New Study Challenges ED Protocols for Geriatric Head Injuries and Blood Thinners

Falls are the leading cause of injury in adults aged 65 and older, accounting for about 90% of head injuries in this age group. The evaluation of head injuries in older adults in the emergency department (ED) is particularly complex due to the higher risk of complications like intracranial hemorrhage (ICH). There is an additional concern for older patients who are on anticoagulants or blood thinners, as they have an increased risk of delayed ICH, which can occur up to several weeks after the injury but most commonly within 48 hours. This has led some healthcare providers to hospitalize these patients for observation and to perform repeat CT scans, which are the preferred method for assessing acute head injuries. Previous studies have indicated rates of delayed ICH as high as 7.2% in these patients, leading to ongoing debates about the best management practices. However, the need for hospital observation and routine follow-up CT scans remains a debatable issue.

Now, a new study by researchers at Florida Atlantic University (Boca Raton, FL, USA) has brought new insights into this issue, challenging earlier high estimates of delayed ICH rates among this demographic. The researchers undertook a prospective cohort study to determine the actual incidence of delayed ICH among geriatric patients in the ED who are on anticoagulants. Conducted between August 2019 and July 2020 at two hospitals, the study included 3,425 patients aged 65 and older who suffered acute head injuries. The majority of these injuries were due to ground-level falls, accounting for 77.9% of cases, followed by motor vehicle accidents at 6.2%, with all other causes constituting less than 7%. Follow-up methods included telephone calls and chart reviews to identify occurrences of delayed ICH.

Image: The new study assessed the actual incidence of delayed ICH in geriatric ED patients on anticoagulants (Photo courtesy of Adobe Stock)

Participants were categorized into four groups based on their anticoagulant usage: those not using anticoagulants; those on Warfarin; those taking direct oral anticoagulants such as dabigatran, rivaroxaban, and apixaban; and those using Heparinoid medications like heparin and enoxaparin. The findings revealed that only 0.4% (13 patients) experienced delayed ICH, a rate significantly lower than previously reported. The study also found no significant differences in the rates of delayed ICH between patients on anticoagulants and those who were not. These results suggest that older patients who visit the ED for head trauma and are taking anticoagulants such as Warfarin do not require hospital admission for 24-hour observation nor do they need routine repeat CT scans.

“Our study provides important data for clinicians managing older patients on anticoagulants who present with head trauma, potentially influencing guidelines and practices regarding observation and imaging protocols,” said Richard Shih, M.D., senior author and a professor of emergency medicine, FAU Schmidt College of Medicine. The study's findings were published in The Journal of Emergency Medicine on June 13, 2024.

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