warfarin and Wounds-and-Injuries

Patients sustaining traumatic injuries are at high risk for the development of venous thromboembolism. The reported incidence of deep venous thrombosis in trauma patients ranges from 20 to 90%. The reported incidence of pulmonary embolism in trauma patients varies between 2.3 and 22%. The aging population and the survival of more severely injured patients may suggest an increasing risk of thromboembolism in the trauma patient population. There have been few randomized prospective studies assessing methods of thromboembolism prophylaxis in trauma patients. Controversy exists as to the optimal method of prophylaxis in this high-risk population. Contraindications arising from associated injuries often limit the potential options for prophylaxis in patients with trauma. Large prospective randomized studies are needed to determine the most effective means of prophylaxis in trauma patients, who have a wide range of both isolated and combined injuries. Future studies should also address the duration of prophylaxis because many trauma patients remain immobile for an extended time.

Topics: Aged; Anticoagulants; Clinical Trials as Topic; Diagnosis, Differential; Female; Fractures, Bone; Heparin; Heparin, Low-Molecular-Weight; Humans; Incidence; Leg; Male; Middle Aged; Risk Factors; Thromboembolism; Vena Cava Filters; Venous Thrombosis; Warfarin; Wounds and Injuries

Thirteen of 394 (3.3%) regularly dialyzed patients of the Regional Kidney Disease Program developed subdural hematoma. The following factors contributed to formation of subdural hematoma: head trauma, ultrafiltration to control excessive accumulation of fluid and hypertension, anticoagulants, and frequent vascular access infection and clotting. Neurologic symptoms and signs, which may be similar to dialysis disequilibrium, aid only in signifying the presence, not the ultimate localization, of subdural hematoma. Our experience underscores the frequency of bilateral disease, irrespective of neurologic findings. Skull films, lumbar puncture, and electroencephalography were of little diagnostic help. Although valuable and safe, brain scanning was not as useful as desired due to occurrences of false-negative studies and failure to identify bilaterality of lesions. Cerebral angiography was always diagnostic. Surgical intervention yielded disappointing results, and only 2 patients (15%) survived. A review of 9 other patient reports is included.

Topics: Adult; Aged; Central Nervous System Diseases; Cerebral Angiography; Female; Hematoma, Subdural; Humans; Male; Middle Aged; Peritoneal Dialysis; Renal Dialysis; Ultrafiltration; Warfarin; Wounds and Injuries

We determine the efficacy of active reversal of warfarin anticoagulation with intravenous vitamin K compared to withholding warfarin in patients requiring urgent orthopedic trauma surgery.. This was a prospective cohort with immediate prehypothesis consecutive retrospective comparative case series conducted at a level 1 university hospital trauma unit.. Forty-eight consecutive patients between 1998 and 2004 in a study composed of a prospective cohort were compared with a retrospective consecutive case series of warfarinized orthopedic trauma patients requiring urgent surgery. The prospective arm directly followed the historic case series from which the hypothesis was generated.. Vitamin K administration.. Primary outcome was time to surgery. Secondary outcomes were problems with active reversal, length of time for warfarin stabilization after surgery, and complications.. The mean time to surgery in warfarinized patients not given vitamin K was 111.9 hours; in the intervention group, it was 67.4 hours, giving a mean difference of 44.5 hours (P = 0.01). Vitamin K reduced the international normalized ratio (INR) to less than 2.0 in 74% of patients within 24 hours. There were no complications of vitamin K administration. A dose of vitamin K costs approximately 1/1000 of a hospital bed day cost. A loading dose of warfarin on the second postoperative day took approximately 1 day longer to reach an INR of greater than 2.0 in the intervention patients than in those who had not been given vitamin K.. Warfarin reversal with vitamin K was successful and facilitated earlier surgery in all patients; the first dose was effective in approximately three quarters of patients. It is cost-effective, with no side effects caused in this study.

Topics: Administration, Oral; Anticoagulants; Blood Coagulation; Blood Coagulation Disorders; Cohort Studies; Drug Administration Schedule; Female; Humans; Injections, Intravenous; Male; Orthopedic Procedures; Preoperative Care; Thrombosis; Treatment Outcome; Vitamin K; Warfarin; Wounds and Injuries

Topics: Age Factors; Anticoagulants; Humans; Warfarin; Wounds and Injuries

The number of anticoagulated trauma patients is increasing. Trauma patients on warfarin have been found to have poor outcomes, particularly after intracranial hemorrhage (ICH). However, the effect of novel oral anticoagulants (NOAs) on trauma outcomes is unknown. We hypothesized that patients on NOAs would have higher rates of ICH, ICH progression, and death compared with patients on traditional anticoagulant and antiplatelet agents.. This was a prospective observational trial across 16 trauma centers. Inclusion criteria was any trauma patient admitted on aspirin, clopidogrel, warfarin, dabigatran, rivaroxaban, or apixaban. Demographic data, admission vital signs, mechanism of injury, injury severity scores, laboratory values, and interventions were collected. Outcomes included ICH, progression of ICH, and death.. A total of 1,847 patients were enrolled between July 2013 and June 2015. Mean age was 74.9 years (SD ± 13.8), 46% were female, 77% were non-Hispanic white. At least one comorbidity was reported in 94% of patients. Blunt trauma accounted for 99% of patients, and the median Injury Severity Score was 9 (interquartile range, 4-14). 50% of patients were on antiplatelet agents, 33% on warfarin, 10% on NOAs, and 7% on combination therapy or subcutaneous agents.Patients taking NOAs were not at higher risk for ICH on univariate (24% vs. 31%) or multivariate analysis (incidence rate ratio, 0.78; confidence interval 0.61-1.01, p = 0.05). Compared with all other agents, patients on aspirin (90%, 81 mg; 10%, 325 mg) had the highest rate (35%) and risk (incidence rate ratio, 1.27; confidence interval, 1.13-1.43; p < 0.001) of ICH. Progression of ICH occurred in 17% of patients and was not different between medication groups. Study mortality was 7% and was not significantly different between groups on univariate or multivariate analysis.. Patients on NOAs were not at higher risk for ICH, ICH progression, or death.. Prognostic/epidemiologic study, level III.

Topics: Administration, Oral; Aged; Anticoagulants; Aspirin; Clopidogrel; Dabigatran; Female; Humans; Injury Severity Score; Intracranial Hemorrhages; Male; Platelet Aggregation Inhibitors; Prospective Studies; Pyrazoles; Pyridones; Rivaroxaban; Ticlopidine; Trauma Centers; Warfarin; Wounds and Injuries; Wounds, Nonpenetrating

Topics: Aged; Anticoagulants; Blood Coagulation Tests; Case-Control Studies; Female; Glasgow Coma Scale; Hemorrhage; Humans; Injury Severity Score; Intensive Care Units; Length of Stay; Male; Risk Factors; Trauma Centers; Treatment Outcome; United States; Warfarin; Wounds and Injuries

The anticoagulated trauma patient presents a particular challenge to the critical care physician. Our understanding of these patients is defined and extrapolated by experience with patients on warfarin pre-injury. Today, many patients who would have been on warfarin are now prescribed the Direct Oral Anticoagulants (DOACs) a class of anticoagulants with entirely different mechanisms of action, effects on routine coagulation assays and approach to reversal.. Trauma registry data from Toronto's (Ontario, Canada) two Level 1 trauma centres were used to identify patients on oral anticoagulation pre-injury from June 1, 2014 to June 1, 2015. The trauma registry and medical records were reviewed and used to extract demographic and clinical data.. We found 81 patients were on oral anticoagulants pre-injury representing 3.2% of the total trauma population and 33% of the orally anticoagulated patients were prescribed a DOAC prior to presentation. Comparison between the DOAC and warfarin groups showed similar age, mechanisms of injury, indications for anticoagulation, injury severity score and rate of intracranial hemorrhage. Patients on DOACs had higher initial mean hemoglobin vs warfarin (131 vs 120) and lower serum creatinine (94.8 vs 129.5). The percentage of patients receiving a blood transfusion in the trauma bay and total in-hospital transfusion was similar between the two groups however patients on DOACs were more likely to receive tranexamic acid vs patients on warfarin (32.1% vs 9.1%) and less likely to receive prothrombin concentrates (18.5% vs 60%). Patients on DOACs were found to have higher survival to discharge (92%) vs patients on warfarin (72%).. Patients on DOACs pre-injury now represent a significant proportion of the anticoagulated trauma population. Although they share demographic and clinical similarities with patients on warfarin, patients on DOACs may have improved outcomes despite lack of established drug reversal protocols and challenging interpretation of coagulation assays.. III; Study Type: Retrospective Review.

