Under Triage and Anticoagulants in the Geriatric Trauma Population Fragile Must be Italian. Barry McKenzie, MD St. Vincent Healthcare

Transcription

1 Under Triage and Anticoagulants in the Geriatric Trauma Population Fragile Must be Italian Barry McKenzie, MD St. Vincent Healthcare

2 Objectives Describe the increasing frequency of trauma patients being elderly. Understand the consequences of under activation in the geriatric trauma patient. Describe some of the challenges in identifying a geriatric trauma patient. Discuss the various forms of common oral anticoagulants. Review existing means and agents for reversal of common anticoagulants.

3 Data What is geriatric? Age - 55? 65? 70? 80? EAST guidelines For all ISS and body region injured Age Sharp increase in mortality Age 75 Doubled mortality

4 Data % of all traumas victims are > 65 33% of all trauma care costs are spent on elderly patients Trauma care costs 3 times as much for an elderly person compared to a younger person Undertriage of the elderly two-fold increase in risk of death

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6 Issues with Geriatric Trauma Increased morbidity and mortality across all injuries They are old why try? Many will return to pre-injury status with appropriate management Functional status becomes critical outcome measure Presenting GCS

7 Who is a Trauma? 69 year old female struck by a vehicle in Costco parking lot. She has GCS of 13 and left chest pain. 92 year old male who fell and struck her night stand going to the bathroom at night. He now has headache and hip pain. 76 year old female tripped while walking and struck her chin. Now with bilateral upper extremity paresthesia. 67 year old male farmer fell out of his tractor. He is mad because he got started late due to the local Coumadin clinic running behind.

8 Issues with Identifying Geriatric Trauma Patients Elderly normal physiology Chest and pulmonary function Neurological baseline Anticoagulants

9 Blood Pressure

10 Chest Injuries Bulger et al. Geriatric trauma patients and chest wall injuries 3-4 rib fractures Pneumonia increase 31% Mortality 19% More than 6 rib fractures 33% mortality 51% occurrence of pneumonia For each additional rib fracture Mortality increased by 19% Risks of pneumonia increased by 27%

11 Neurological Status Alteration in mental status Delirium Dementia Traumatic Brain Injury Organ failure leading to decreased organ perfusion Shock Quick escalation of injury due to anticoagulation Less endurance Airway management

12 GCS and Mortality

13 Under Triage JACS Stanford University study 6,015 patients Age 55 and older Called 911 and admitted to hospital Records reviewed Mortality rates Trauma center 5.7% Nontrauma center 9% 32.8% met criteria for referral to trauma center (ISS > 15) Less procedures performed at nontrauma centers 1 day less in the trauma center

14 Ohio Geriatric Trauma Triage > 70 years old considered geriatric trauma patient GCS < 15 with evidence of traumatic brain injury Systolic BP < 100 mmhg Falls with evidence of TBI (even from standing height) Pedestrian struck by motor vehicle Multiple body regions injury Known or suspected proximal long bone fracture in MVC

15 Montana Geriatric Activation GCS < or equal to 13 with known/suspected TBI Decreased LOC Unequal pupils Persistent headache Blurred vision Nausea or vomiting Change in neurological status Systolic BP <110 mmhg or absent radial/carotid pulse Known/suspected proximal long bone fx with hx of MVC Multiple body regions injured Auto vs pedestrian Fall from any height with evidence of TBI Co-morbidities Anticoagulation agents

16 Scary News Over 6 million people on anticoagulants US population 326 million 30 million warfarin prescriptions written annually Over 2/3 of Medicare patients with atrial fibrillation are on warfarin Once anticoagulants start they stay

17 Anti-coagulation and Trauma Alert Protocol Triage parameters Age > or equal to 65 Anticoagulation agents GCS < or equal to 13 Hx of head within past 24 hours Response protocol ED response team (Provider, RN and lab) 15 minutes Coagulation lab tests and INR completed within 20 minutes Stat/priority head CT completed within 30 minutes

