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Prehospital Triage of Older Adults with Head Injury: A Retrospective Study of the Impact of Adding “Anticoagulation or Antiplatelet Medication Use” as a Criterion
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Feb 24 2017
Source: Ann Emerg Med. 70(2):127-138.e6.
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Alternative Title:Ann Emerg Med
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Description: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.
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Pubmed ID:28238499
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Pubmed Central ID:PMC5522761
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