Topics: Administration, Oral; Aged; Anticoagulants; Female; Humans; Injury Severity Score; Male; Middle Aged; Ontario; Registries; Retrospective Studies; Trauma Centers; Warfarin; Wounds and Injuries

The aim of this study was to compare the efficacy, safety, and cost-effectiveness of 3-factor prothrombin complex concentrate (3F-PCC) vs 4-factor prothrombin complex concentrate PCC (4F-PCC) in trauma patients requiring reversal of oral anticoagulants.. All consecutive trauma patients with coagulopathy (international normalized ratio [INR] ≥1.5) secondary to oral anticoagulants who received either 3F-PCC or 4F-PCC from 2010 to 2014 at 2 trauma centers were reviewed. Efficacy was determined by assessing the first INR post-PCC administration, and successful reversal was defined as INR less than 1.5. Safety was assessed by reviewing thromboembolic events, and cost-effectiveness was calculated using total treatment costs (drug acquisition plus transfusion costs) per successful reversal.. Forty-six patients received 3F-PCC, and 18 received 4F-PCC. Baseline INR was similar for 3F-PCC and 4F-PCC patients (3.1 ± 2.3 vs 3.4 ± 3.7, P = .520). The initial PCC dose was 29 ± 9 U/kg for 3F-PCC and 26 ± 6 U/kg for 4F-PCC (P = .102). The follow-up INR was 1.6 ± 0.6 for 3F-PCC and 1.3 ± 0.2 for 4F-PCC (P = .001). Successful reversal rates in patients were 83% for 4F-PCC and 50% for 3F-PCC (P = .022). Thromboembolic events were observed in 15% of patients with 3F-PCC vs 0% with 4F-PCC (P = .177). Cost-effectiveness favored 4F-PCC ($5382 vs $3797).. Three-factor PCC and 4F-PCC were both safe in correcting INR, but 4F-PCC was more effective, leading to better cost-effectiveness. Replacing 3F-PCC with 4F-PCC for urgent coagulopathy reversal may benefit patients and institutions.

Topics: Aged; Anticoagulants; Blood Coagulation Disorders; Calcium; Cost-Benefit Analysis; Critical Care; Female; Hemostatics; Humans; International Normalized Ratio; Male; Retrospective Studies; Safety; Thromboplastin; Trauma Centers; Warfarin; Wounds and Injuries

Reversal of warfarin-induced coagulopathy after traumatic injury may be done exclusively with prothrombin complex concentrates (PCCs). No direct comparisons between different PCC regimens exist to guide clinical decision-making. Our institution has used 2 distinct PCC strategies for warfarin reversal; a 3-Factor PCC (Profilnine) combined with activated Factor VII (3F-PCC+rVIIa), and a 4-Factor PCC (Kcentra) given without additional factor supplementation.. Retrospective review of all PCC administrations to trauma patients with acute bleeding who were taking warfarin before injury. Primary endpoints were international normalized ratio (INR) reduction, in-hospital mortality, and diagnosis of deep venous thrombosis (DVT).. Eighty-seven patients were identified from 2011 to 2015. Fifty-three were treated with 3F-PCC+rVIIa and 34 with 4F-PCC. Patient demographics, injury severity, and presenting laboratory data were similar. The 3F-PCC+rVIIa produced a lower median (IQR) INR postreversal compared with 4F-PCC (.75 (.69, 1.00) vs 1.28 (1.13, 1.36), P<.001). Both regimens were able to obtain an INR lower than 1.5 immediately after administration (3F+rVIIA 93.9% vs 4F 97.1%, P =.51). In the 4F-PCC group, there was a significant decrease in the incidence of DVT (2.9% vs 22.6%), P < .01), and a nonsignificant reduction in mortality (2.9% vs 17.0%, P = .08).. Use of 4F-PCC for warfarin reversal after traumatic hemorrhage is associated with a less severe decrease in INR, a significant reduction in DVT rates and a trend toward reduced mortality when compared with similar patients treated with 3F-PCC+rVIIa.

Topics: Aged; Aged, 80 and over; Blood Coagulation Factors; Chi-Square Distribution; Cohort Studies; Dose-Response Relationship, Drug; Drug Administration Schedule; Drug Combinations; Emergencies; Factor IX; Factor VII; Factor X; Female; Follow-Up Studies; Hemorrhage; Humans; International Normalized Ratio; Male; Middle Aged; Prothrombin; Retrospective Studies; Risk Assessment; Severity of Illness Index; Statistics, Nonparametric; Treatment Outcome; Vitamin K; Warfarin; Wounds and Injuries

Although anticoagulation with warfarin has been associated with increased risk of adverse outcomes after trauma, the effects of the new oral agents (NOA) such as dabigatran, apixaban, rivaroxaban are not yet well characterized.. A retrospective review of a level 1 trauma center database identified all patients aged ≥ 50 admitted after trauma during a 24 month period starting September 2013. Demographics, including preadmission anticoagulation agents, injuries, hospital course and outcomes were abstracted from the electronic medical record.. Over the 24-month period, 3,392 patients were admitted; 112 (3.3%) were anticoagulated with NOA and 373 (11.0%) with warfarin with a trend toward increasing utilization of the new agents compared with warfarin over that period. Although comparable in age, injury severity scores, and mechanism of injury, patients anticoagulated with warfarin had both a higher overall mortality (10.9%) compared with the NOA (6.25%) and the non-anticoagulated control (5.5%) groups (p < 0.001) as well as a higher trauma-related mortality (9.0%) versus NOA (2.8%) and control (3.7%) groups (p < 0.001). Patients on warfarin or NOA were admitted to intensive care unit or step down unit more frequently than control patients. (45.0% and 41.9% vs. 35.7% respectively; p < 0.001). The incidence of traumatic brain injury was similar among the three groups. Although it did not reach statistical significance, trauma-specific mortality in the traumatic brain injury subset was higher in the warfarin group (19.3%) than the NOA (16.7%) or control (10.9%) groups (p = 0.08). In a multivariable logistic regression, warfarin (odds ratio, 2.215; 95% confidence interval, 1.365-3.596; p = 0.001), but not the NOA (odds ratio, 0.871; 95% confidence interval, 0.258-2.939; p = 0.823), was an independent predictor for mortality.. Although the experience with the new oral anticoagulation agents is still limited, patients on these agents appear to have lower mortality after traumatic injury than patients on warfarin.. Epidemiologic study, level III.

