Predictors of direct oral anticoagulant concentrations in the trauma population.

Introduction: Direct oral anticoagulant (DOAC) use is becoming more prevalent in patients presenting after trauma. We sought to identify the prevalence and predictors of subtherapeutic and therapeutic DOAC concentrations and hypothesized that increased anti-Xa levels would correlate with increased risk of bleeding and other poor outcomes. Methods: A retrospective cohort study of all trauma patients on apixaban or rivaroxaban admitted to a level 1 trauma center between January 2015 and July 2021 was performed. Patients were excluded if they did not have a DOAC-specific anti-Xa level at presentation. Therapeutic levels were defined as an anti-Xa of 50 ng/mL to 250 ng/mL for rivaroxaban and 75 ng/mL to 250 ng/mL for apixaban. Linear regression was used to identify correlations between study variables and anti-Xa level, and binomial logistic regression was used to test the association of anti-Xa level with outcomes. Results: There were 364 trauma patients admitted during the study period who were documented to be on apixaban or rivaroxaban. Of these, 245 patients had anti-Xa levels measured at admission. The population was 53% woman, with median age of 78 years, and median Injury Severity Score of 5. In total, 39% of patients had therapeutic and 20% had supratherapeutic anti-Xa levels. Female sex, increased age, decreased height and weight, and lower estimated creatinine clearance were associated with higher anti-Xa levels at admission. There was no correlation between anti-Xa level and the need for transfusion or reversal agent administration, admission diagnosis of intracranial hemorrhage (ICH), progression of ICH, hospital length of stay, or mortality. Conclusions: Anti-Xa levels in trauma patients on DOACs vary widely; female patients who are older, smaller, and have decreased kidney function present with higher DOAC-specific anti-Xa levels after trauma. We were unable to detect an association between anti-Xa levels and clinical outcomes. Level of evidence: III-Prognostic and Epidemiological.

Robotic repair of traumatic bronchial disruption: A minimally invasive and multi-disciplinary approach to a complex constellation of injuries.

Bronchial disruption is a catastrophic consequence of blunt thoracic trauma with high pre-hospital lethality. This injury is classically managed through a large thoracotomy incision to facilitate adequate exposure for open repair. Here, we describe a case of complete bronchus intermedius disruption following a motor vehicle accident that was repaired via robotic thoracoscopy. The patient sustained multi-system trauma, including a grade III liver laceration, an innominate artery pseudoaneurysm, and femoral condyle fracture, all of which required systematic intervention and multi-disciplinary coordination to best facilitate this patient's care. This patient recovered well from his multiple injuries and was discharged after an uneventful post-operative course.

Management of choledocholithiasis in the elderly: Same-admission cholecystectomy remains the standard of care.

BACKGROUND: Current guidelines recommend that patients with choledocholithiasis undergo same-admission cholecystectomy. The compliance with this guideline is poor in elderly patients. We hypothesized that elderly patients treated with endoscopic retrograde cholangiopancreatography (ERCP) alone would have higher complication and readmission rates than the patients treated with cholecystectomy. METHODS: The Nationwide Readmissions Database was queried for all patients aged ≥65 years with admission for choledocholithiasis January to June 2016. The patients were divided based on index treatment received: (1) no intervention; (2) ERCP alone; or (3) cholecystectomy. Multivariate analyses identified predictors of cholecystectomy during index admission and of readmissions. RESULTS: A total of 16,121 patients with choledocholithiasis were admitted; 38.4% underwent cholecystectomy, 37.6% endoscopic retrograde cholangiopancreatography alone, and 24.0% no intervention. The patients not receiving a cholecystectomy were more likely to be older, female, have a higher Elixhauser score, do-not-resuscitate status, and at a teaching hospital (all P < .001). Emergency readmissions for recurrent biliary disease were lowest in patients undoing a cholecystectomy (2.2% vs 9.2% endoscopic retrograde cholangiopancreatography and 12.4% no intervention, P < .001), as were readmissions for complications (3.6% vs 5.5% and 7.8%, P < .001). Cholecystectomy reduced rates of readmissions for recurrent disease (odds ratio 0.168, P < .001), for complications (odds ratio 0.540, P < .001), and death during readmission (odds ratio 0.503, P = .007); endoscopic retrograde cholangiopancreatography alone reduced only rates of readmissions. Age was not a predictor of readmission or death. CONCLUSION: Index admission cholecystectomy is associated with a lower risk of readmission for biliary disease or complications, as well as death during readmission, in elderly patients. Age alone is not predictive of outcomes; surgical intervention should be guided by clinical condition, comorbidities, and patient preference.

