Preinjury Warfarin Worsens Outcome in Elderly Patients Who Fall From Standing
ABSTRACT Fall from standing (FFS) has become one of the most common mechanisms of injury for admission to the trauma center in the elderly population. Many of these patients present anticoagulated with warfarin. This two-center study was designed to examine the effects of preinjury warfarin use on outcome in the elderly.
A retrospective review of prospectively collected registry data at two Level I trauma centers was conducted from 2003 to 2006. The study population included patients age > or = 65 admitted to the trauma center after an FFS. These centers are relatively close geographically and have similar patient demographics. Data collected included: age, Injury Severity Score, Abbreviated Injury Score (AIS) for head, mortality, admission Glasgow Coma Score, and admission international normalized ratio (INR). Patients were divided into two groups based on the preinjury condition of warfarin use. Statistical differences were determined by unpaired t test for continuous variables and chi and odds ratios (ORs) for dichotomous variables.
Of the 27,812 patients admitted to these two trauma centers over this time period, 2,791 (10.0%) were of age > or = 65 and admitted after an FFS. INR was 2.8 +/- 1.1 in warfarin group (+warf). The number of patients with AIS head 4 and 5 was similar between groups (-warf 22.1%, +warf 25.9%). Overall, preinjury warfarin use had a negative effect on the in-hospital mortality rate, +warf 8.6% and -warf 5.7% (OR 1.54, 1.09-2.19, p = 0.015). There was no difference in mortality between groups in patients with an AIS head < 4. The negative impact of preinjury warfarin use on mortality was most pronounced in patients with an AIS head 4 and 5 who presented awake (Glasgow Coma Score 14 and 15), +warf 13.5% and -warf 6.4% (OR 2.30, 95% confidence interval 1.12-4.70, p = 0.019).
Preinjury warfarin use has an adverse effect on outcome (mortality) in elderly FFS patients. Importantly, this effect is most prominent in patients admitted awake with significant findings on computed tomography scan. This argues for rapid emergency department triage to computed tomography scan and rapid INR correction in this population.
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ABSTRACT: Atrial fibrillation prophylaxis with warfarin and strong antiplatelet agent use in cardiovascular diseases has increased the incidence of anticoagulation in the elderly. We studied traumatic intracranial hemorrhage (TICH) in patients ≥55 years of age on anticoagulation and antiplatelet agents in a stable population. We used a Level 1 Trauma Center registry study comparing TICH in patients on anticoagulation drugs during the index periods 1999 to 2000 (T1) and 2007 to 2008 (T2). A total of 526 TICH patients were seen in T1 and T2 (age, 77.6 vs 77.5 years; not significant [NS]), with the rate doubling from 6.2% to 12.3% of all trauma activations (P < .01). There was no increase in atrial fibrillation, warfarin use, or CHADS(2) scores in atrial fibrillation patients on anticoagulation therapy. TICH in patients taking antiplatelet agents increased 5-fold (2.2 % vs 10.3%; P < .01). Overall TICH mortality rate was the same (12.4% vs 12.2%, NS). TICH mortality among patients on therapeutic warfarin was greater in T1 (26%; P < .05), but mortality was similar to TICH in patients not on anticoagulants in T2 (19% vs 12.2%, NS), suggesting treatment improved. Prevalence and mortality of TICH in patients on antiplatelet agents were similar to TICH in patients on warfarin. TICH in patients on anticoagulants is epidemic in patients ≥55 years of age. Despite national trends, our well-served population has not seen an increase in warfarin use for atrial fibrillation. Instead, use of antiplatelet agents has increased and is associated with an increased incidence of TICH.Surgery 10/2010; 148(4):724-9; discussion 729-30. DOI:10.1016/j.surg.2010.07.014 · 3.11 Impact Factor
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ABSTRACT: Normal vital signs are typically associated with improved outcomes in trauma patients. Whether this association is true for geriatric patients is unclear. A Level 1 trauma center retrospective chart review of vital signs on presentation (heart rate [HR] and blood pressure) in young (aged 17-35 years) and geriatric (aged 65 years or older) blunt trauma victims from September 2003 to September 2008 was preformed. Generalized nonlinear using piecewise regression for the linear portion of standard logistic models was used to model risk of mortality as a function of HR and blood pressure. Independent models were selected for elderly and young trauma patients based on blood pressure and HR. Models of the same complexity were then fit within each gender and age. There were 2,194 geriatric and 2,081 young patients. Two hundred fifty-one (11.4%) geriatric and 49 (2.4%) young patients died. At all points of "normality," the mortality of the geriatric patients was higher than the young group. Mortality increases considerably in the elderly patients for HRs >90 beats per minute (bpm), an association not seen until HR of 130 bpm in the young group. Mortality significantly increases with systolic blood pressure (SBP) <110 mm Hg in the geriatric patients but not until a SBP of 95 mm Hg in the young patients. HR and mortality association was most variable in the male geriatric patients. Vital signs on presentation are less predictive of mortality in geriatric blunt trauma victims. Geriatric blunt trauma patients warrant increased vigilance despite normal vital signs on presentation. New trauma triage set points of HR >90 or SBP <110 mm Hg should be considered in the geriatric blunt trauma patients.The Journal of trauma 10/2010; 69(4):813-20. DOI:10.1097/TA.0b013e3181f41af8 · 2.96 Impact Factor
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ABSTRACT: Ground-level fall is the most common cause of traumatic intracranial hemorrhage (TICH) in the elderly. Many studies on geriatric TICH have regarded patients aged ≥65 years as a single group, but substantial heterogeneity is likely to exist within this population. Eighty-two elderly patients with fall-related TICH treated in our institution during a 6-year period were stratified into 3 age groups (65-74, 75-84, and ≥85 years), and intergroup differences in the demographics and outcomes at discharge were evaluated. The influence of the use of anti-platelet/anti-coagulant (AP/AC) agent on outcomes was also investigated. Comparison of demographic variables demonstrated significant differences in the frequency of preinjury alcohol consumption and use of AP/AC agents between the 3 groups, indicating that the causes or triggers of fall might be substantially different between the 65-74 years group and the other two groups combined. The frequency of unfavorable outcomes increased with age, and the increase was statistically significant. The 82 patients were divided into two subgroups depending on the use of AP/AC agents. The outcomes of the ≥85 years group taking AP/AC agents were particularly poor compared with those of the ≥85 years group not using AP/AC agents. Advancing age may be associated with unfavorable outcomes in elderly patients with fall-related TICH, and patients aged ≥85 years taking AP/AC have the greatest risk of unfavorable outcomes. Physicians must consider the risk/benefit analysis before prescribing AP/AC agents to patients aged ≥85 years.Neurologia medico-chirurgica 12/2010; 50(12):1051-5. DOI:10.2176/nmc.50.1051 · 0.65 Impact Factor