Topics: Administration, Oral; Aged; Anticoagulants; Antithrombins; Connecticut; Dabigatran; Demography; Factor Xa Inhibitors; Female; Humans; Injury Severity Score; Male; Middle Aged; Pyrazoles; Pyridones; Retrospective Studies; Risk Factors; Rivaroxaban; Trauma Centers; Warfarin; Wounds and Injuries

This research study aims to identify the effect of anticoagulation status on hospital course, complications, and outcomes among geriatric fall trauma patients.. The study design is a retrospective cohort study, looking at fall trauma among patients aged 60 to 80 years from 2009 to 2013 at a university hospital in the United States. The statistical analysis, conducted with SPSS software with a threshold for statistical significance of P < .05, was stratified by anticoagulation status and then further by type of anticoagulation (aspirin, warfarin, clopidogrel, enoxaparin, and dipyridamole). Outcomes variables include mortality, length of stay (LOS), intensive care unit (ICU) admission, and complications.. The total number of patients included in this study was 1,121. Compared with patients not on anticoagulation, there was a higher LOS among patients on anticoagulation (6.3 ± 6.2 vs 4.9 ± 5.2, P = .001). A higher LOS (7.2 ± 6.8 vs 5.0 ± 5.3, P = .001) and days in the ICU (2.1 ± 5.4 vs 1.1 ± 3.8, P = .010) was observed in patients on warfarin. A higher mortality (7.1% vs 2.8%, P = .013), LOS (6.3 ± 6.2 vs 5.1 ± 5.396, P = .036), and complication rate (49.1 vs 36.7, P = .010) was observed among patients on clopidogrel.. In this study, a higher mortality and complication rate were seen among clopidogrel, and a greater LOS and number of days in the ICU were seen in patients on warfarin. These differences are important, as they can serve as a screening tool for triaging the severity of a geriatric trauma patient's condition and complication risk. For patients on clopidogrel, it is essential that these patients are recognized early as high-risk patients who will need to be monitored more closely. For patients on clopidogrel or warfarin, bridging a patient's anticoagulation should be initiated as soon as possible to prevent unnecessary increased LOS. At last, these data also provide support against prescribing patients clopidogrel when other anticoagulation options are available.

Topics: Accidental Falls; Age Factors; Aged; Aged, 80 and over; Anticoagulants; Clopidogrel; Critical Care; Dipyridamole; Enoxaparin; Female; Humans; Length of Stay; Male; Middle Aged; Retrospective Studies; Ticlopidine; Warfarin; Wounds and Injuries

To define the relationship between preinjury warfarin use and mortality in a large European sample of trauma patients.. A multicentred study was conducted using data collated from European (predominately English and Welsh) trauma receiving hospitals. Patient data from the Trauma Audit and Research Network database from 2009 to 2013 were analysed. Univariate and multivariate logistic regression was used to estimate OR for mortality associated with preinjury warfarin use in the whole adult trauma cohort and a matched sample of patients comparable in terms of age, gender, GCS, pre-existing medical conditions and injury severity.. A total of 136 617 adult trauma patients (2009-2013) were included, with 499 patients reported to be using warfarin therapy at the time of trauma. Preinjury warfarin use was associated with a significantly higher mortality rate at 30 days postinjury compared with the non-users. Following adjustment of age, injury severity and GCS, preinjury warfarin use was associated with increased mortality in trauma patients (adjusted OR 2.14; 95% CI 1.66 to 2.76; p<0.001). In the matched subset, 22% of warfarinised trauma patients died compared with 16.3% of non-warfarinised trauma patients with comparable age, injury severity and GCS (adjusted OR 1.94; 95% CI 1.25 to 3.01; p=0.003).. Preinjury warfarin use has been demonstrated to be an independent predictor of mortality in trauma patients. Clinicians managing major trauma patients on warfarin need to be aware of the vulnerability of this group.

Topics: Adult; Age Factors; Aged; Aged, 80 and over; Anticoagulants; Craniocerebral Trauma; Europe; Female; Glasgow Coma Scale; Hospital Mortality; Humans; Injury Severity Score; Intracranial Hemorrhages; Logistic Models; Male; Middle Aged; Odds Ratio; Retrospective Studies; Sex Factors; Trauma Centers; Warfarin; Wounds and Injuries; Young Adult

Optimal dosing of prothrombin complex concentrate (PCC) has yet to be defined and varies widely due to concerns of efficacy and thrombosis. We hypothesized a dose of 15 IU/kg actual body weight of a three-factor PCC would effectively correct coagulopathy in acute care surgery patients. Retrospective review of 41 acute care surgery patients who received 15 IU/kg (± 10%) actual body weight PCC for correction of coagulopathy. Demographics, laboratory results, PCC dose, blood and plasma transfusions, and thrombotic complications were analyzed. We performed subset analyses of trauma patients and those taking warfarin. Mean age was 69 years (18-94 years). Thirty (73%) trauma patients, 8 (20%) emergency surgery patients, 2 (5%) burns, and 1 (2%) nontrauma neurosurgical patient were included. Mean PCC dose was 1305.4 IU (14.2 IU/kg actual body weight). Mean change in INR was 2.52 to 1.42 (p 0.00004). Successful correction (INR <1.5) was seen in 78 per cent. Treatment failures had a higher initial INR (4.3 vs 2.03, p 0.01). Mean plasma transfusion was 1.46 units. Mean blood transfusion was 1.61 units. Patients taking prehospital warfarin (n = 29, 71%) had higher initial INR (2.78 vs 1.92, p 0.05) and received more units of plasma (1.93 vs 0.33, p 0.01) than those not taking warfarin. No statistical differences were seen between trauma and nontrauma patients. One thrombotic event occurred. Administration of low-dose PCC, 15 IU/kg actual body weight, effectively corrects coagulopathy in acute care surgery patients regardless of warfarin use, diagnosis or plasma transfusion.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Antifibrinolytic Agents; Blood Coagulation Disorders; Blood Coagulation Factors; Blood Transfusion; Body Weight; Burns; Drug Dosage Calculations; Emergencies; Humans; International Normalized Ratio; Middle Aged; Plasma; Retrospective Studies; Surgical Procedures, Operative; Thrombosis; Vitamin K; Warfarin; Wounds and Injuries; Young Adult

Patients on anticoagulation are at increased risk for intracranial hemorrhage (ICH) after trauma. This is important for geriatric trauma patients, who are increasing in number, frequently fall, and often take anticoagulants. This study sought to evaluate whether prehospital use of dabigatran, a newer anticoagulant, is associated with outcome differences in geriatric trauma patients suffering falls when compared with warfarin. The registry of a Level II community trauma center was used to identify 247 patients aged 65 and older who sustained a fall while taking prehospital dabigatran or warfarin admitted between December 2010 and March 2014. Patients on warfarin were included if their International Normalized Ratio was therapeutic (2-3). About 176 of the 247 patients were then compared using coarsened exact matching. In the matched analysis, overall population means for age, Glasgow Coma Score, and Injury Severity Score were 83.5, 14.7, and 5.1, respectively. The overall rate of ICH was 12.5 per cent, with a mortality rate of 16.1 per cent for patients who sustained an ICH. There were no observed differences in ICH, hospital length of stay, intensive care unit length of stay, or mortality between patients taking prehospital warfarin or dabigatran.

Topics: Accidental Falls; Aged; Aged, 80 and over; Anticoagulants; Antithrombins; California; Dabigatran; Female; Follow-Up Studies; Glasgow Coma Scale; Humans; Incidence; Intracranial Hemorrhages; Male; Registries; Retrospective Studies; Risk Assessment; Risk Factors; Thromboembolism; Warfarin; Wounds and Injuries

Topics: Anticoagulants; Data Collection; Enoxaparin; Humans; Practice Patterns, Physicians'; United States; Vena Cava Filters; Venous Thromboembolism; Warfarin; Wounds and Injuries

Topics: Anticoagulants; Humans; Warfarin; Wilderness; Wounds and Injuries

Topics: Anticoagulants; Humans; Warfarin; Wilderness; Wounds and Injuries

An increasing number of patients routinely undergo long-term anticoagulation with warfarin or other pharmacological agents. There is little evidence and no consensus documents in the literature regarding the appropriateness and relative risk of their participation in wilderness activities. We present a case report, conduct an analysis of the limited literature that is available, and make recommendations for wilderness medicine practitioners and screening personnel.

