 13 packs respectively (p = 0.011). Patients on warfarin had the longest hospital length of stay (LOS) at 13 days and ICU LOS at 9 days, compared to those on DOACs (8 and 4), those on clopidogrel (7 and 3), and those not taking AC/AP (7 and 4) (hospital LOS p = 0.03, ICU LOS p = 0.019). Those on AC/AP were also noted to be significantly older than those on neither, with those taking these medications averaging out to be approximately 69 years old and those not on these medications averaging 37 years old (p < 0.001). Conclusion There was significantly higher mortality in patients on clopidogrel and increased length of stay and risk of serious complications in patients taking DOACs and warfarin. In patients on AP/AC there was also a significantly longer time to surgery than in those not taking either. Given these associations trauma surgeons should consider intervening sooner on patients taking AP/AC on admission, as the delay to intervention may contribute to the risks for trauma patients and result in worse outcomes as well as higher rates of mortality.
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Affiliation(s)
- Victoria Sharp
- Trinity Health Ann Arbor, Department of Surgery, 5301 McAuley Dr Suite 2402, Ypsilanti, MI 48197, United States of America
| | - Rola Bazzi
- Trinity Health Ann Arbor, Department of Pharmacy, 5301 E. Huron River Dr Ann Arbor, MI 48106-0995, United States of America
| | - Jason P. Hecht
- Trinity Health Ann Arbor, Department of Pharmacy, 5301 E. Huron River Dr Ann Arbor, MI 48106-0995, United States of America
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Kishawi SK, Adomshick VJ, Halkiadakis PN, Wilson K, Petitt JC, Brown LR, Claridge JA, Ho VP. Development of Imaging Criteria for Geriatric Blunt Trauma Patients. J Surg Res 2023; 283:879-888. [PMID: 36915016 DOI: 10.1016/j.jss.2022.10.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 10/07/2022] [Accepted: 10/18/2022] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Current decision tools to guide trauma computed tomography (CT) imaging were not validated for use in older patients. We hypothesized that specific clinical variables would be predictive of injury and could be used to guide imaging in this population to minimize risk of missed injury. METHODS Blunt trauma patients aged 65 y and more admitted to a Level 1 trauma center intensive care unit from January 2018 to November 2020 were reviewed for histories, physical examination findings, and demographic information known at the time of presentation. Injuries were defined using the patient's final abbreviated injury score codes, obtained from the trauma registry. Abbreviated injury score codes were categorized by corresponding CT body region: Head, Face, Chest, C-Spine, Abdomen/Pelvis, or T/L-Spine. Variable groupings strongly predictive of injury were tested to identify models with high sensitivity and a negative predictive value. RESULTS We included 608 patients. Median age was 77 y (interquartile range, 70-84.5) and 55% were male. Ground-level fall was the most common injury mechanism. The most commonly injured CT body regions were Head (52%) and Chest (42%). Variable groupings predictive of injury were identified in all body regions. We identified models with 97.8% sensitivity for Head and 98.8% for Face injuries. Sensitivities more than 90% were reached for all except C-Spine and Abdomen/Pelvis. CONCLUSIONS Decision aids to guide imaging for older trauma patients are needed to improve consistency and quality of care. We have identified groupings of clinical variables that are predictive of injury to guide CT imaging after geriatric blunt trauma. Further study is needed to refine and validate these models.
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Affiliation(s)
- Sami K Kishawi
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Victoria J Adomshick
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Penelope N Halkiadakis
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Keira Wilson
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, Ohio; Northeast Ohio Medical University, Rootstown, Ohio
| | - Jordan C Petitt
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Laura R Brown
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Jeffrey A Claridge
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Vanessa P Ho
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio; Case Western Reserve University, Department of Population and Quantitative Health Sciences, Cleveland, Ohio.
