Prehospital Triage of Older Adults with Head Injury: A Retrospective Study of the Impact of Adding “Anticoagulation or Antiplatelet Medication Use” as a Criterion

Details

• Alternative Title:
  Ann Emerg Med
• Personal Author:
  Nishijima, Daniel K. ; Gaona, Samuel ; Waechter, Trent ; Maloney, Ric ; Bair, Troy ; Blitz, Adam ; Elms, Andrew R. ; Farrales, Roel D. ; Howard, Calvin ; Montoya, James ; Bell, Jeneita M. ; Faul, Mark ; Vinson, David R. ; Holmes, James F. ; Ballard, Dustin W.
• Corporate Authors:
  for the Sacramento County Prehospital Research Consortium
• 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.
  
  
• Subjects:
  Aged Aged, 80 And Over Anticoagulants Article California Craniocerebral Trauma Emergency Medical Services Female Guidelines As Topic Hospital Mortality Humans Intracranial Hemorrhage, Traumatic Male Middle Aged Neurosurgical Procedures Platelet Aggregation Inhibitors Retrospective Studies Tomography, X-Ray Computed Transportation Of Patients Trauma Centers Triage

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• Source:
  Ann Emerg Med. 70(2):127-138.e6.
• Pubmed ID:
  28238499
• Pubmed Central ID:
  PMC5522761
• Document Type:
  Journal Article
• Funding:
  L30 TR000286/TR/NCATS NIH HHS/United States ; KL2 TR000134/TR/NCATS NIH HHS/United States ; UL1 TR001860/TR/NCATS NIH HHS/United States ; U01 CE002177/CE/NCIPC CDC HHS/United States ; CC999999/Intramural CDC HHS/United States ; UL1 TR000002/TR/NCATS NIH HHS/United States
• Volume:
  70
• Issue:
  2
• Collection(s):
  CDC Public Access
• Main Document Checksum:
  urn:sha256:7665473f83f31517155817230146245fb571d397724125bb8eb47f835fe0e1a6
• Download URL:
  https://stacks.cdc.gov/view/cdc/46884/cdc_46884_DS1.pdf
• File Type:
  [PDF - 208.84 KB ]