Topics: Anticoagulants; Drug Interactions; Hemorrhage; Humans; Practice Patterns, Physicians'; Risk Factors; Sports; Vitamin K; Warfarin; Wilderness; Wounds and Injuries

Topics: Anticoagulants; Blood Coagulation Disorders; Blood Coagulation Tests; Blood Component Transfusion; Hemorrhage; Humans; Plasma; Practice Guidelines as Topic; Treatment Outcome; Warfarin; Wounds and Injuries

Damage control resuscitation advocates correction of coagulopathy; however, options are limited and expensive. The use of prothrombin complex concentrate (PCC), also known as factor IX complex, can quickly accelerate reversal of coagulopathy at relatively low cost. The purpose of this study is to describe our experience in the use of factor IX complex in coagulopathic trauma patients.. All patients receiving PCC at our Level I trauma center over a two-year period (2008-2010) were reviewed. PCC was used at the discretion of the trauma attending for treatment of coagulopathy, reversal of coumadin, and when recombinant factor VIIa was indicated.. Forty-five trauma patients received 51 doses of PCC. Sixty-two per cent were male and mean Injury Severity Score was 23 (± 14.87). Standard dose was 25 units per kg and mean cost per patient was $1,022 ($504-3,484). Fifty-eight per cent of patients were on warfarin before admission. Mean international normalized ratio (INR) was decreased after PCC administration (p = 0.001). Packed red blood cell transfusion was also reduced after factor IX complex (p = 0.018). Mean INR was reduced in both the nonwarfarin (p = 0.001) and warfarin (p = 0.001) groups. Packed red blood cell transfusion was less in the nonwarfarin group (p = 0.002) however was not significant in the warfarin group. Subsequent thromboembolic events were observed in 3 of the 45 patients (7%). Mortality was 16 of 45 (36%).. PCC rapidly and effectively treats coagulopathy after traumatic injury. PCC therapy leads to a significant correction in INR in all trauma patients, regardless of coumadin use, and concomitant reduction in blood product transfusion. PCC should be considered as an effective tool to treat acute coagulopathy of trauma. Further prospective studies examining the safety, efficacy, cost, and outcomes comparing PCC and recombinant factor VIIa are needed.

Topics: Aged; Blood Coagulation Disorders; Erythrocyte Transfusion; Factor IX; Factor VIIa; Female; Humans; Injury Severity Score; International Normalized Ratio; Male; Recombinant Proteins; Retrospective Studies; Treatment Outcome; Warfarin; Wounds and Injuries

Therapeutic anticoagulation in the geriatric trauma population is increasingly common. Fresh frozen plasma, while the criterion standard for correction, has limited availability and associated transfusion risks. We examined our use of prothrombin complex concentrate for immediate reversal of therapeutically anticoagulated geriatric trauma patients.. This was a 1-year, retrospective review of 25 geriatric trauma patients who received either fresh frozen plasma alone or prothrombin complex concentrate and met the inclusion criteria of age >55 years, current warfarin use, and an admission international normalized ratio of >1.5. Fifteen patients received prothrombin complex concentrate and 10 patients received fresh frozen plasma alone. We examined demographics, laboratory values, and blood product use.. The mean ages were similar (77 vs 80 years). Patients had similar mean Injury Severity Score (19.1 vs 19.2). Survivor duration of hospital stay (7.7 vs 9.5; P = .37) and duration of stay in the intensive care unit (4.4 vs 7.1; P = .25) trended positively in the prothrombin complex concentrate group. The prothrombin complex concentrate group received fewer units of fresh frozen plasma (1.6 [range, 0-6] vs 2.7 [range, 2-4]; P = .05), with a greater decrease in international normalized ratio (51% vs 43%; P = .05). Six patients (40%) in the prothrombin complex concentrate group avoided fresh frozen plasma transfusion altogether.. Prothrombin complex may be used safely and effectively to reverse emergently anticoagulation in geriatric trauma patients.

Topics: Aged; Aged, 80 and over; Anticoagulants; Blood Coagulation Factors; Critical Care; Humans; International Normalized Ratio; Length of Stay; Middle Aged; Plasma; Retrospective Studies; Rural Population; Trauma Centers; Warfarin; Wounds and Injuries

To describe the prevalence of preinjury warfarin use in a large national sample of trauma patients and to define the relationship between preinjury warfarin use and mortality.. Retrospective cohort study.. The National Trauma Databank (7.1).. All patients admitted to eligible trauma centers during the study period; 1,230,422 patients (36,270 warfarin users) from 402 centers were eligible for analysis.. Prevalence of warfarin use and all-cause in-hospital mortality. Multivariate logistic regression was used to estimate the odds ratio (OR) for mortality associated with preinjury warfarin use.. Warfarin use increased among all patients from 2.3% in 2002 to 4.0% in 2006 (P < .001), and in patients older than 65 years, use increased from 7.3% in 2002 to 12.8% in 2006 (P < .001). Among all patients, 9.3% of warfarin users died compared with only 4.8% of nonusers (OR, 2.02; 95% confidence interval [CI], 1.95-2.10; P < .001). After adjusting for important covariates, warfarin use was associated with increased mortality among all patients (OR, 1.72; 95% CI, 1.63-1.81; P < .001) and patients 65 years and older (OR, 1.38; 95% CI, 1.30-1.47; P < .001).. Warfarin use is common among injured patients and its prevalence has increased each year since 2002. Its use is a powerful marker of mortality risk, and even after adjusting for confounding comorbidities, it is associated with a significant increase in death.

Topics: Adult; Age Factors; Aged; Aged, 80 and over; Anticoagulants; Cause of Death; Cohort Studies; Comorbidity; Cross-Sectional Studies; Databases, Factual; Drug Utilization; Female; Hospital Mortality; Humans; Intracranial Hemorrhage, Traumatic; Long-Term Care; Male; Middle Aged; Odds Ratio; Retrospective Studies; Survival Analysis; Trauma Centers; Trauma Severity Indices; United States; Warfarin; Wounds and Injuries; Young Adult

Warfarin is a commonly prescribed anticoagulant that may, in selected situations, require rapid reversal of its effects. Several approaches to achieve reversal have been explored, including the administration of prothrombin complex concentrates (PCCs), Many factors can influence determination of an appropriate PCC dose and the resulting effects. Considerations on the use of PCC products to expedite the reversal of warfarin are described.

Topics: Anticoagulants; Blood Coagulation Factors; Female; Hemorrhage; Hemostatics; Humans; International Normalized Ratio; Male; Warfarin; Wounds and Injuries

Prothrombin complex concentrate (PCC) is recommended as a therapy to be considered for the reversal of warfarin's effects. Few published data are available on the use of PCC for this indication in traumatically injured patients.. To determine whether the addition of PCC to standard approaches to warfarin reversal more rapidly corrects the international normalized ratio (INR) in injured patients.. A retrospective analysis was performed in trauma patients who were on warfarin preinjury from January 2007 to September 2009 at North Memorial Medical Center. Data were collected from medical records and the trauma registry. Patients were separated based on whether or not they received PCC. The groups were compared on the basis of demographics, units of fresh frozen plasma (FFP), vitamin K use, units of PCC, number of patients achieving an INR of 1.5 or less, time to an INR of 1.5 or less, mortality, intensive care unit (ICU) and hospital length of stay, and the incidence of thromboembolic events during hospitalization.. Thirty-one patients were included in the analysis; 13 patients who received a total mean (SD) dose of 2281 (1053) units (25.6 [12.2] units/kg) of PCC (Profilnine SD) were compared to 18 patients who did not receive PCC. There was no significant difference between groups in FFP units received or the number of patients who received vitamin K. Most patients in both groups achieved an INR of 1.5 or less (92% PCC vs 89% no PCC). However, the mean time to achieve an INR of 1.5 or less was 16:59 (20:53) hours in the PCC group versus 30:03 (23:10) hours in the no PCC group (p = 0.048). There were 3 deaths in the PCC group and no deaths in the no PCC group (p = 0.06). ICU and hospital length of stay and number of thromboembolic events did not differ significantly between the 2 groups.. PCC, when added to FFP and vitamin K, resulted in a more rapid time to reversal of the INR.

