Association between anticoagulants and mortality and functional outcomes in older patients with major trauma

BackgroundThe number of trauma patients taking anticoagulants and antiplatelet agents is increasing as society ages. However, there have been limited and inconsistent reports of the association between anticoagulants and mortality and functional outcomes. This study aimed to quantify the association between anticoagulant/antiplatelet medication at the time of injury and both short-term and longer-term outcomes in older major trauma patients.MethodsThis was a population-based registry study using data from the Victorian State Trauma Registry from July 2017 to June 2018. We included patients with major trauma aged 65 years and older. The outcomes of interest were in-hospital mortality, hospital length of stay, intensive care unit length of stay and the Extended Glasgow Outcome Scale (GOS-E) at 6 months after injury. We examined the association between the outcomes and anticoagulants/antiplatelet agents at the time of injury and used multivariable logistic regression models to account for known confounders.ResultsThere were 1323 older adults eligible for inclusion in the study, of which 249 (18.8%) were taking anticoagulants (n=8 were taking both anticoagulants and antiplatelet agents), 380 (28.7%) were taking antiplatelet agents and 694 (52.5%) were not using either. Any anticoagulant use was associated with higher odds of in-hospital mortality (adjusted OR (AOR), 2.38; 95% CI 1.58 to 3.59) compared with not using anticoagulants. No differences were observed in the GOS-E at 6 months after injury between any anticoagulants use, antiplatelet use and no anticoagulant use (anticoagulant AOR, 0.71; 95% CI 0.48 to 1.05, antiplatelet AOR, 1.02; 95% CI 0.73 to 1.42).ConclusionAnticoagulant use at the time of injury was associated with higher odds of in-hospital mortality but did not adversely impact functional outcomes at 6 months after injury. These findings demonstrate the importance of seeking an accurate history of anticoagulant use and its indication, as well as the immediate initiation of reversal therapies.

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Intraabdominal Injury is Common in Blunt Trauma Patients who Sustain Spinal Cord Injury

The American Surgeon ◽

10.1177/000313480707301025 ◽

2007 ◽

Vol 73 (10) ◽

pp. 1035-1038

Author(s):

Ali Salim ◽

Marcus Ottochian ◽

Ryan J. Gertz ◽

Carlos Brown ◽

Kenji Inaba ◽

...

Keyword(s):

Spinal Cord ◽

Spinal Cord Injury ◽

Length Of Stay ◽

Blunt Trauma ◽

Injury Severity ◽

Unit Length ◽

Hospital Length Of Stay ◽

Trauma Patients ◽

Cord Injury ◽

Intraabdominal Injury

The evaluation of the abdomen in patients with spinal cord injury (SCI) is challenging for obvious reasons. There are very little data on the incidence and complications of patients who sustain SCI with concomitant intraabdominal injury (IAI). To determine the incidence and outcomes of IAI in blunt trauma patients with SCI, a trauma registry and record review was performed between January 1998 and December 2005. Baseline demographic data, Injury Severity Score, and associated IAI were collected. Two groups were established and outcomes were analyzed based on the presence or absence of IAI. Intraabdominal and hollow viscus injures were found in 15 per cent and 6 per cent, respectively, of 292 patients with blunt SCI. The presence of intraabdominal injury varied according to the level of the SCI: 10 per cent of cervical, 23 per cent of thoracic, and 18 per cent of lumbar SCI. The overall mortality was 16 per cent. The presence of intraabdominal injury was associated with longer intensive care unit length of stay (13 versus 6 days, P < 0.01), hospital length of stay (23 versus 18 days, P < 0.05), higher complication rate (46% versus 33%, P = 0.09), and higher mortality (44% versus 11%, P < 0.01) when compared with patients with SCI without IAI. Intraabdominal injuries are common in blunt SCI. Liberal evaluation with computed tomography is necessary to identify injuries early.

