Management of the Elderly Anti-coagulated Trauma Patient Dr Paul Bradford ER Physician, Trauma Team Leader Hotel Dieu Hospital Windsor
Geriatric Trauma Issues 5 th leading cause of death Higher mortality, in lower ISS than expected Physiological changes in resuscitation Comorbidities (diabetes, CHF, COPD) Medications alter physiologic and metabolic responses responses Anticoagulants 1 1
Case Study 74 year old woman pedestrian struck by car going 50 km/h at intersection. Struck hood of car on her right side landing beside the vehicle. Awake and alert at the scene, remembers all details, no loc, GCS=15. VS BP 130/84, HR 80,RR 16 Prehospital Diagnosis: R leg pain, Lac head. On coumadin for A-fib 2 2
Case Study 1839 patch info to trauma centre BP128 palp. HR 84 RR 16 GCS 15 1850 Arrived at HDGH CTAS 2 BP91/60,HR 80 s,rr16 T36.1 1900 Physician and Nurse assessment BP 75/53,HR 87, RR 21, 1915 Trauma labs, T&C 4 units, 2 IV s 3 3
Case Study 1935 Art line in,ns infusing, X-rays in ER 1948 pt complaining of LUQ pain,mass on L flank increasing, BP64/40,HR 107, RR 26 colour pale 2001 TTL called. To CT for chest, abd, &pelvis 4 2020 TTL arrived. Crossmatched blood started. Lab results INR 2.9. On Coumadin. Vit K and 4 u FFP 4
Case Study Resuscitated x2hrs 7u blood, 7 l fluid, 4u FFP, 2u pentaspan. Intubated CT # s pelvis, #RFib/Tib, bleeding internal iliac artery (not able to embolize per radiologist) Pelvic Sling on 2220 To ICU 0005 to OR exploration by vascular surgeon. Still hypotensive 5 5
Anticoagulation Atrial Fibrillation TIA/ CVA Prosthetic Heart Valves Revascularized limb Cardiac stenting CAD Hypercoagulable state DVT/ PE Aortic stenosis 6 6
Quality Assurance Data 2006-2007 ISS >12 35% of patients over 70 years were on anticoagulants INR ranged 1.0-6.9 75% of these patients died 4 patients on anticoagulants had reversal of INR. 3 of these patients lived. 7 7
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Literature Review Very limited research. Need clinical trials Geriatric trauma patients are at very high risk. Those on anticoagulants esp. with HI are at 5x greater risk of death. Mina AM, Bair HA, Howells GA, Bendick PJ. Complications of preinjury warfarin use in the trauma patient. J Trauma. 2003;54:842 847. Protocols are needed to reduce the risk and improve outcome Rapid confirmation of ICH with expedient head CT scan combined with prompt reversal with warfarin anticoagulation with FFP decreases ICH progression and reduces mortality J of Trauma, Ivascu et al Beaumont 2005 9 9
Recommendations Move the trigger for patients needing blood and anticoagulation outside ER (EMS) Flag anticoagulants Decrease critical value for INR Adopt /modify Beaumont s Protocol Already have faster CT head times, and instant interpretation, less steps in trauma patient management, proactive nursing 10 10
Recommendations Educate patients at risk (INR Clinic) Educate physicians and staff (rounds) What INR are we aiming for (1.4) Conduct research ( quality assurance) Continue HDGH Data collection to monitor outcomes 11 11
Mechanism of Injury Age >65 Years, ISS >12 2006-08 HDGH Trauma Services Age > 65yrs, ISS >12 Mechanism of Injury Report April 1, 2006 - March 31, 2008 2006-07 n= 56 2007-08 n=92 75% 82% 2006-07 2007-08 21% 16% 4% 2% 12 Falls MVC Other 12
Diagnosis Breakdown Age >65 yrs, ISS >12 2006-08 HDGH Trauma Services Diagnosis Breakdown Report of Pts on Bloodthinners Bloodthinners,Age > 65 yrs, ISS >12 April 1, 2006- March 31, 2008 2006-07 n= 56 2007-08 n= 92 77% 2006-07 2007-08 68% 21% 18% 0% 7% 2% 8% 13 Head Injury Chest/Ortho Burns/Other Spinal Bloodthinners included: Coumadin, Plavix, ASA, Heparin, Argrrenox, Warfin and other. 13
Death Data Age >65yrs, ISS>12 2006-08 HDGH Trauma Service Death Data Report Age >65yrs, ISS >12 April 1, 2006 - March 31, 2008 2006-07 n= 56 2007-08 n= 92 % of Pts on Blood Thinners who Died 38% 80% % of Pts on Blood Thinners 45% 51% % of Pts with Falls who Died 73% 85% % of All PT with HI who Died 80% 92% % of All Pts who Died 14% 23% 2007-08 2006-07 14 14
Data Collected in the Trauma Data Base, ISS >12,TTLA INR Level in ED FFP given in ED (yes no) Whether patient was on a anticoagulant ( Yes or No) Type of anticoagulant 15 15
Types of Anticoagulants Collected Type of Anticoagulant: 1, Coumadin 2, Plavix 3, ASA 4, Heparin 5, Aggrenox 6, Warfarin 7, Other 16 16
Pre-Hospital PLEASE remember to ask your patients about blood thinners: Examples Aggrenox Plavix Coumadin ASA Heparin R U Bloodthinners??? Sticker for your Zip Pack 17 17
Case 2 Pit Stop 32 yo male shot L chest just lateral to box, and nipple, exit wound under L scapula Shot heard 12 minutes ago, combative drinking, possibly drugs, 9mm hand gun Minimal blood at scene, lots of vomit Pulled 16 gauge IV out of L arm on route SOB, swearing in short sentences, obviously dyspneic No Vasc, No thoracic, decision to go Pitstop based on patch Team assembled, o neg brought down, rapid transfuser primed with saline 18
Case 2 19 Vitals T 36.2, Pulse 148, BP 137/79 Resp =24 No air entry Lung RSI Versed 10, Fent 250, Succ 100 L chest tube simultaneously, drained 700cc blood, better AE, still draining 500cc next 5 min Foley, NG clear Three large bore 16 gauges, rapid transfuser 2 L saline, and 2 units o neg started Portable chest done after tubes in
Case 2 ISS 16 37 minutes ER time Arrived Detroit Receiving in 7 minutes Approx 40 minutes saved on transfer back to ambulance, and wait for second ambulance, No pumps used, just transfuser Two physician Resuscitation 20
Triage 21 21
Community Partnerships 22 22
Mock Trauma Code Test the process 23 23
Mock Trauma Code Test Response Times 24 24
Mock Trauma Code Test Equipment & Resources 25 25
Latest Mock Trauma April 27 th 2009 Dispatch call 7:25 Patch 7:40 suggest patient may need blood Trauma code 7:53 Lab arrival 7:55 Uncrossed blood arrival 8:01 Conducted every three months, simultaneously with ATLS lecture for medical students 26 26
Future Advances Prothombin Complex Concentrates (PCC) Octaplex For emergency reversal of warfarin Vit K 10 mg IV stat Then 1000 IU = 40 ml IV in 15 min Effect immediate, lasts 6 to 12 hrs Doesn t need to be thawed Pooled, virally inactivated, prion reduced Trace heparin Same cost as FFP 27 27
References 1. Kirsch et al JOT 2004 2. Coimbra et al JOT 2005 3. Guly,Jones & Nokes Trauma 2005 4. Mina,Howells,Bair et al JOT 2002-2006 5. Bair, Ivascu, Janczyk JOT Nursing 2005 28 28