J. A. Simon1,2,3, J. Catino1,2, L. Zucker1, S. Evans1, I. Puente1,2, F. Habib1,2, M. Bukur1,2 1Delray Medical Center,Trauma Surgery,Delray Beach, FL, USA 2Broward General Medical Center,Trauma Surgery,Fort Lauderdale, FL, USA 3Larkin Community Hospital,General Surgery,South Miami, FL, USA
Introduction: With the elderly population increasing patients presenting on pre-existing antiplatelet or anticoagulant medications after traumatic injury is more common. The current CDC field triage criteria suggest that anticoagulant history should be considered in patients not meeting physiologic or mechanistic criteria for trauma activation. We hypothesized that using anticoagulant history alone as a criteria after minor head trauma would result in a high over-triage rate and that patients transferred with documented Traumatic Brain Injury (TBI) after minor head trauma would have similar outcomes to patients evaluated immediately by the trauma team.
Methods: This was a retrospective review of all trauma patients seen at a Level I trauma center (TC) during the past 3 years. History of antiplatelet or anticoagulant medication was abstracted from chart review as well as admission demographic, physiologic, and outcome characteristics. Minor head injury was defined as an admission GCS≥13, SBP>90, as well absence of tachypnea or mechanistic criteria set forth in the CDC field triage guidelines. Isolated TBI was defined as radiographic TBI+ other AIS≤2. Over-triage was defined as patients that were discharged or admitted to medical services without traumatic injuries. Our primary outcomes were the over-triage rate as well as the comparison of in-hospital mortality, need for craniotomy, worsening GCS, and discharge disposition for those patients with TBI not directly seen in our trauma center (NTC). Chi-Square and Fishers exact test were used to compare categorical outcomes, continuous variables were compared using the students t-test or Mann-Whitney test for non-parametric variables.
Results: During the 3 year period a total of 273 patients with minor head injury were directly evaluated in TC with 108 (39.5%) patients having radiographic TBI resulting in an over-triage rate of 60.5%. During the same period 54 NTC anticoagulated patients were transferred with documented TBI. Patients sustaining TBI were similar with respect to age, race, mechanism of injury, GCS, and type of intracranial bleed. Median Head AIS (4) was similar as well as type of anticoagulant (ASA TC 63% vs. NTC 57%,p=0.500, Plavix 24%vs.15%,p=0.221, Coumadin 31%vs.46%,p=0.057). Therapeutic INR (14%vs.20%,p=0.352) and platelet function abnormality (50%vs.48%,p=0.869) were similar between TC/NTC patients. Need for craniotomy (16%vs22%,p=0.385), in-hospital mortality(1.9%,p=1.000), worsening GCS (16%vs.17%,p=1.000), and discharge disposition (Home 36%vs.28%,p=0.337,Rehab 24%vs.35%, p=0.142,SNF 27%vs.26%,p=1.000) were also equivalent.
Conclusion: Use of anticoagulant status alone after minor head trauma results in a high rate of over triage and unnecessary utilization of trauma resources. Initial NTC evaluation of these patients even when TBI is discovered is safe with equivalent outcomes. Triage criteria incorporating anticoagulant status may offer an opportunity for process improvement.