Antiplatelet and anticoagulant agents have minimal impact on traumatic brain injury incidence, surgery, and mortality in geriatric ground level falls: A multi-institutional analysis of 33,710 patients. Fakhry SM, Morse JL, Garland JM, Wilson NY, Shen Y, Wyse RJ, Watts DD. J Trauma Acute Care Surg. 2021 Feb 1;90(2):215-223.
Summary: The authors looked at 33,710 patients after exclusion criteria, who were 65 years of age or older and sustained a ground level fall (GLF). Antithrombotic (AT) use was present in 47.6%, and this population was more likely to be older, female, have a higher admission GCS and have comorbidities than patients who did not use ATs.
There was no statistically significant difference in overall mortality rate in the two groups, but patients with AT use were more likely to be discharged to a nursing facility and less likely to be discharged from the ED.
There was no difference in the incidence of TBI for all admission GCS scores (combined 21.4%), but lower GCS scores were associated with a higher incidence of TBI, mortality, and need for cranial surgery. Patients with a GCS of 13-15 had a significantly higher mortality in patients taking ATs. The authors recognize that cofounding factors such as intubation and dementia influence the data for this patient population.
When specific medications were examined it was noted that patients on aspirin-clopidogrel had a higher rate of TBI diagnosis, while those taking Apixaban, and Dabigatran had significantly lower rates of TBI when compared to the group not taking AT’s. The reason for the latter is not clear. No AT regime was associated with a higher mortality, but ASA had a lower mortality when compared to no ATs.
Take Home: As noted by the authors, GLF in patients over 65 years old, a common mechanism had a surprising risk of TBI (>20%) and it is imperative that complete evaluation be performed. While realizing the limitations of the study, the large sample size suggests that the use of ATs in general has little effect on incidence of TBI, need for OR and mortality. Article 2Hard signs gone soft: A critical evaluation of presenting signs of extremity vascular injury
. Romagnoli AN, DuBose J, Dua A, Betzold R, Bee T, Fabian T, Morrison J, Skarupa D, Podbielski J, Inaba K, Feliciano D, Kauvar D, AAST PROOVIT Study Group. J Trauma Acute Care Surg
. 2021 Jan 1;90(1):1-10.
Summary: The PROspective Observational Vascular Injury Treatment
(PROOVIT) registry enrolled patients from 25 participating trauma centers with extremity arterial injury. A total of 1910 patients were enrolled in the study. The study evaluated the hard signs of vascular injury (Arterial bleed, expanding hematoma, absent distal pulse, thrill, bruit), traditionally indications for imaging and operative exploration and instead classified patients into hemorrhagic and ischemic signs of injury.
The majority (58%) of patients had hard signs of vascular injury. In this group 65.1% had operative exploration alone, 68% of these requiring operative repair. 16.2% had CTA alone, with 1.4% having injuries addressed endovascularly. Patients with hard signs had a statistically higher in-patient mortality rate, amputation rate and reintervention rate.
The authors then looked at this population from the perspective of hemorrhagic (915) and ischemic (490) signs. All patients with hemorrhagic signs and 35% of those with ischemic signs had traditional hard signs present. CTA was performed in 14.5% and 31.6% of these groups, respectively. Patients who had CTA in both groups were more likely to be managed with observation, more likely to be managed with an endovascular procedure and less likely to require operative repair. There was no difference in the reintervention rate, need for packed cells, amputation rate, mortality, or LOS.
Take Home: Traditionally hard signs of vascular injury are an indication for operative exploration without the need for CTA, however many of these patients are getting CTA first. This paper suggests that classifying injuries into hemorrhagic and occlusive type injuries can better identify patients who will benefit from CTA. CTA is associated with reduced need for operative repair with similar complications when compared to non-CTA patients. Further prospective studies with larger patient populations is warranted.