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Kania T, Pandya S, Demissie S, Abdelhalim D, Governo C, Hawkins S, Younan D, Atanassov K, Gave A. Physical exam is not an accurate predictor of injury in geriatric patients with low-energy blunt trauma - A retrospective cohort study. Ann Med Surg (Lond) 2022; 81:104503. [PMID: 36147051 PMCID: PMC9486729 DOI: 10.1016/j.amsu.2022.104503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 08/20/2022] [Accepted: 08/21/2022] [Indexed: 11/30/2022] Open
Abstract
Background When evaluating trauma patients, many centers perform computed tomography of the head, cervical spine, chest, abdomen, and pelvis, the so-called “pan-scan.” Here, we evaluate the utility of physical exam against pan-scan in geriatric patients who sustained ground-level falls. Methods We performed a single-centered retrospective cohort review of consecutive patients from the trauma registry of a large, urban Level 1 trauma center. Inclusion criteria were registration during the 2019 calendar year, age ≥65, mechanism of fall from either sitting or standing, and performance of “pan-scan” at time of assessment. The sensitivity, specificity, positive and negative predictive values of the physical exam for significant injuries were calculated. The effect of such injuries on disposition from the emergency department and hospital were determined. Results An initial query for patients age ≥65 yielded 1280 patients. After exclusion of patients who did not undergo pan-scan or who had GCS <14, 751 patients were included in analysis. Median age was 84 years old. 351 patients had at least one injury identified on pan-scan. Physical exam was determined to have a sensitivity of 0.69 when compared to pan-scan as a gold standard. Patients with injury identified on CT scan had significantly more admissions, mortalities, and ICU and OR requirements. Conclusion Approximately half of all patients were found to have at least one injury on pan-scan. Physical examination was insensitive at identifying such injuries which ultimately altered patient management, disposition, and outcomes. Pan-scan is recommended in this vulnerable population. A selective approach to CT scan may not be appropriate for elderly patients with low-energy blunt falls. Approximately half of all elderly patients who fall from sitting or standing have at least one traumatic injury. Traumatic injuries alter the hospital course and disposition of elderly fall patients. Physical exam is neither sensitive nor specific enough to detect these injuries.
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Affiliation(s)
- T. Kania
- Staten Island University Hospital/Hofstra Northwell Zucker School of Medicine, United States
- Corresponding author.475 Seaview Ave. Staten Island, NY, 10305, United States.
| | - S. Pandya
- Staten Island University Hospital/Hofstra Northwell Zucker School of Medicine, United States
| | - S. Demissie
- Staten Island University Hospital/Hofstra Northwell Zucker School of Medicine, United States
| | - D. Abdelhalim
- Touro College of Osteopathic Medicine, United States
| | - C. Governo
- Staten Island University Hospital/Hofstra Northwell Zucker School of Medicine, United States
| | - S. Hawkins
- Hackensack University Medical Center, United States
| | - D. Younan
- Staten Island University Hospital/Hofstra Northwell Zucker School of Medicine, United States
| | - K. Atanassov
- Staten Island University Hospital/Hofstra Northwell Zucker School of Medicine, United States
| | - A. Gave
- Hackensack Meridian Health JFK University Medical Center, United States
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Baig A, Drabkin MJ, Khan F, Fogel J, Shah S. Patients with falls from standing height and head or neck injury may not require body CT in the absence of signs or symptoms of body injury. Emerg Radiol 2020; 28:239-243. [PMID: 32814988 DOI: 10.1007/s10140-020-01843-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 08/16/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To determine the rate of clinically impactful body injury among patients who had a fall from standing height with an associated head/neck injury, but without evidence of body injury on physical exam or plain radiographs. We also examine surgical/endovascular intervention related to body injury and mortality rates for head/neck and body injury. METHODS Retrospective study of 288 patients with CT evidence of acute head/neck injury that underwent body CT despite the absence of clinical or radiographic evidence of body injury. Predictor variables were age, sex, race/ethnicity, and body mass index (BMI). RESULTS There were 11.5% (n = 33) with body injury on CT (n = 33). There were 3.1% (n = 9) with clinically impactful body injury. No patient had either surgical/endovascular intervention or mortality related to body injury. Additionally, 8.7% (n = 25) had mortality from head/neck injury. Increased age (OR = 1.05, 95% CI: 1.01, 1.08, p = 0.01) and overweight BMI (25-29.99 kg/m2) (OR = 2.85, 95% CI: 1.07, 7.62, p = 0.04) were each significantly associated with increased odds for mortality from head/neck injury. CONCLUSION Patients with falls from standing height and known head/neck injury had a low rate of clinically impactful body injury. None of the studied variables were associated with increased risk of body injury in this patient population. The low rate of clinically impactful body injury and the lack of any mortality, procedure, or transfusion resulting from body injury suggest that body CT may not be necessary in patients with head/neck injury in the absence of clinical or radiographic evidence of body injury.