Youth violence prevention can be enhanced by geospatial analysis of trauma registry data.

BACKGROUND: Geographic information systems (GIS) have been used to understand relationships between trauma mechanisms, locations, and social determinants for injury prevention. We hypothesized that GIS analysis of trauma center registry data for assault patients aged 14 years to 29 years with census tract data would identify geospatial and structural determinants of youth violence. METHODS: Admissions to a Level I trauma center from 2010 to 2019 were retrospectively reviewed to identify assaults in those 14 years to 29 years. Prisoners were excluded. Home and injury scene addresses were geocoded. Cluster analysis was performed with the Moran I test for spatial autocorrelation. Census tract comparisons were done using American Communities Survey (ACS) data by t-test and linear regression. RESULTS: There were 1,608 admissions, 1,517 (92.4%) had complete addresses and were included in the analysis. Mean age was 23 ± 3.8 years, mean ISS was 7.5 ± 6.2, there were 11 (0.7%) in-hospital deaths. Clusters in six areas of the trauma catchment were identified with a Moran I value of 0.24 ( Z score = 17.4, p < 0.001). Linear regression of American Communities Survey demographics showed predictors of assault were unemployment (odds ratio, 4.5; 95% confidence interval, 2.7-6.4; p < 0.001), Spanish spoken at home (odds ratio, 6.6; 95% confidence interval, 3.4-9.8; p < 0.001) and poverty level (odds ratio, 1.9; 95% confidence interval, 1.1-2.7; p < 0.001). Education level of less than high school diploma, single parent households and race were not significant predictors. CONCLUSION: GIS analysis of registry data can identify high-risk areas for youth violence and correlated social and structural determinants. Violence prevention efforts can be better targeted geographically and socioeconomically with better understanding of these risk factors. LEVEL OF EVIDENCE: Prognostic/Epidemiological; Level III.

Readmission after splenic salvage: How real is the risk?

BACKGROUND: Hemorrhage due to delayed splenic rupture is a potentially fatal complication of nonoperative management of splenic injuries. Suboptimal postdischarge follow-up has made measuring the incidence of failed splenic salvage challenging. We hypothesized that readmission after splenic salvage is rare; however, readmissions for splenic conditions would be associated with a high rate of splenectomy. METHODS: The National Readmission Database for 2016 and 2017 was queried for trauma admissions with the International Classification of Diseases 10th revision codes for splenic injury. Patients with missing discharge disposition, discharge to a short-term hospital, death during index admission, or admitted in December were excluded. The primary endpoint was nonelective 30-day readmission for splenic diagnoses after nonoperative management during the index admission. Outcomes collected included transfusions, complications, interventions at readmission, and mortality. RESULTS: There were 22,736 patients admitted for a traumatic splenic injury; 15,596 (68.6%) underwent no intervention, 2,261 (9.9%) were treated with embolization only, and 4,509 (19.8%) underwent splenectomy. The overall 30-day readmission rate was 8.4%, whereas the spleen-related readmission rate was 2.0%. For those treated with embolization or no intervention, the spleen-related 30-day readmission rate was 2.4%, with the majority (69.4%) occurring within 7 days of discharge. The most common complications were pleural effusion (23.0%), sepsis (4.4%), splenic abscess (3.9%), and splenic infarct (3.0%). Those patients readmitted for spleen-related diagnoses after undergoing splenic salvage during the index admission had a 22.3% rate of splenectomy and mortality of 1.6%. CONCLUSION: Readmission after splenic salvage is rare, with the majority presenting within 1 week of discharge. However, of those readmitted for spleen injury-related diagnoses there was a high rate of splenectomy. Patients managed with splenic salvage should be counseled on the risk of potential failure and need for readmission and operation after discharge.

Methamphetamine Use is Associated with Increased Surgical Site Infections after Trauma Laparotomy.

