(P10) Association of Antithrombotic and Anticoagulant Medications and Outcomes in Elderly Patients with Minor Trauma

Objectives: This study will try to identify high risk geriatric ED patients who may not meet criteria for trauma activation but will benefit from faster head CT imaging due to concern for TICH.

Background: Traumatic brain injury (TBI) is a common and serious presentation to the emergency department (ED). Geriatric patients have higher mortality and poorer outcomes compared to younger patients with TBI1. Most concerning is the increasing use of anticoagulation (AC) or antiplatelet medications (AP) which can increase the risk of traumatic intracranial hemorrhage (TICH) and worsen prognosis2. Current literature is heterogenous on whether these medications increase the risk of TICH making it difficult to risk stratify these patients and no studies have been identified that evaluated for high-risk features in geriatric trauma patients who did not meet the threshold for trauma activation.

Methods: A retrospective structured chart review of 1,000 geriatric ED patients presenting to a large academic ED from January 2021 through July 2022 with acute minor trauma. Trained investigators extracted demographic, clinical, laboratory and imaging data from the electronic health records. Inclusion criteria included patients who were 65yrs and older and required a head CT. Exclusion criteria included if patients were trauma activations upon triage as defined by the American College of Surgeons, were transferred from an outside facility, presented to the ED with a diagnosis of TICH on outside imaging, had a Glasgow Coma Scale (GCS) less than 14, or had trauma more than 24hrs since ED visit. Primary outcome measured rates of TICH while secondary outcomes included mortality, admission, neurosurgical intervention within 24hrs.
Patients using AC and/or AP medications were grouped into none, DOAC only, warfarin only, aspirin only, P2Y12 inhibitor only, AC+AP agent, or dual antiplatelet agent. Univariate and multivariate analyses were conducted to explore the associations and outcomes.

Results: Mean (SD) age was 82 (9), and 60% were females. Mechanisms of injury include falls (92%) and MVCs (7%). Use of AC or AT agents includes aspirin (24%), NOAC (18%), Warfarin (4%), P2Y12 inhibitor (2%), Dual antiplatelet agents (6%), combined AC and AT agents (7%), none (40%). There were 29 instances of TICH (3%). Rates of TICH by exposure as shown in table 1: none (3%, 1.7-5.2), DOAC (1%, 0.2-4.4), Warfarin (3%, 0.1-15.4), ASA (3%, 1.6-6.8), P2Y12 (0%, 0-22.9) dual antiplatelets (7%, 2.2-17.3), and AC+AT (3%, 0.5-11.3). Only 4 patients (0.3%) required neurosurgical intervention within 24 hours and there were 5 total deaths. Only trauma above clavicles was found to increase risk of TICH (5% vs 1%) as shown in table 2. Of patients with TICH, 19 (66%) were admitted to the ICU compared to 10 (34%) who were admitted to intermediate level of care. Only patients with subdural hemorrhages (93%) were found to be statistically more likely to be admitted to the ICU compared to patients with subarachnoid (46%) or intracerebral hemorrhages (50%) as seen in table 3. No AC or AP agent, symptom, physical exam finding, or demographic was associated with a higher likelihood of ICU admission.

Conclusions: No combination of AC or AP agents or other characteristics were able to be identified to have a TICH incidence high enough to warrant faster CT imaging. These results suggest that geriatric patients who present to the ED with minor trauma had low rates of TICH and low mortality rates. Even if a TICH was identified on imaging, a low percentage required urgent neurosurgical intervention. Our results suggest that these patients can be safely evaluated in the ED without the need for rapid imaging and the trauma activation protocol was sufficient.

References (Optional): 1. Ramanathan DM, McWilliams N, Schatz P, Hillary FG. Epidemiological Shifts in Elderly Traumatic Brain Injury: 18-Year Trends in Pennsylvania. Journal of neurotrauma. 2012;29(7):1371-1378. doi:10.1089/neu.2011.2197
2. Angelozzi, A., Renda, G., Mercuri, M., & Caterina, R. (2015, December 21). The Risk of Intracranial Hemorrhage with Anticoagulation in the Elderly - Estimates of Prevalence and Therapeutic Strategies. Retrieved October 19, 2021, from https://www.acc.org/latest-in-cardiology/articles/2015/12/21/12/59/the-risk-of-intracranial-hemorrhage-with-anticoagulation-in-the-elderly

Funding (Optional): none