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Placement of Surgical Feeding Tubes Among Patients With Severe Traumatic Brain Injury Requiring Exploratory Abdominal Surgery

The American Surgeon ◽

10.1177/0003134820923302 ◽

2020 ◽

Vol 86 (6) ◽

pp. 635-642

Author(s):

Peter I. Cha ◽

Ronald M. Jou ◽

David A. Spain ◽

Joseph D. Forrester

Keyword(s):

Length Of Stay ◽

Abdominal Surgery ◽

Injury Severity ◽

Unit Length ◽

Feeding Tube ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Fascial Closure ◽

Trauma Patients ◽

Percutaneous Endoscopic Gastrostomy Placement

Objectives The purpose of this study was to identify trauma patients who would benefit from surgical placement of an enteral feeding tube during their index abdominal trauma operation. Methods We performed a retrospective analysis of all patients admitted to 2 level I trauma centers between January 2013 and February 2018 requiring urgent exploratory abdominal surgery. Results Six-hundred and one patients required exploratory abdominal surgery within 24 hours of admission after trauma activation. Nineteen (3% of total) patients underwent placement of a feeding tube after their initial exploratory surgery. On multivariate analysis, an intracranial Abbreviated Injury Scale ≥4 (odds ratio [OR] = 9.24, 95% CI 1.09-78.26, P = .04) and a Glasgow Coma Scale ≤8 (OR = 4.39, 95% CI 1.38-13.95, P = .01) were associated with increased odds of requiring a feeding tube. All patients who required a feeding tube had an Injury Severity Score ≥15. While not statistically significant, patients with an open surgical feeding tube compared with interventional radiology/percutaneous endoscopic gastrostomy placement had lower median intensive care unit length of stay, fewer ventilator days, and shorter median total hospital length of stay. Conclusions Trauma patients with severe intracranial injury already requiring urgent exploratory abdominal surgery may benefit from early, concomitant placement of a feeding tube during the index abdominal operation, or at fascial closure.

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An Objective Study of the Impact of the Electronic Medical Record on Outcomes in Trauma Patients

The American Surgeon ◽

10.1177/000313481207801134 ◽

2012 ◽

Vol 78 (11) ◽

pp. 1249-1254 ◽

Cited By ~ 4

Author(s):

Paul J. Schenarts ◽

Claudia E. Goettler ◽

Michael A. White ◽

Brett H. Waibel

Keyword(s):

Length Of Stay ◽

Medical Record ◽

Electronic Medical Record ◽

Injury Severity ◽

Unit Length ◽

Traumatic Injury ◽

Hospital Length Of Stay ◽

Trauma Patients ◽

Delay In Diagnosis ◽

The Impact

It is commonly believed that the electronic medical record (EMR) will improve patient outcomes. However, there is scant published literature to support this claim and no studies in any surgical population. Our hypothesis was that the EMR would not improve objective outcome measures in patients with traumatic injury. Prospectively collected data from our university-based Level I trauma center was retrospectively reviewed. Demographic, injury severity as well as outcomes and complications data were compared for all patients admitted over a 20-month period before introduction of the EMR and a 20-month period after full, hospital-wide use of the EMR. Implementation of the EMR was associated with a decreased hospital length of stay, P = 0.02; intensive care unit length of stay, P = 0.001; ventilator days, P = 0.002; acute respiratory distress syndrome, P = 0.006, pneumonia, P = 0.008; myocardial infarction, P = 0.001; line infection, P = 0.03; septicemia, P = 0.000; renal failure, P = 0.000; drug complication, P = 0.001; and delay in diagnosis, P = 0.04. There was no difference in mortality, unexpected cardiac arrest, missed injury, pulmonary embolism/deep vein thrombosis, or late urinary tract infection. This is the first study to investigate the impact of the EMR in surgical patients. Although there was an improvement in some complications, the overall impact was inconsistent.

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Risk for Contrast-Induced Nephropathy in Elderly Trauma Patients

The American Surgeon ◽

10.1177/000313481207801023 ◽

2012 ◽

Vol 78 (10) ◽

pp. 1114-1117 ◽

Cited By ~ 6

Author(s):

Ryan Finigan ◽

Jacqueline Pham ◽

Rosemarie Mendoza ◽

Michael Lekawa ◽

Matthew Dolich ◽

...