BACKGROUND: Methamphetamine (METH) use causes significant vasoconstriction, which can be severe enough to cause bowel ischemia. Methamphetamines have also been shown to alter the immune response. These effects could predispose METH users to poor wound healing, increased infections, and other post-operative complications. We hypothesized that METH users would have longer length of stay and higher rates of complications compared to non-METH users. METHODS: The trauma registry for our urban Level 1 trauma center was searched for patients that received an exploratory laparotomy from 2016 to 2019. A total 204 patients met criteria and 52 (25.5%) were METH positive. Length of stay (LOS), ventilator days, abbreviated injury scale (AIS), and wound class were compared using nonparametric statistics. Age and injury severity score (ISS) were compared using a Student's t-test. A Chi Square or Fisher's Exact test was used to compare sex, mechanism of injury, and rates of infectious complications. RESULTS: Methamphetamine-positive patients had a significantly higher rate of surgical site infections (7.4% versus 0%, P = 0.001). Patients that developed surgical site infection had equivalent rates of smoking and diabetes, as well as equivalent abdominal AIS and wound class compared to those who did not develop surgical site infection. Hospital and ICU LOS, ventilator days, ISS, and mortality were equivalent between METH positive and negative patients. Rates of other infectious complications were the same between groups. CONCLUSIONS: Methamphetamine use is associated with an increased rate of surgical site infection after trauma laparotomy. Other serious complications and mortality were not affected by METH use.

Repeat head computed tomography for anticoagulated patients with an initial negative scan is not cost-effective.

BACKGROUND: Patients on antithrombotic medications presenting with blunt trauma are at risk for delayed intracranial hemorrhage. We hypothesized that clinically significant delayed intracranial hemorrhage is rare in patients presenting on antithrombotic medications and therefore routine, repeat head computed tomography imaging is not a cost-effective practice to monitor for delayed intracranial hemorrhage. METHODS: Patients presenting to our institution on antithrombotic (anticoagulant and antiplatelet) medications during a 5-y period from January 2014 through March 2019 who underwent a head computed tomography for blunt trauma were identified in our trauma registry. Patients with an initial negative head computed tomography underwent repeat imaging 6 h after their initial head computed tomography. Patient demographics, antithrombotic medication, international normalized ratio, Glasgow Coma Score, clinical change in neurologic status, and need for neurosurgical intervention were collected. RESULTS: Our institution evaluated 1,676 patients on antithrombotic therapy with blunt trauma. The initial head computed tomography was negative in 1,377 patients (82.0%). Of those with an initial negative head computed tomography, 12 patients (0.9%) developed an intracranial hemorrhage that was identified on the second head computed tomography. Delayed intracranial hemorrhage included 6 patients with intraventricular hemorrhage, 3 with subdural hematoma, 2 with subarachnoid hemorrhage, and 1 with an intraparenchymal hemorrhage. None of the patients with delayed intracranial hemorrhage developed a change in neurologic status, required an intracranial pressure monitor, or underwent neurosurgical intervention. The estimated total direct cost of the negative head computed tomography scans was $926,247. CONCLUSION: Clinically significant delayed intracranial hemorrhage is rare in trauma patients on antithrombotic therapy, with an initial negative head computed tomography. Routine repeat head computed tomography imaging in patients with a negative scan on admission is not cost-effective.

The AAST prospective observational multicenter study of the initial experience with reversal of direct oral anticoagulants in trauma patients.

BACKGROUND: Drug-specific agents for the reversal of direct oral anticoagulants (DOACs) were recently approved. We hypothesized that the approval of these reversal agents would lead improved outcomes for trauma patients taking DOACs. METHODS: A multicenter, prospective (2015-2018), observational study of all adult trauma patients taking DOACs who were admitted to one of fifteen participating trauma centers was performed. The primary outcome was mortality. RESULTS: For 606 trauma patients on DOACs, those reversed were older (78 vs. 74, p = 0.007), more severely injured (ISS: 16 vs. 5, p < 0.0001), had more severe head injuries (Head AIS: 2.9 vs. 1.3, p < 0.0001), and higher mortality (11% vs. 3%, p = 0.001). Patients who received drug-specific agents (idarucizumab, andexanet alfa) had higher mortality (30% vs. 8%, p = 0.04) than those reversed with factor concentrates. However, the low usage of drug-specific reversal agents limits our ability to assess their efficacy and safety. CONCLUSIONS: DOAC reversal was not independently associated with mortality. At present, the overall usage of drug-specific reversal agents is too sparing to meaningfully assess outcomes in trauma.

Enhancing trauma registries by integrating traffic records and geospatial analysis to improve bicyclist safety.