Topics: Aged; Aged, 80 and over; Anticoagulants; Blood Coagulation Factors; Critical Care; Female; Hemorrhage; Hemostatics; Humans; Incidence; International Normalized Ratio; Length of Stay; Male; Medical Records; Middle Aged; Minnesota; Registries; Retrospective Studies; Thromboembolism; Warfarin; Wounds and Injuries

Warfarin and antiplatelet agents (WAA) are prevalent among trauma patients, but the impact of these agents on patient outcomes has not been clearly defined. In this study, we examined the impact of preinjury WAA on outcomes in trauma patients.. A 40-month (September 2004 to December 2007) retrospective review of data in the trauma registry at a New York State level 1 trauma center was performed. Patients on WAA were compared to those not on these medications. The primary outcome of interest was mortality, and the secondary outcomes of interest were as length of stay (LOS) and disposition on discharge. A separate analysis was done for patients with intracranial hemorrhage (ICH). The chi-square test, the Student t test, and the modified Poisson regression analysis were used to estimate the incident risk ratios for the outcomes.. A total of 3,436 trauma patients were identified, of whom 456 were taking anticoagulants (warfarin, n = 91 patients; aspirin, n = 228; clopidogrel, n = 43; and various combinations, n = 94). Patients on warfarin were 3.1 times more likely to die (relative risk [RR], 3.2; 95% confidence interval [CI], 1.6-6.6), after adjusting for potential confounders. Aspirin and clopidogrel were not associated with increased mortality, but WAA were associated with increased risk of ICH (49.8% vs 30.5%; RR, -1.6; 95% CI, 1.4-1.9). WAA did not affect LOS or disposition. Among patients with ICH, only warfarin increased mortality (28.9% vs 5.8%; RR, -3.1; 95% CI, 1.3-7.2).. Preinjury warfarin treatment was found to be an independent risk factor for mortality. WAA agents increased risk of ICH. Among those patients with ICH, only warfarin was associated with increased mortality. Antiplatelet agents did not affect mortality or LOS.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anticoagulants; Aspirin; Child; Child, Preschool; Clopidogrel; Cohort Studies; Female; Humans; Infant; Intracranial Hemorrhages; Length of Stay; Male; Middle Aged; Multivariate Analysis; New York; Platelet Aggregation Inhibitors; Registries; Retrospective Studies; Risk Factors; Ticlopidine; Trauma Centers; Warfarin; Wounds and Injuries; Young Adult

To describe the characteristics, management and outcomes of patients with major trauma who were taking warfarin; explore the use of rapid anticoagulation reversal; and assess the effect of reversal on outcomes.. Retrospective cohort analysis of prospective data extracted from the trauma registries and patient charts of the two adult trauma referral hospitals with neurosurgical units in Western Australia, 2000 to 2005. Inclusion criteria were: major trauma (injury severity score > 15); first international normalised ratio (INR) after injury > 1.4; and documented (in registry or chart) warfarin use.. Eighty patients were identified. Their mean age was 76.8 years. Forty-six were men; 34 were transferred from another hospital; 28 died; and the functional outcomes of 58 were worse at discharge from hospital than before injury. Intracranial haemorrhage (ICH) occurred in 62, of whom 25 died; the difference in mortality between those with ICH and those without ICH was insignificant. Warfarin reversal started 17.4 hours (mean) after injury and the documented period between injury and completion of reversal was 54.2 hours (mean). Multiple logistic regression models, controlling for age, sex, on-scene Glasgow Coma Scale (GCS), initial INR and progressive ICH, showed no independent survival benefit for rapid reversal. Factors associated with mortality were age (22% increase per year [95% CI, 17%-34%]) and progressive ICH on computed tomography scan (24 of the 36 patients with progressive ICH died v one of the 26 patients with stable ICH died). Every point increase in on-scene GCS > 8 increased survival likelihood by 215% (95% CI, 119%-388%).. Patients with major trauma taking warfarin at the time of injury have high mortality rates, poor functional outcomes and long delays to initiation and completion of anticoagulation reversal. Rapid, appropriate warfarin reversal was rarely performed and was not independently associated with survival. Age, low on-scene GCS and progressive ICH were strongly associated with mortality, but presenting INR, ICH v no ICH, and sex were not.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Blood Coagulation Factors; Causality; Cohort Studies; Factor VIII; Female; Fibrinogen; Hemorrhage; Humans; Intracranial Hemorrhages; Male; Middle Aged; Plasma; Registries; Treatment Outcome; Vitamin K; Warfarin; Western Australia; Wounds and Injuries

While mortality from trauma increases, there has been a decline in mortality from cardiovascular and cerebrovascular diseases which parallels advances in antithrombotic and anticoagulation therapy. Warfarin (coumadin) is the most common oral anticoagulant used for chronic anticoagulant therapy and most patients requiring such therapy are elderly (greater than 65 years old). The most common complication of warfarin use is adverse bleeding. It is becoming increasingly evident the population at highest risk for sustaining a complication related to anticoagulation is that group presenting with traumatic brain injury. Recent studies show that patients with other injury patterns do not appear to have significant differences post trauma, although the data about such outcomes is sparse. Significant bleeding from retroperitoneal hematomas is more often associated with major pelvic fractures from high energy blunt force mechanisms, and the blood loss may be tamponaded by the retroperitoneal structures if natural clotting mechanisms are intact. Recombinant Factor VIIa (FVIIa) can be used to reverse coagulopathy in patients on coumadin who sustain a traumatic injury.

Topics: Aged, 80 and over; Anticoagulants; Factor VIIa; Female; Fluid Therapy; Hematoma; Humans; Recombinant Proteins; Retroperitoneal Space; Time Factors; Warfarin; Wounds and Injuries

Fall from standing (FFS) has become one of the most common mechanisms of injury for admission to the trauma center in the elderly population. Many of these patients present anticoagulated with warfarin. This two-center study was designed to examine the effects of preinjury warfarin use on outcome in the elderly.. A retrospective review of prospectively collected registry data at two Level I trauma centers was conducted from 2003 to 2006. The study population included patients age > or = 65 admitted to the trauma center after an FFS. These centers are relatively close geographically and have similar patient demographics. Data collected included: age, Injury Severity Score, Abbreviated Injury Score (AIS) for head, mortality, admission Glasgow Coma Score, and admission international normalized ratio (INR). Patients were divided into two groups based on the preinjury condition of warfarin use. Statistical differences were determined by unpaired t test for continuous variables and chi and odds ratios (ORs) for dichotomous variables.. Of the 27,812 patients admitted to these two trauma centers over this time period, 2,791 (10.0%) were of age > or = 65 and admitted after an FFS. INR was 2.8 +/- 1.1 in warfarin group (+warf). The number of patients with AIS head 4 and 5 was similar between groups (-warf 22.1%, +warf 25.9%). Overall, preinjury warfarin use had a negative effect on the in-hospital mortality rate, +warf 8.6% and -warf 5.7% (OR 1.54, 1.09-2.19, p = 0.015). There was no difference in mortality between groups in patients with an AIS head < 4. The negative impact of preinjury warfarin use on mortality was most pronounced in patients with an AIS head 4 and 5 who presented awake (Glasgow Coma Score 14 and 15), +warf 13.5% and -warf 6.4% (OR 2.30, 95% confidence interval 1.12-4.70, p = 0.019).. Preinjury warfarin use has an adverse effect on outcome (mortality) in elderly FFS patients. Importantly, this effect is most prominent in patients admitted awake with significant findings on computed tomography scan. This argues for rapid emergency department triage to computed tomography scan and rapid INR correction in this population.

