Mortality among head trauma patients taking preinjury antithrombotic agents: a retrospective cohort analysis from a Level 1 trauma centre

Abstract

BackgroundBleeding represents the most well-known and the most feared complications caused by the use of antithrombotic agents. There is, however, limited documentation whether pre-injury use of antithrombotic agents affects outcome after head trauma. The aim of this study was to define the relationship between the use of preinjury antithrombotic agents and mortality among elderly people sustaining blunt head trauma.MethodsA retrospective cohort analysis was performed on the hospital based trauma registry at Oslo University Hospital. Patients aged 55 years or older sustaining blunt head trauma between 2004 and 2006 were included. Multivariable logistic regression analyses were used to identify independent predictors of 30-day mortality. Separate analyses were performed for warfarin use and platelet inhibitor use.ResultsOf the 418 patients admitted with a diagnosis of head trauma, 137 (32.8 %) used pre-injury antithrombotic agents (53 warfarin, 80 platelet inhibitors, and 4 both). Seventy patients died (16.7 %); 15 (28.3 %) of the warfarin users, 12 (15.0 %) of the platelet inhibitor users, and two (50 %) with combined use of warfarin and platelet inhibitors, compared to 41 (14.6 %) of the non-users. There was a significant interaction effect between warfarin use and the Triage Revised Trauma Score collected upon the patients’ arrival at the hospital. After adjusting for potential confounders, warfarin use was associated with increased 30-day mortality among patients with normal physiology (adjusted OR 8,3; 95 % CI, 2.0 to 34.8) on admission, but not among patients with physiological derangement on admission. Use of platelet inhibitors was not associated with increased mortality.ConclusionsThe use of warfarin before trauma was associated with increased 30-day mortality among a subset of patients. Use of platelet inhibitors before trauma was not associated with increased mortality. These results indicate that patients on preinjury warfarin may need closer monitoring and follow up after trauma despite normal physiology on admission to the emergency department.

Antiplatelet Agent Reversal Is Unnecessary in Blunt Traumatic Brain Injury Patients Not Requiring Immediate Craniotomy

“…Multiple studies have been unable to demonstrate a consistent benefit with or without TEG guidance. [11][12][13][14][15][16] We have confirmed, as reported by previous studies, that there was no increase in patient safety complications among patients who did not receive antiplatelet therapy reversal. We have further demonstrated that platelet transfusions do not prevent the need for invasive neurosurgical interventions including ICP monitoring, burr holes, and craniotomy for TICH extension in blunt TBI patients.…”

“…10 Multiple studies, however, have been unable to demonstrate a consistent benefit to platelet transfusion in this patient population. [11][12][13][14][15][16] A recent large trial utilizing thromboelastography with platelet mapping (TEG-PM) to direct the decision for platelet transfusion to reverse platelet dysfunction similarly demonstrated no improvement in clinical outcomes. 17 We sought to determine whether emergent platelet transfusion reduces the incidence of hemorrhage expansion, mortality, or need for neurosurgical intervention such as intracranial pressure (ICP) monitoring, burr holes, or craniotomy.…”

Characteristics of traumatic brain injury patients with abnormal neuroimaging in Southeast Norway

“…Patients with a pre-injury ASA-PS score of ≥ 3 were substantial (28%) compared to CENTER-TBI which was 11% (Steyerberg et al 2019); the latter is similar to the general trauma population admitted to OUH (10%) (Sovik et al 2014). The more silent comorbidity; antithrombotics, were used by 42% of our TBI patients > 50 years and this compares to other TBI studies, 33-47%, on the elderly population (Gaist et al 2017;Julien et al 2017;Narum et al 2016;Lenell et al 2019). In the total Norwegian population 18% ≥ 40 years use antithrombotic drugs (Berg et al 2017) in line with previously mentioned EU study (Steyerberg et al 2019).…”

The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition

“…In patients with blunt head trauma, a previous meta-analysis of case-control and cohort studies showed only a slight and non-significant increased risk of death in patients who were taking pre-injury APA [ 790 ]. Further studies found both an association with worsening of the lesion [ 791 , 792 ], need for neurosurgical intervention [ 791 ], prolonged hospital stay and increased rate of disability [ 793 ], or no influence on survival [ 794 , 795 ], neurological outcome [ 786 , 796 ], need for neurosurgical intervention [ 794 , 797 ], haemorrhagic complications and need of re-operation after decompressive craniectomy [ 798 ], questioning the need for routine neurosurgical consultation [ 797 ] or repeat CT [ 799 ] in cases of mild head trauma or low-altitude falls in patients treated with APA (mainly aspirin, clopidogrel or both).…”