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Loved the discussion. I reviewed the Probst paper, and I have a theory why there was no difference in older patients with or without anti-platelet/warfarin use. Patients were prospectively enrolled when clinicians decided to order a CT scan. In the table showing only patients >65 years old, patients not on anti-platelets or warfarin had a 6.1% incidence of significant intracranial injury, compared to a rate of 0.5-1.8% in patients taking an anti-platelet or warfarin. Those numbers seem backwards, but I have a theory to explain it. Most clinicians will order a CT scan in patients with medication-induced coagulopathy even with minimal mechanism, whereas if they are not taking these medications they would only get a CT scan based on criteria similar to a clinical decision instrument, making them higher risk. My point being, the numbers may say the rate of significant intracranial injury in adults >65 years old is the same with or without anti-platelets or warfarin, but I'm not so sure that is the truth. So be careful in thinking ALL patients >65 years old need a CT scan with any minimal head trauma based on this study.
Thanks for the comments. Yes, the retrospective studies are always going to be prone to this type of bias. And they did find that there was significant heterogeneity. So I would not want to suggest that we lower our level of concern for anti-coagulated patients, but rather that we raise the level of concern for non-anticoagulated patients. Thank you for the excellent points!
Thank you for the discussion. I was hoping to get your thoughts on disposition of patients on anti-platelet therapy or anticoagulation with a negative head CT. Some literature concludes that these patients are a significant risk for delayed intracranial bleeding even up to a week later. Very tought to sit on some one in the hospitla for a week. Thanks, John A
Great question! The risk of delayed bleeds seems to be quite low (eg: Scantling et al. Eur J Trauma Emerg Surg 2017 43). In most hospitals patients are not admitted or observed for delayed bleed. However, it is important to make sure the patient has a safe place to discharge home to, and ideally someone who can watch them or make sure they are not becoming altered so that they can bring them back in if needed.
Great piece! There are two papers mentioned in the discussion of intracranial hemorrhage without anticoagulant use. One is the Probst et al study but, unless I am missing something, the second paper mentioned is never mentioned by name. Does anyone know what paper they are referring to? Thanks!
Apologies, the other paper is this one: De Wit Incidence of intracranial bleeding in seniors presenting to the emergency department after a fall: A systematic review, Injury, 51, 2020
Thank you for the great review on elderly trauma/falls in the July 2020 EMRAP!
I wanted to ask if you had any further recommendations or literature on patients who fall but do NOT sustain any actual head injury, whether reported or seen on exam. I have had attendings scan heads based on the "bridging veins" theory that these weak vessels will tear and cause a bleed with just the jolting movement alone, and I have had others argue that with no evidence of head trauma, no AMS, and no reported head injury (even in a patient with dementia) that insurance companies will not reimburse because a CT is not warranted in these patients. Do you have any further guidance on this? THanks!
That's a great question. You can have ICH even without signs of head trauma. It's a difficult population because our usual prediction rules are not applicable. Many studies have found that signs of external trauma (bruising, lacs, etc) ARE associated with ICH, but we cannot conclude that their absence rules out ICH. If there is no head trauma (and reliable observer or patient) it is likely lower risk, but I do not know of a specific study that looks at this.
What you do matters.