Keyword(s):

Diabetes Mellitus ◽

Length Of Stay ◽

Injury Severity ◽

Unit Length ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Trauma Patients ◽

Contrast Induced Nephropathy ◽

History Of ◽

Elderly Trauma Patients

The objective of this study was to determine if elderly trauma patients are at risk for contrast-induced nephropathy (CIN). A retrospective study was conducted identifying 362 patients 65 years and older in our Level I trauma center who received computerized tomography (CT) scans with intravenous contrast. CIN was defined as a 25 per cent increase in serum creatinine levels or a 0.5 mg/dL increase above baseline after CT. History of diabetes mellitus, hospital length of stay, intensive care unit length of stay, Injury Severity Score (ISS), and age were recorded. Eighteen per cent (21 of 118) of the patients had a peak in creatinine, 12 per cent (14 of 118) peaked and returned to baseline, and 6 per cent (7 of 118) peaked and stayed high. Pre-CT elevated creatinine, diabetes mellitus, increased hospital length of stay, ISS, and age show little association to CIN. The data suggest that CIN in elderly trauma patients is rare, regardless of history of diabetes mellitus, age, creatinine, high ISS, or result in higher length of stay. Therefore, there is little justification for the delay in diagnosis to assess a patient's renal susceptibility.

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‘Normal’ Vital Signs Belie Occult Hypoperfusion in Geriatric Trauma Patients

The American Surgeon ◽

10.1177/000313481007600113 ◽

2010 ◽

Vol 76 (1) ◽

pp. 65-69 ◽

Cited By ~ 22

Author(s):

Jeremiah T. Martin ◽

Fuad Alkhoury ◽

Judith A. O'Connor ◽

Tassos C. Kyriakides ◽

John A. Bonadies

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Length Of Stay ◽

Unit Length ◽

Vital Signs ◽

Intensive Care Unit Length ◽

Hospital Length Of Stay ◽

Common Finding ◽

Trauma Patients ◽

Severity Scores

Base deficit (BD) and lactic acid (LA) are accepted markers of hypoperfusion and predictors of outcome in the trauma patient and we aim to assess the value of these markers in the triage of the elderly with “normal” vital signs. Patients older than age 65 who presented between 1997 and 2004 but who did not have isolated head injuries were included. Three patient groups were established: normal, occult hypoperfusion (OH), and shock. Outcome measures included mortality, hospital length of stay, intensive care unit length of stay, and discharge disposition. One hundred six patients were included in the analysis and had similar Injury Severity Scores. Mean systolic blood pressure was similar in the normal and OH groups. Forty-two per cent of patients had abnormal BD or LA in the emergency room indicating OH. These patients were more likely to have a longer intensive care unit length of stay (8.6 days vs 3 days; P = 0.01) and were also more likely to be discharged to a nursing facility ( P = 0.03). The trend was toward increased mortality in the OH group. OH is a common finding in elderly trauma patients. Outcomes in these patients are different and more like those presenting in shock.

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Propofol Infusion Syndrome: Efficacy of a Prospective Screening Protocol

The American Surgeon ◽

10.1177/000313481808400848 ◽

2018 ◽

Vol 84 (8) ◽

pp. 1333-1338 ◽

Cited By ~ 1

Author(s):

Thomas J. Schroeppel ◽

L. Paige Clement ◽

Danielle L. Barnard ◽

Whitney Guererro ◽

Margaret D. Ferguson ◽

...

Keyword(s):

Length Of Stay ◽

Injury Severity ◽

Unit Length ◽

Hospital Length ◽

Serum Lactate ◽

Hospital Length Of Stay ◽

Trauma Patients ◽

Propofol Infusion Syndrome ◽

Positive Screen ◽

Screening Protocol

Propofol infusion syndrome (PIS) is a potentially lethal complication of propofol marked by rhabdomyolysis, metabolic acidosis, and cardiac arrhythmias or collapse. The objective of this study was to determine the effectiveness of a prospective screening protocol to prevent PIS. All trauma patients admitted who received propofol as a continuous infusion were prospectively screened from November 1, 2013 to December 31, 2015. Variables studied included demographics, injury severity, laboratory values, infusion rates, and mortality. Serum creatine phosphokinase (CPK) and lactate were drawn daily. Propofol was stopped for a positive screen defined as an increase in CPK to greater than 5000 IU/L or lactate greater than 4 mmol/L. Positive and negative cohorts were compared. Two hundred and twenty-five patients met the inclusion criteria and 12 patients (5.3%) had propofol stopped because of elevated CPK. No differences were identified in demographics, transfusions, injury severity, hospital length of stay, or propofol dose. The positive screened group had longer intensive care unit length of stay (20 vs 13 days; P = 0.002) and increased vent days (14.5 vs 10 days; P = 0.008). Max serum osmolality (334 vs 305 mosm/kg; P = 0.049) and max serum CPK (6782 vs 1058 IU/L; P < 0.0001) were higher in the positive cohort. No cases of PIS occurred, and mortality (16.7 vs 15.5%; P = 0.999) was not different between the cohorts. The screening protocol was effective in eliminating PIS. Serial CPK evaluations provided an effective screening tool and serum lactate can be dropped from screening.