Topics: Accidental Falls; Aged; Aged, 80 and over; Anticoagulants; Hemorrhage; Humans; Retrospective Studies; Treatment Outcome; Warfarin; Wounds and Injuries

Topics: Administration, Oral; Anticoagulants; Blood Coagulation; Blood Coagulation Disorders; Cohort Studies; Drug Administration Schedule; Female; Humans; Injections, Intravenous; Male; Orthopedic Procedures; Preoperative Care; Thrombosis; Treatment Outcome; Vitamin K; Warfarin; Wounds and Injuries

Trauma patients are at risk of developing an acute coagulopathy of trauma (ACT) related to tissue injury, shock, and hemodilution. ACT is incompletely understood, but is similar to disseminated intravascular coagulation (DIC) and is associated with poor outcome.. Thrombin generation assays were used to evaluate plasma hemostasis in 42 trauma patients, 25 normal subjects, and 45 patients on warfarin and in laboratory-prepared factor reduced plasma.. Prolonged prothrombin time (PT), more than 18 seconds, or an international normalized ratio of greater than 1.5 was present in 15 trauma patients indicating possible ACT. Native thrombin generation (no activator added, contact activation blocked) showed that Trauma with ACT patients had lag times 68% shorter and peak thrombin generation threefold higher than normal patients indicating the presence of circulating procoagulants capable of initiating coagulation systemically. Trauma patients had lower platelet counts and fibrinogen and Factor (F)II levels putting them at increased risk of bleeding. In laboratory-prepared isolated factor-reduced samples and in patients with vitamin K-dependent factor deficiency due to warfarin, thrombin generation decreased in direct proportion to FII levels. In contrast, in diluted plasma and in trauma patients with reduced factor levels, thrombin generation was increased and associated with slower inhibition of thrombin generation (prolonged termination time) and decreased antithrombin levels (43% of normal in Trauma with ACT).. Thrombin generation studies indicate that Trauma with ACT patients show dysregulated hemostasis characterized by excessive non-wound-related thrombin generation due to a combination of circulating procoagulants capable of activating coagulation systemically and reduced inhibitor levels allowing systemic thrombin generation to continue once started.

Topics: Adult; Anticoagulants; Antithrombins; Disseminated Intravascular Coagulation; Female; Hemostasis; Humans; Male; Middle Aged; Plasma; Prothrombin; Prothrombin Time; Thrombin; Thromboplastin; Vitamin K; Warfarin; Wounds and Injuries

Trauma patients who require therapeutic anticoagulation pose a difficult treatment problem. The purpose of this study was to determine: (1) the incidence of complications using therapeutic anticoagulation in trauma patients, and (2) if any patient factors are associated with these complications.. An 18-month retrospective review was performed on trauma patients >or= 15 years old who received therapeutic anticoagulation using unfractionated heparin (UH) and/or fractionated heparin (FH). Forty different pre-treatment and treatment patient characteristics were recorded. Complications of anticoagulation were documented and defined as any unanticipated discontinuation of the anticoagulant for bleeding or other adverse events.. One-hundred-fourteen trauma patients were initiated on therapeutic anticoagulation. The most common indication for anticoagulation was deep venous thrombosis (46%). Twenty-four patients (21%) had at least 1 anticoagulation complication. The most common complication was a sudden drop in hemoglobin concentration requiring blood transfusion (11 patients). Five patients died (4%), 3 of whom had significant hemorrhage attributed to anticoagulation. Bivariate followed by logistic regression analysis identified chronic obstructive pulmonary disease (OR = 9.2, 95%CI = 1.5-54.7), UH use (OR = 3.8, 95%CI = 1.1-13.0), and lower initial platelet count (OR = 1.004, 95%CI = 1.000-1.008) as being associated with complications. Patients receiving UH vs. FH differed in several characteristics including laboratory values and anticoagulation indications.. Trauma patients have a significant complication rate related to anticoagulation therapy, and predicting which patients will develop a complication remains unclear. Prospective studies are needed to determine which treatment regimen, if any, is appropriate to safely anticoagulate this high risk population.

Topics: Adult; Anticoagulants; Cohort Studies; Confidence Intervals; Emergency Treatment; Female; Follow-Up Studies; Heparin, Low-Molecular-Weight; Humans; Injury Severity Score; Male; Middle Aged; Odds Ratio; Postoperative Care; Preoperative Care; Probability; Retrospective Studies; Risk Assessment; Safety Management; Survival Analysis; Thromboembolism; Thrombolytic Therapy; Trauma Centers; Treatment Outcome; Warfarin; Wounds and Injuries

The trauma literature is inconsistent in its conclusions and recommendations concerning the influence of oral anticoagulation on outcomes after injury. Some report worse outcomes, whereas others showed no effect. We approached this problem by using the patients' admission international normalized ratio (INR) values to document anticoagulation and hypothesized that warfarin anticoagulation is associated with increased mortality after trauma in the elderly. We further questioned the cost-effectiveness of admission INR testing.. We conducted a retrospective review of 3,242 trauma patients aged 50 and older. INR data were used as a surrogate for warfarin anticoagulation and was related to age, sex, and Injury Severity Scale score (ISS) to analyze effects on mortality. Logistic regression was used to perform multivariate analyses. INR costs were summed from all laboratory department costs.. Of the 3,242 elderly injured patients, admission INR was obtained in 1,251 patients. One hundred and two patients had an "elevated" INR of >1.5. Mortality for those with an INR >1.5 was 22.6%, versus 8.2% for those with an INR <1.5 (p < 0.0001). The logistic regression gave an age and ISS adjusted odds of death of 30% for a one unit increase in INR (OR 1.3, 95% CI 1.1-1.5; p value 0.002). This correlates to an age and injury score adjusted odds of death of 2.5 for an INR >1.5 (95% CI 1.2-4.2; p value 0.014). INR cost was estimated at $5 per blood draw.. After adjusting for age, gender, and ISS, anticoagulation was associated with increased overall mortality. Elderly patients are commonly anticoagulated and anticoagulation is a therapeutically reversible risk factor. Considering the increasing number of indications for and prevalence of anticoagulation, the low cost of an INR and the potential reduction in costs associated with traumatic brain injury, these data support the recommendation to assess a coagulation profile in elderly trauma patients to identify earlier those in need of closer monitoring and a more aggressive reversal of their anticoagulation.

Topics: Administration, Oral; Age Factors; Aged; Aged, 80 and over; Analysis of Variance; Anticoagulants; Blood Coagulation Tests; Cause of Death; Cohort Studies; Female; Geriatric Assessment; Hospital Mortality; Humans; Injury Severity Score; International Normalized Ratio; Logistic Models; Male; Middle Aged; Needs Assessment; Probability; Registries; Retrospective Studies; Risk Assessment; Survival Analysis; Trauma Centers; Warfarin; Wounds and Injuries

Preinjury warfarin anticoagulation has been shown to increase the mortality of traumatic intracranial hemorrhage. We have evaluated the impact on patient mortality of the rapid triage of patients at risk for warfarin associated traumatic intracranial hemorrhage.. A "Coumadin Protocol" was implemented in January, 2001 in the Emergency Department that expedited triage of anticoagulated trauma patients to immediate physician evaluation. Patient outcomes during a 2 year period were compared with a matched control group of similarly injured, anticoagulated patients who were treated before protocol initiation.. Thirty-five patients were treated after implementation of the Coumadin Protocol. Mean time until warfarin reversal was 4.3 +/- 4.4 hours, and there was a 37% mortality. Twenty-two control patients had a mean time to reversal of 4.2 +/- 2.9 hours, with a 45% mortality (p = 0.610). Ten protocol patients were shown to have intracranial hemorrhage progression by computed tomography (CT) scan, with a 60% mortality rate. Seventeen patients had follow-up CT scan and showed no progression; only one of these patients (6%) died (p = 0.004). Hemorrhage severity based on the initial CT scan did not predict mortality or hemorrhagic progression.. We conclude from these data that a trauma center protocol for rapid identification of intracranial bleeding without a concomitant therapeutic protocol does not improve survival in head injured patients on preinjury warfarin.