18 Anticoagulants Vitamin K antagonists Warfarin Antiplatelet agents Clopidogrel (Plavix) ASA Direct oral thrombin inhibitors Dabigatran (Pradaxa) Direct oral factor Xa inhibitors Apixaban (Eliquis) Ribaroxaban (Xarelto) Edoxaban (Savaysa) Indirect factor Xa inhibitors Fondaparinux (Arixtra)

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20 Coumadin Inhibits Vitamin K dependent clotting factors II, VII, X Protein C & S Affects extrinsic & common pathways

21 Coumadin Reversal Vitamin K Four factor prothrombin complex concentrates (PCC) Rapid reversal of vitamin K antagonists Plasma derived products Kcentra, CSL Behring Expensive (single dose of Kcentra for 80 kg patient - $5,080) Effects can wear off Fresh frozen plasma

22 Plavix (clopidogrel) Inhibits function of ADP associated with platelet activation Most literature associated with ICH Platelets transfusion Desmopressin (DDAVP; promotes VWF as well as Factor VIII) Some discussion of steroids No great answer

23 Direct Thrombin Inhibitors Dabigatran (Pradaxa) Direct inhibitor of thrombin Prevents conversion of fibrinogen to fibrin Reversal Idarucizumab (Praxbind) Monoclonal antibody Binds to drug $3,000 to $4,000

24 Factor Xa Factor Xa is central to the propagation of coagulation In combination with cofactors bound to activated platelets, Factor Xa amplifies coagulation by converting prothrombin to thrombin

25 Factor Xa Inhibitors Direct Factor Xa inhibitor Rivaroxaban (Xarelto) Apixaban (Eliquis) Edoxaban (Savaysa) Indirect Factor Xa inhibitor Binds antithrombin - accelerates its inhibition of factor Xa. Fondaparinux (Arixtra)

26 Factor Xa inhibitors Reversal agent for Xarelto and Eliquis Andexxa FDA approval May 2018 Low and high dose regiment $25,000 to $50,000 projected figures for cost of treatment Drug cost only administration cost to patient? Only in 10 to 20 institutions throughout the US

27 Local challenges

28 Who is a Trauma? 69 year old female struck by a vehicle in Costco parking lot. She has GCS of 13 and left chest pain. 92 year old male who fell and struck her night stand going to the bathroom at night. He now has headache and hip pain. 76 year old female tripped while walking and struck her chin. Now with bilateral upper extremity paresthesia. 67 year old male farmer fell out of his tractor. He is mad because he got started late due to the local Coumadin clinic running behind.

29 Summary The geriatric population is becoming more and more the trauma population. Identifying the geriatric trauma patient requiring trauma activation can be difficult and likely requires separate activation criteria. Under activation of the geriatric trauma patient is a growing issue and has a negative effect on outcome. A growing number of patients are on some form anti coagulation and trauma providers need to be familiar with the various agents. Reversal agents for new anti coagulants exist but can be expensive and create a resource utilization challenge. Open discussions need to happen regarding maintenance of anticoagulants after trauma event.

30 Questions?

31 References ACS TQIP Geriatric Trauma Management Guidelines Bulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib fractures in elderly. J Trauma. 2000;48: ems.ohio.gov Jacobs, Plaisier, Barie, Hammond, Holevar, Sinclair, Scalea and Wahl (EAST Practice Management Guidelines Work Group, Pracitice Management Guidelines of Geriatric Trauma: The EAST Practice Management Guidelines Work Group, J Trauma. 54(2): , February Jürgen Koscielny and Edita Rutkauskaite, Rivaroxaban and Hemostasis in Emergency Care, Emergency Medicine International, vol. 2014, Article ID , 9 pages, doi: /2014/ Meadow, Dierks, Williams and Zacko, The Emergent Reversal of Coagulopathies Encountered in Neurosurgery and Neurology: A technical note, CM&R Rapid Release, November 7, 2014 Staudenmayer, Hsia, Mann, Spain and Newgard, Triage of Elderly Trauma Patients: A Population-Based Perspective, Journal of the American College of Surgeons, 2013; 217 (4): 569