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Dabigatran Use Does Not Increase Intracranial Hemorrhage in Traumatic Geriatric Falls When Compared with Warfarin

The American Surgeon ◽

10.1177/000313481508101025 ◽

2015 ◽

Vol 81 (10) ◽

pp. 1039-1042 ◽

Cited By ~ 4

Author(s):

Anthony Pozzessere ◽

Jonathan Grotts ◽

Stephen Kaminski

Keyword(s):

Length Of Stay ◽

Intracranial Hemorrhage ◽

Injury Severity ◽

Unit Length ◽

Hospital Length Of Stay ◽

Geriatric Trauma ◽

Trauma Patients ◽

Exact Matching ◽

Increased Risk ◽

Community Trauma

Patients on anticoagulation are at increased risk for intracranial hemorrhage (ICH) after trauma. This is important for geriatric trauma patients, who are increasing in number, frequently fall, and often take anticoagulants. This study sought to evaluate whether prehospital use of dabigatran, a newer anticoagulant, is associated with outcome differences in geriatric trauma patients suffering falls when compared with warfarin. The registry of a Level II community trauma center was used to identify 247 patients aged 65 and older who sustained a fall while taking prehospital dabigatran or warfarin admitted between December 2010 and March 2014. Patients on warfarin were included if their International Normalized Ratio was therapeutic (2–3). About 176 of the 247 patients were then compared using coarsened exact matching. In the matched analysis, overall population means for age, Glasgow Coma Score, and Injury Severity Score were 83.5, 14.7, and 5.1, respectively. The overall rate of ICH was 12.5 per cent, with a mortality rate of 16.1 per cent for patients who sustained an ICH. There were no observed differences in ICH, hospital length of stay, intensive care unit length of stay, or mortality between patients taking prehospital warfarin or dabigatran.

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Outcomes in Trauma Patients with Isolated Epidural Hemorrhage: A Single-Institution Retrospective Cohort Study

The American Surgeon ◽

10.1177/000313481608201228 ◽

2016 ◽

Vol 82 (12) ◽

pp. 1209-1214 ◽

Cited By ~ 2

Author(s):

Bardiya Zangbar ◽

Bradley Serack ◽

Peter Rhee ◽

Bellal Joseph ◽

Viraj Pandit ◽

...

Keyword(s):

Length Of Stay ◽

Unit Length ◽

Retrospective Chart Review ◽

Hospital Length ◽

Adverse Outcomes ◽

Hospital Length Of Stay ◽

Progression Rate ◽

Trauma Patients ◽

Head Ct ◽

Epidural Hemorrhage

The type, location, and size of intracranial hemorrhage are known to be associated with variable outcomes in patients with traumatic brain injury (TBI). The aim of our study was to assess the outcomes in patients with isolated epidural hemorrhage (EDH) based on the location of EDH. We performed a 3-year (2010–2012) retrospective chart review of the patients with TBI in our level 1 trauma center. Patients with an isolated EDH on initial head CT scan were included. Patients were divided into four groups based on the location of EDH: frontal, parietal, temporal, and occipital. Differences in demographics and outcomes between the four groups were assessed. Outcome measures were progression on repeat head CT and neurosurgical intervention (NI). A total of 76 patients were included in this study. The mean age was 20.6 ± 15.2 years, 68.4 per cent were male, median Glasgow Coma Scale (GCS) score 15 (13–15), and median head Abbreviated Injury Scale score was 3 (2–4). About 32.9 per cent patients (n = 25) had frontal EDH, 26.3 per cent (n = 20) had temporal EDH, 10.5 per cent (n = 8) had occipital EDH, while the remaining 30.3 per cent (n = 23) had parietal EDH. The overall progression rate was 21.1 per cent (n = 12) and NI rate was 29 per cent (n = 22). There was no difference in the outcome of patients based on location of EDH. Patients with NI had a longer hospital length of stay ( P = 0.02) and longer intensive care unit length of stay ( P = 0.05). The incidence of isolated EDH is low in patients with blunt TBI. Patients with isolated EDH undergoing NI have longer hospital stays compared to patients without NI. Further investigation is warranted to identify factors associated with need for NI and adverse outcomes in the cohort of patients with isolated EDH.