Topics: Aged; Anticoagulants; Disease Progression; Female; Humans; Intracranial Hemorrhages; Male; Retrospective Studies; Risk; Tomography, X-Ray Computed; Triage; Warfarin; Wounds and Injuries

Warfarin therapy is often withheld from elderly patients who fall or otherwise experience injury because of concerns regarding the long-term risk of hemorrhage in these individuals. We studied whether stopping warfarin after trauma is associated with a higher risk of subsequent adverse cardiovascular events.. We conducted a retrospective, population-based, cohort study using linked administrative databases in the province of Ontario, Canada for the years 1992 to 2001. A total of 8450 elderly patients (age >65 years) who survived an incident of major trauma and were receiving warfarin before injury were followed up for a mean of 3.3 years. During the 6-month interval after trauma, 1827 (22%) patients discontinued warfarin, whereas 6623 (78%) patients continued warfarin. Warfarin cessation was not associated with an increased risk of subsequent stroke (hazard ratio [HR] 0.99, 95% CI 0.82 to 1.21) or myocardial infarction (HR 0.94, 95% CI 0.74 to 1.20) but was associated with a lower risk of major hemorrhage (HR 0.69, 95% CI 0.54 to 0.88) and a higher risk of venous thromboembolism (HR 1.59, 95% CI 1.07 to 2.36). Adjustment for baseline demographics, stroke risk factors, other comorbidities, and characteristics of the trauma did not materially change these findings. On-treatment analyses yielded similar results.. Cessation of warfarin in elderly patients after major trauma was not associated with an increased risk of arterial thrombotic events but was associated with a significantly increased risk of venous thromboembolism.

Topics: Aged; Aged, 80 and over; Cohort Studies; Contraindications; Female; Follow-Up Studies; Hemorrhage; Humans; Incidence; Male; Myocardial Infarction; Prognosis; Retrospective Studies; Risk; Stroke; Thrombosis; Warfarin; Wounds and Injuries

With rising health care costs, methods to decrease length of hospital stay without compromising care are necessary. One area that extends length of stay in trauma patients is inpatient anticoagulation to a therapeutic international normalized ratio. The 1998 American College of Chest Physicians guidelines recommend thromboprophylaxis with low-molecular-weight heparin (LMWH) and oral warfarin in this population. The LMWH Expedited Anticoagulation Program (LEAP) was created with the following goals: to decrease the number of inpatient warfarin days and to reduce overall number of hospital days.. Inpatient anticoagulation was initiated with warfarin and LMWH. LEAP included early multidisciplinary collaboration to ensure third-party approval, outpatient primary care physician follow-up, and LMWH self-injection before discharge. Patients were discharged on LMWH (discontinued by primary care provider when a therapeutic international normalized ratio was attained) and warfarin (continued until resolution of orthopedic injuries). From August 2000 to August 2001, adult patients were included in the prospective study. Primary inclusion criteria were blunt acetabular fracture, bilateral lower extremity fracture, and contralateral upper and lower extremity fractures. Patients with similar injuries receiving warfarin for deep venous thrombosis prophylaxis between June 1999 and June 2000 were the control population. Anticoagulation care was similar for the study and control subjects.. There were 182 patients evaluated for LEAP inclusion. After initial evaluation, 108 patients were enrolled in LEAP (Injury Severity Score of 13). There were 69 control subjects (Injury Severity Score of 13). The average number of inpatient warfarin days was decreased from 8.8 days to 5.0 days in the control and study populations, respectively (p < 0.0001). The average length of hospitalization was shortened from 17.3 days in the control group to 12.9 days in the study (LEAP) population (p < 0.002).. LEAP has successfully decreased the number of inpatient days on warfarin and total hospital days for trauma patients requiring deep venous thrombosis prophylaxis. These results have substantially decreased health care costs and increased available hospital beds in this era of high hospital occupancy.

Topics: Adult; Aged; Anticoagulants; Case-Control Studies; Female; Heparin, Low-Molecular-Weight; Humans; Injury Severity Score; Length of Stay; Male; Middle Aged; Venous Thrombosis; Warfarin; Wounds and Injuries

The objective of this study was to determine whether the preinjury condition of anticoagulation had an adverse impact on patients sustaining injury.. A retrospective analysis was performed for prospectively collected registry data from 1995-2000 from all accredited trauma centers in Pennsylvania. The registry was queried for all trauma patients who had anticoagulation therapy as a preinjury condition (PIC). This group served as our experimental cohort. A control cohort (not having warfarin therapy as a PIC) was developed using case-matching techniques for age, sex, Glasgow Coma Scale (GCS), Injury Severity Score (ISS), A Severity Characterization of Trauma (ASCOT) score, and in the head injured patients, International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnoses. Head and non-head injured patients were evaluated separately. The cohorts were examined for 28-day mortality, intensive care unit length of stay (ICU-LOS), hospital length of stay (HOS-LOS), PICs, occurrences, discharge destinations, and functional status at discharge. Chi2 and Student's t test were used to evaluate the data; p values < 0.05 were considered significant.. Two thousand nine hundred forty-two patients were available for analysis. The prevalence of PICs was significantly greater in the warfarin group for both the head and non-head injured populations (p < 0.003 and p < 0.0001, respectively). The incidence of occurrences in the non-head injured population was statistically higher for the warfarin patients (p < 0.001), but showed no difference in the head injured group regardless of warfarin use (p = 0.15). Functional status at discharge demonstrated no clinically significant difference between the warfarin and non-warfarin groups in both head and non-head injured populations. There was no difference in discharge destination in the head injured population; however, in the non-head injured population a greater percentage of non-warfarin patients was discharged to home when compared with the warfarin patients.. Our data suggest that the PIC of anticoagulation with warfarin does not adversely impact mortality or LOS outcomes in both head and non-head injured patients. In non-head injured patients, however, the occurrence rates and discharge destination were different. More research needs to be done to determine whether this is related to anticoagulation or other reasons (i.e., number of PICs). These data should be used when weighing risk/benefit ratios of prescribing chronic anticoagulation.

Topics: Aged; Anticoagulants; Case-Control Studies; Cohort Studies; Craniocerebral Trauma; Female; Humans; Injury Severity Score; Length of Stay; Male; Patient Discharge; Pennsylvania; Prospective Studies; Registries; Retrospective Studies; Trauma Centers; Warfarin; Wounds and Injuries

This study examined the hypothesis that elderly trauma patients on warfarin before injury will have increased morbidity and mortality compared with elderly trauma patients not on warfarin.. From 1993 to 1995, trauma patients were grouped by age and presence or absence of warfarin use before injury. Groups were analyzed with respect to Injury Severity Score, Trauma Registry and Injury Severity Score, Glasgow Coma Scale score, Intensive Care Unit days, hospital days, units of blood transfused, and mortality rates. Statistical analysis was completed by using the Student's t test.. Records of 61 patients administered warfarin and 800 patients not administered warfarin were available for analysis. There were no statistically significant differences between patients on prehospital warfarin and those not on prehospital warfarin.. This study indicates that elderly trauma patients on warfarin before injury do not have increased morbidity and mortality compared with elderly trauma patients not on warfarin.

Topics: Aged; Aged, 80 and over; Anticoagulants; Female; Humans; Male; Postoperative Complications; Risk Factors; Survival Rate; Warfarin; Wounds and Injuries

The incidence of deep venous thrombosis (DVT) in the pediatric population has been reported to be lower than in adults. Pediatric trauma patients have predisposing risk factors for DVT similar to those in the general trauma population. We reviewed the records of 2746 children under 16 years of age admitted to our Level I pediatric trauma service from 1989 to 1997. Only three cases of DVT were documented, all adolescents. DVT was located in the upper (n = 1) and lower (n = 1) extremity venous system. One patient presented with pulmonary embolism alone without identifiable DVT. Risk factors found were venous system manipulations, including atriocaval shunt, subclavian central line, and hyperinflated medical antishock trousers garment. Therapy consisted of heparin followed by warfarin anticoagulation. A vena cava filter was inserted in one patient for whom systemic anticoagulation was contraindicated. No DVT was seen in 1123 closed head injury patients or 29 spinal cord injury patients without associated risk factors. The thrombotic risk in pediatric trauma patients is low. Routine screening or prophylaxis is not indicated except for patients who are likely to remain immobile for an extended period of time and require prolonged rehabilitation, have venous manipulations, or present with clinical symptoms. Hematologic evaluation in patients with diagnosed DVT is necessary to identify individual risk factors.

