Out-of-Hospital Triage of Older Adults With Head Injury: A Retrospective Study of the Effect of Adding “Anticoagulation or Antiplatelet Medication Use” as a Criterion

Abstract

Study Objective Field triage guidelines recommend EMS providers consider transport of head injured older adults with anticoagulation use to trauma centers. However the triage patterns and the incidence of intracranial hemorrhage or neurosurgery in these patients are unknown. Our objective was to describe the characteristics and outcomes of older adults with head trauma transported by EMS, particularly in patients that do not meet physiological, anatomical, or mechanism of injury (Step 1-3) field triage criteria but are taking anticoagulant or antiplatelet medications. Methods This was a retrospective study at 5 EMS agencies and 11 hospitals (4 trauma centers, 7 non-trauma centers). Patients ≥55 years with head trauma who were transported by EMS were included. The primary outcome was the presence of intracranial hemorrhage. The secondary outcome was a composite measure of in-hospital death or neurosurgery. Results 2110 patients were included; 131 (6%) had intracranial hemorrhage and 41 (2%) had in-hospital death or neurosurgery. There were 162 patients (8%) with Step 1-3 criteria. Of the remaining 1948 patients without Step 1-3 criteria, 566 (29%) had anticoagulant or antiplatelet use. Of these patients, 52 (9%) had traumatic intracranial hemorrhage and 15 (3%) died or had neurosurgery. The sensitivity of Step 1-3 criteria was 19.8% (26/131; 95% CI 5.5-51.2%) for identifying traumatic intracranial hemorrhage and 34.1% (14/41; 95% CI 28.9-90.1%) for death or neurosurgery. The additional criterion of anticoagulant or antiplatelet use improved the sensitivity for intracranial hemorrhage (78/131; 59.5%, 95% 42.9-74.2%) and death or neurosurgery (29/41; 70.7%, 95% CI 61.0-78.9%). Conclusions Relatively few patients met Step 1-3 triage criteria. In those who did not have Step 1-3 criteria, nearly 30% had anticoagulant or antiplatelet use. A relatively high proportion of these patients had intracranial hemorrhage but a much smaller proportion died or had neurosurgery during hospitalization. Use of Step 1-3 triage criteria alone is not sufficient in identifying intracranial hemorrhage and death or neurosurgery in this patient population. The additional criterion of anticoagulant or antiplatelet use improves the sensitivity of the instrument with only a modest decrease in specificity.

The Association of Trauma Center Transport and Long‐term Functional Outcomes in Head‐injured Older Adults Transported by Emergency Medical Services

“…7 Prior studies have also shown that current field triage guidelines are not accurate in predicting trauma center need in this population. [8][9][10]…”

“…Older adults with head injury often have minor mechanisms of injury, such as falls from standing height, yet have significant traumatic intracranial hemorrhage . Prior studies have also shown that current field triage guidelines are not accurate in predicting trauma center need in this population …”

Improvement in geriatric trauma outcomes in an evolving trauma system

“…Numerous reports have pointed out that the use of standard triage criteria is followed by undertriage of patients over the age of 60 1 11 12 14 28 36. Several studies have tried to demonstrate an effect on undertriage and outcome by redefining trauma criteria for the elderly 13 37 38. Brown et al found that substituting SBP of less than 110 mm Hg with the current 90 mm Hg in patients older than 65 achieves a larger reduction in undertriage than increase in overtriage and the risk for mortality is similar in these groups 39.…”

The Incidence of Traumatic Intracranial Hemorrhage in Head-Injured Older Adults Transported by EMS with and without Anticoagulant or Antiplatelet Use

“…To our knowledge, this is the first study that prospectively compares the incidence of tICH in head-injured older adults transported by EMS with and without anticoagulation. Prior studies related to this topic have been limited by their retrospective design, 9,10,18,29 lack of patients taking direct oral anticoagulants, 9,10,18,29 and lack of comparator group (i.e., patients not taking anticoagulant or antiplatelet agents). 9,18,28,30 Given the aging population in the United States and the increasing proportion of injured older adults being transported by EMS agencies and evaluated in EDs, this is a high priority area of study for pre-hospital and ED providers.…”