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Pain Assessment and Control in the Injured Elderly

The American Surgeon ◽

10.1177/000313481608201001 ◽

2016 ◽

Vol 82 (10) ◽

pp. 867-871 ◽

Cited By ~ 1

Author(s):

Ara Ko ◽

Megan Y. Harada ◽

Eric J.T. Smith ◽

Michael Scheipe ◽

Rodrigo F. Alban ◽

...

Keyword(s):

Risk Factors ◽

Length Of Stay ◽

Injury Severity ◽

Unit Length ◽

Patient Characteristics ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Trauma Patients ◽

Increased Risk ◽

Elderly Trauma Patients

Elderly trauma patients may be at increased risk for underassessment and inadequate pain control in the emergency department (ED). We sought to characterize risk factors for oligoanalgesia in the ED in elderly trauma patients and determine whether it impacts outcomes in elderly trauma patients. We included elderly patients (age ≥55 years) with Glasgow Coma Scale scores 13 to 15 and Injury Severity Score (ISS) ≥9 admitted through the ED at a Level I trauma center. Patient characteristics and outcomes were compared between those who reported pain and received analgesics medication in the ED (MED) and those who did not (NO MED). A total of 183 elderly trauma patients were identified over a three-year study period, of whom 63 per cent had pain assessed via verbal pain score; of those who reported pain, 73 per cent received analgesics in the ED. The MED and NO MED groups were similar in gender, race, ED vitals, ISS, and hospital length of stay. However, NO MED was older, with higher head Abbreviated Injury Scale score and longer intensive care unit length of stay. Importantly, as patients aged they reported lower pain and were less likely to receive analgesics at similar ISS. Risk factors for oligoanalgesia may include advanced age and head injury.

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Long-term outcomes of major trauma with unstable open pelvic fractures: A population-based cohort study

Trauma ◽

10.1177/1460408620933203 ◽

2020 ◽

pp. 146040862093320

Author(s):

Belinda J Gabbe ◽

Ian Stewart ◽

William Veitch ◽

Ben Beck ◽

Peter Cameron ◽

...

Keyword(s):

Health Status ◽

Hospital Mortality ◽

Pelvic Fracture ◽

Major Trauma ◽

Road Traffic ◽

Population Based ◽

Pelvic Fractures ◽

Pelvic Injury ◽

Trauma Patients ◽

Post Injury

Aims The aims of this study were to describe the profile and longer-term outcomes of major trauma patients with unstable open pelvic fractures. Patients and methods An observational study was performed using data from the population-based Victorian State Trauma Registry. Adult (≥16 years) major trauma patients who had sustained an unstable open pelvic fracture between 1 July 2010 and 30 June 2017 in Victoria (Australia) were included. Patient demographics, injury event, severity and management data were extracted. Patients were followed up at 6, 12 and 24 months post-injury to collect information about health status, function and return to work. Results There were 67 patients. The mean (SD) age was 41.4 (18.3) years, and 66% were male. Seventy-six per cent were road traffic injuries, 96% were managed at Level 1 trauma centres and all were multi-trauma patients. A third were Tile C fractures and 80% underwent surgical stabilisation of the pelvic injury. Eighty per cent were admitted to intensive care. The in-hospital mortality rate was 9%. Most (89%) survivors were discharged to an inpatient rehabilitation facility. The proportion classified as ‘severe disability’ on the Glasgow Outcome-Scale Extended declined from 38% at 6 months to 19% at 24 months. The overall three-level EuroQoL five-dimensional instrument score increased with time indicating better health status, and 50% of patients returned to work by 24 months. Conclusions Major trauma with unstable, open pelvic fracture is rare. Low in-hospital mortality was observed. Most survived to hospital discharge and outcomes improved with time post-injury, but 75% of patients experienced persistent pain and ongoing mobility and activity restrictions.

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