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Affiliation(s)
- Asad Baig
- Department of Radiology, Nassau University Medical Center, 2201 Hempstead Turnpike, East Meadow, NY, 11554, USA.
| | - Michael J Drabkin
- Department of Radiology, Nassau University Medical Center, 2201 Hempstead Turnpike, East Meadow, NY, 11554, USA
| | - Fiza Khan
- Department of Radiology, Nassau University Medical Center, 2201 Hempstead Turnpike, East Meadow, NY, 11554, USA
| | - Joshua Fogel
- Department of Business Management, Brooklyn College of the City University of New York, Brooklyn, NY, USA
| | - Salman Shah
- Department of Radiology, Nassau University Medical Center, 2201 Hempstead Turnpike, East Meadow, NY, 11554, USA
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Hagan NE, Berdel HO, Tefft A, Bernard AC. Torso injuries after fall from standing-empiric abdominal or thoracic CT imaging is not indicated. Injury 2020; 51:20-25. [PMID: 31648788 DOI: 10.1016/j.injury.2019.10.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 08/30/2019] [Accepted: 10/09/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE Falls from standing (FFS) have become the most common mechanism of injury at many trauma centers. Liberal imaging of low energy trauma has questionable value. We hypothesize that torso trauma intervention is rare in the FFS population, and physical examination sufficiently screens for torso injuries needing intervention. METHODS We queried our ACS-verified Level 1 trauma center registry for falls from standing from 1/1/14 to 12/31/16. Exclusion criteria were: falls from height, falls associated with penetrating trauma, lack of an abdominal or chest CT, a Glasgow Coma Scale Score (GCS) less than 15, and surgical intervention at another facility prior to arrival at our center. Demographics, historical details, hemodynamics, injuries, injury severity, procedures, initial vital signs, and outcome were recorded. RESULTS 1,654 patients had a FFS during our study period. 728 had an abdominal or chest CT and a GCS of 15 and comprised the evaluable population. Mean age was 56.5 years. 55.8% were female. The mortality rate was 8%. There were 179 chest injuries in 121 patients, and 54 abdominal injuries in 43 patients. 379 patients had a GCS of 15 and underwent thoracic CT, yet only 11 (3%) underwent intervention. The negative predictive value for physical exam was 100% for chest intervention. 349 patients had a GCS of 15 and abdominal CT, yet only 13 (3.7%) underwent procedural intervention. Abdominal physical exam had a negative predictive value of 99.7% for intervention, but when combined with vital signs, the value was 100%. CONCLUSION Torso injuries in FFS are rare. Of our study population, 13 abdominal injuries underwent intervention, and 11 chest injuries underwent intervention. Screening patients by physical examination and vital signs is sufficient and safely allows for the use of selective abdominal and chest CT.
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Affiliation(s)
- Natalie E Hagan
- Section of Trauma and Acute Care Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, KY, USA.
| | - Henrik O Berdel
- Section of Trauma and Acute Care Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Amy Tefft
- Section of Trauma and Acute Care Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Andrew C Bernard
- Section of Trauma and Acute Care Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, KY, USA.
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Gartin CG, Reyes J, Helmer SD, Haan JM. Injury patterns and incidence of intra-abdominal injuries in elderly ground level fall patients: Is the PAN-SCAN warranted? Am J Surg 2019; 218:847-850. [DOI: 10.1016/j.amjsurg.2018.11.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 11/08/2018] [Accepted: 11/29/2018] [Indexed: 10/27/2022]
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Hanna P, Lee S, Guerrero M, O'Neal L, Conway L, Zuberi J, Matarlo J, Madlinger R. Necessity of Abdominal CT Scan in Falls from Standing Height: A Retrospective Study—A Move toward Selective Imaging. Am Surg 2019. [DOI: 10.1177/000313481908500302] [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)
- Paul Hanna
- St. Joseph's University Medical Center Paterson, New Jersey
| | - Sang Lee
- Saint George's University Saint George, Grenada
| | | | | | | | - Jamshed Zuberi
- St. Joseph's University Medical Center Paterson, New Jersey
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