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

Abstract

Field triage guidelines recommend transport of head-injured patients on anticoagulants or antiplatelets to a higher-level trauma center based on studies suggesting a high incidence of traumatic intracranial hemorrhage (tICH). We compared the incidence of tICH in older adults transported by EMS with and without anticoagulation or antiplatelet use and evaluated the accuracies of different sets of field triage criteria to identify tICH. This was a prospective, observational study at 5 EMS agencies and 11 hospitals. Older adults (≥55 years) with head trauma and transported by EMS from Aug 2015 to Sept 2016 were eligible. EMS providers completed standardized data forms and patients were followed through ED or hospital discharge. We enrolled 1,304 patients; 1147 (88%) received a cranial CT scan and were eligible for analysis. 434 (33%) patients had anticoagulant or antiplatelet use and 112 (10%) had tICH. The incidence of tICH in patients with (11%, 95%CI 8-14%) and without (9%, 95%CI 7-11%) anticoagulant or antiplatelet use was similar. Anticoagulant or antiplatelet use was not predictive of tICH on adjusted analysis. Steps 1-3 criteria alone were not sensitive in identifying tICH (27%) while the addition of anticoagulant or antiplatelet criterion improved sensitivity (63%). Other derived sets of triage criteria were highly sensitive (>98%) but poorly specific (<11%). The incidence of tICH was similar between patients with and without anticoagulant or antiplatelet use. Use of anticoagulant or antiplatelet medications was not a risk factor for tICH. We were unable to identify a set of triage criteria that was accurate for trauma center need.

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 …”

Prevalence and Severity of Traumatic Intracranial Hemorrhage in Older Adults with Low‐Energy Falls

“…To date, specific recommendations are missing for low‐energy trauma in older patients such as ground‐level falls with or without anticoagulation or antiplatelet treatments and equivocal clinical signs of traumatic brain injury. Current studies on these particular patients are heterogeneous and bear some limitations, such as missing control group, small sample sizes, or lacking information about injury severity …”

Intracranial Hemorrhage in Older Adults: Implications for Fall Risk Assessment and Prevention

“…The vast majority were ground level falls. Previous research has reported a 2.3% rate of ICH in low‐risk head injury patients (Glasgow Coma Scale of 15, no neurologic findings, no visible wounds, and no coagulation diseases or medications) and 11% in hospitalized head trauma patients …”

“…Some studies suggest that the incidence of ICH is more common and outcomes are worse when they occur in patients on anticoagulation . Others report that the incidence of ICH with anticoagulation is unchanged . These studies, in general, are limited as most are retrospective, have relatively low numbers of subjects, or have other methodologic limitations.…”