The Anticoagulated trauma patient in the age of the direct oral anticoagulants: a Canadian perspective

Abstract

BackgroundThe anticoagulated trauma patient presents a particular challenge to the critical care physician. Our understanding of these patients is defined and extrapolated by experience with patients on warfarin pre-injury. Today, many patients who would have been on warfarin are now prescribed the Direct Oral Anticoagulants (DOACs) a class of anticoagulants with entirely different mechanisms of action, effects on routine coagulation assays and approach to reversal.MethodsTrauma registry data from Toronto’s (Ontario, Canada) two Level 1 trauma centres were used to identify patients on oral anticoagulation pre-injury from June 1, 2014 to June 1, 2015. The trauma registry and medical records were reviewed and used to extract demographic and clinical data.ResultsWe found 81 patients were on oral anticoagulants pre-injury representing 3.2% of the total trauma population and 33% of the orally anticoagulated patients were prescribed a DOAC prior to presentation. Comparison between the DOAC and warfarin groups showed similar age, mechanisms of injury, indications for anticoagulation, injury severity score and rate of intracranial hemorrhage. Patients on DOACs had higher initial mean hemoglobin vs warfarin (131 vs 120) and lower serum creatinine (94.8 vs 129.5). The percentage of patients receiving a blood transfusion in the trauma bay and total in-hospital transfusion was similar between the two groups however patients on DOACs were more likely to receive tranexamic acid vs patients on warfarin (32.1% vs 9.1%) and less likely to receive prothrombin concentrates (18.5% vs 60%). Patients on DOACs were found to have higher survival to discharge (92%) vs patients on warfarin (72%).ConclusionPatients on DOACs pre-injury now represent a significant proportion of the anticoagulated trauma population. Although they share demographic and clinical similarities with patients on warfarin, patients on DOACs may have improved outcomes despite lack of established drug reversal protocols and challenging interpretation of coagulation assays.Level of Evidence: III; Study Type: Retrospective Review.

The impact of direct oral anticoagulants in traumatic brain injury patients greater than 60-years-old

“…In contrast, only 24.2% of DOAC patients were treated with the specific antagonist Idarucizumab or PCC ( p = 0.024). This is comparable to the report of Wood et al, where 60% of patients on VKA and only 19% of DOAC patients received reversal agents [ 13 ]. In a multicentre study published by Kobayashi et al, the anticoagulant effect of warfarin was reversed in only 47% compared with 13% of the DOAC patients ( p < 0.001) [ 24 ].…”

“…Current data suggests that approximately 3–4% of all trauma patients are under ATT before admission [ 3 , 13 ]. TBI patients with preinjury intake of ATT carry a higher risk for ICH formation, haematoma progression and higher mortality rates compared to those without exposure to these substances [ 3 , 4 , 18 – 20 ].…”

“…In a mixed subset of 81 anticoagulated trauma patients, Wood et al reported that DOAC intake resulted in higher survival rates to discharge compared with patients on VKAs (92% vs. 72%, p < 0.03) [ 13 ]. Interestingly, the rates of ICH were comparable between VKA and DOAC patients (70.0% vs. 66.7%, p = 0.74).…”

“…As a consequence, trauma care providers are faced with an increasing number of injured patients under DOAC medication [ 12 , 13 ]. Particularly for TBI patients, there remains uncertainty about whether DOACs provoke higher bleeding rates or carry a greater risk for posttraumatic haematoma progression compared to patients on VKAs or PIs [ 14 ].…”

Retrospective Analysis of Geriatric Major Trauma Patients Admitted in the Shock Room of a Swiss Academic Hospital: Characteristics and Prognosis

“…In our study, 6.6% of patients were under anti-platelet therapy. Unlike some other studies [27,28,35], anticoagulation was not significantly associated with mortality in our study, potentially due to the low number of observations.…”