Topics: Accidents, Traffic; Adolescent; Anticoagulants; Extremities; Female; Heparin; Humans; Immobilization; Male; Risk Factors; Vena Cava Filters; Venous Thrombosis; Warfarin; Wounds and Injuries

Patients on warfarin are at high risk for potentially life-threatening hemorrhage even after relatively minor trauma. Outcomes of these patients and the potential complications of reversing the effects of anticoagulation have received little attention. This study was performed to determine the overall outcome of orally anticoagulated patients who sustained injury as well as to determine any untoward effects of reversing their anticoagulated states. A retrospective study of injured patients on warfarin was conducted on patients admitted to an urban, university, tertiary-referral, level I trauma center between 1/1/93 and 12/31/96. Surviving patients were followed for a period of at least 1 month. Injuries were grouped by anatomic site. Charts were reviewed for degree of anticoagulation on admission (ie, initial international normalized ratio [INR]), survival, adverse effects of reversal of anticoagulation, and reinstitution of warfarin therapy. Discharged patients were contacted at home for follow-up. Thirty-five consecutive patients, 18 men and 17 women, on warfarin therapy at the time of their injuries were reviewed. The mean age was 75 years, with a range of 39 to 96. The mean follow-up period was 12.7 months. Reasons for anticoagulation included atrial fibrillation, prosthetic heart valves, revascularized limb, hypercoagulable state, deep venous thrombosis, pulmonary embolism, phlebitis, and aortic stenosis. Mean admission INR was 3.2, with a range of 1.6 to 10.0. There were 8 in-hospital deaths. Intracranial hemorrhages accounted for the majority of injuries. Ten patients were not given reversal therapy. Four complications were attributable to reversal therapy (upper extremity hemiplegia, transient ischemic attack, deep venous thrombosis, arterial thrombosis). Twenty-one patients had their warfarin reinstituted. Follow-up of surviving patients ranged from 1.5 to 42 months. Patients on warfarin are at high risk for intracranial hemorrhage following trauma. Patients on warfarin may be reversed during the acute period following injury, but transient complications may arise. Further prospective studies need to be conducted to determine which anticoagulated trauma patients may not require reversal therapy.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Cause of Death; Emergency Service, Hospital; Female; Hemorrhage; Hospital Mortality; Humans; Male; Middle Aged; Retrospective Studies; Risk Factors; Treatment Outcome; Warfarin; Wounds and Injuries

This study was conducted to determine the possibility of detecting dangerous hypocoagulability in trauma victims given warfarin by measuring plasma activated clotting time (ACT). Sensitivity of the plasma ACT to warfarin was tested using lyophilized plasmas and plasma samples from nontraumatized but anticoagulated patients. Lyophilized plasmas were also used to evaluate the effect of defects in the intrinsic coagulation system on the plasma ACT. The plasma ACT, measured using a 4.4-mM calcium solution, showed satisfactory prolongation when the thrombotest of matched samples was within the therapeutic range for warfarin therapy. Conversely, the plasma ACT was not prolonged when the only abnormality of matched samples was mild to moderate prolongation of the activated partial thromboplastin time (APTT). These findings suggest that the plasma ACT could be a reliable indicator of dangerous hypocoagulability in trauma patients receiving warfarin therapy during the immediate postinjury period.

Topics: Anticoagulants; Blood Coagulation; Emergency Treatment; Humans; Prognosis; Sensitivity and Specificity; Warfarin; Wounds and Injuries

Trauma patients are at significant risk for deep venous thrombosis (DVT) and pulmonary embolism (PE). Anticoagulation is standard therapy for DVT/PE, but may cause severe complications. We reviewed the course of 70 trauma ICU patients treated over a 28-month period. Thirty-six patients (51.4 percent) were treated by continuous IV heparin and/or oral warfarin. Of these, 13 patients (36 percent) developed complications requiring termination of anticoagulation. These included recurrent PE (four), subdural hematomas (three), hemothorax (two), heparin-induced thrombocytopenia (one), hemorrhagic pericardial effusion (one), retroperitoneal hematoma (one), and sudden unexplained drop in hemoglobin and shock (one). All patients with subdural hematomas had no prior evidence of head injury on brain computed tomography. All patients with recurrent PE received adequate anticoagulation therapy. Age > 55 was associated with increased risk of complications (8 of 13; p = .02:chi 2). Thirty-four other patients (48.6 percent) received inferior vena caval filters with no related complications or deaths. Anticoagulation for DVT/PE should be used selectively in trauma patients and avoided in elderly patients. Such patients should undergo early caval filter placement.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Hematoma; Hemothorax; Heparin; Humans; Middle Aged; Pulmonary Embolism; Recurrence; Retrospective Studies; Risk Factors; Thrombocytopenia; Thrombophlebitis; Warfarin; Wounds and Injuries

Hypothetical clinical cases were used to investigate transfusion-related decision-making. Three red cell, three fresh frozen plasma (FFP) and three albumin transfusion decision cases were administered by questionnaire to 228 medical staff. The transfusion decision triggers were identified and comparisons made between resident and specialist groups and between Melbourne and Sydney participants. Factors important in red cell transfusion decisions included haemoglobin, symptoms of anaemia, presence of co-morbidities or surgery, gender, period of hospitalisation and the degree of documented blood loss. FFP administration was influenced by an abnormal coagulation test, the presence of co-morbidities and by the number of red cell units transfused. The administration of albumin, concentrated or 5% SPPS, was influenced by the period of hospitalisation and clinical circumstances such as a falling urine output postoperatively, and by the presence of hypotensive complications. Different transfusion responses were noted: resident staff transfused red cells and FFP earlier than specialists; Sydney specialists were more conservative of red cell transfusion; Melbourne specialists more conservative of FFP administration and surgeons were four times more likely to transfuse patients than physicians or anesthetists at certain haemoglobin values.

Topics: Abruptio Placentae; Adult; Aged; Ascites; Blood Component Transfusion; Blood Loss, Surgical; Blood Transfusion; Cesarean Section; Colonic Neoplasms; Decision Making; Disseminated Intravascular Coagulation; Epistaxis; Female; Humans; Hypoproteinemia; Male; Medical Staff, Hospital; Middle Aged; Peptic Ulcer Hemorrhage; Plasma; Pregnancy; Serum Albumin; Sex Factors; Warfarin; Wounds and Injuries

Topics: Adolescent; Adult; Age Factors; Aged; Aneurysm; Arteries; Arteriovenous Fistula; Aspirin; Blood Vessels; Child; Child, Preschool; Colorado; Female; Heparin; Humans; Infant; Male; Methods; Middle Aged; Postoperative Complications; Radiography; Sex Factors; Thrombosis; Veins; Warfarin; Wounds and Injuries

Topics: Adult; Aged; Contraceptives, Oral; Diagnosis, Differential; Female; Fractures, Bone; Heparin; Humans; Ilium; Male; Middle Aged; Myocardial Infarction; Phlebitis; Phlebography; Pneumonia, Viral; Psittacosis; Pulmonary Embolism; Radionuclide Imaging; Recurrence; Thromboembolism; Warfarin; Wounds and Injuries

Topics: Adult; Anticoagulants; Dyspnea; Female; Hemorrhage; Heparin; Humans; Male; Middle Aged; Muscular Diseases; Peripheral Nervous System Diseases; Pregnancy; Warfarin; Wounds and Injuries