BACKGROUND: Trauma registries are used to identify modifiable injury risk factors for trauma prevention efforts. However, these may miss factors useful for prevention of bicycle-automobile collisions, such as vehicle speeds, driver intoxication, street conditions, and neighborhood characteristics. We hypothesize that (GIS) analysis of trauma registry data matched with a traffic accident database could identify risk factors for bicycle-automobile injuries and better inform injury prevention efforts. METHODS: The trauma registry of a US Level I trauma center was used retrospectively to identify bicycle-motor vehicle collision admissions from January 1, 2010, to December 31, 2018. Data collected included demographics, vitals, injury severity scores, toxicology, helmet use, and mortality.Matching with the Statewide Integrated Traffic Records System was done to provide collision, victim and GIS information. The GIS mapping of collisions was done with census tract data including poverty level scoring. Incident hot spot analysis to identify statistically significant incident clusters was done using the Getis Ord Gi* statistic. RESULTS: Of 25,535 registry admissions, 531 (2.1%) were bicyclists struck by automobiles, 425 (80.0%) were matched to Statewide Integrated Traffic Records System. Younger age (odds ratio [OR], 1.026; 95% confidence interval [CI], 1.013-1.040, p < 0.001), higher census tract poverty level percentage (OR, 0.976; 95% CI, 0.959-0.993, p = 0.007), and high school or less education (OR, 0.60; 95 CI, 0.381-0.968; p = 0.036) were predictive of not wearing a helmet. Higher census tract poverty level percentage (OR, 1.019; 95% CI, 1.004-1.034; p = 0.012) but not educational level was predictive of toxicology positive-bicyclists in automobile collisions. Geographic information systems analysis identified hot spots in the catchment area for toxicology-positive bicyclists and lack of helmet use. CONCLUSION: Combining trauma registry data and matched traffic accident records data with GIS analysis identifies additional risk factors for bicyclist injury. Trauma centers should champion efforts to prospectively link public traffic accident data to their trauma registries. LEVEL OF EVIDENCE: Prognostic and Epidemiological, level III.

American Association for the Surgery of Trauma-World Society of Emergency Surgery guidelines on diagnosis and management of peripheral vascular injuries.

The peripheral arteries and veins of the extremities are among the most commonly injured vessels in both civilian and military vascular trauma. Blunt causes are more frequent than penetrating except during military conflicts and in certain geographic areas. Physical examination and simple bedside investigations of pulse pressures are key in early identification of these injuries. In stable patients with equivocal physical examinations, computed tomography angiograms have become the mainstay of screening and diagnosis. Immediate open surgical repair remains the first-line therapy in most patients. However, advances in endovascular therapies and more widespread availability of this technology have resulted in an increase in the range of injuries and frequency of utilization of minimally invasive treatments for vascular injuries in stable patients. Prevention of and early detection and treatment of compartment syndrome remain essential in the recovery of patients with significant peripheral vascular injuries. The decision to perform amputation in patients with mangled extremities remains difficult with few clear indicators. The American Association for the Surgery of Trauma in conjunction with the World Society of Emergency Surgery seeks to summarize the literature to date and provide guidelines on the presentation, diagnosis, and treatment of peripheral vascular injuries. LEVEL OF EVIDENCE: Review study, level IV.

American Association for the Surgery of Trauma-World Society of Emergency Surgery guidelines on diagnosis and management of abdominal vascular injuries.

Abdominal vascular trauma accounts for a small percentage of military and a moderate percentage of civilian trauma, affecting all age ranges and impacting young adult men most frequently. Penetrating causes are more frequent than blunt in adults, while blunt mechanisms are more common among pediatric populations. High rates of associated injuries, bleeding, and hemorrhagic shock ensure that, despite advances in both diagnostic and therapeutic technologies, immediate open surgical repair remains the mainstay of treatment for traumatic abdominal vascular injuries. Because of their devastating nature, abdominal vascular injuries remain a significant source of morbidity and mortality among trauma patients. The American Association for the Surgery of Trauma in conjunction with the World Society of Emergency Surgery seek to summarize the literature to date and provide guidelines on the presentation, diagnosis, and treatment of abdominal vascular injuries. LEVEL OF EVIDENCE: Review study, level IV.

Duodeno-pancreatic and extrahepatic biliary tree trauma: WSES-AAST guidelines.

Duodeno-pancreatic and extrahepatic biliary tree injuries are rare in both adult and pediatric trauma patients, and due to their anatomical location, associated injuries are very common. Mortality is primarily related to associated injuries, but morbidity remains high even in isolated injuries. Optimal management of duodeno-bilio-pancreatic injuries is dictated primarily by hemodynamic stability, clinical presentation, and grade of injury. Endoscopic and percutaneous interventions have increased the ability to non-operatively manage these injuries. Late diagnosis and treatment are both associated to increased morbidity and mortality. Sequelae of late presentations of pancreatic injury and complications of severe pancreatic trauma are also increasingly addressed endoscopically and with interventional radiology procedures. However, for moderate and severe extrahepatic biliary and severe duodeno-pancreatic injuries, immediate operative intervention is preferred as associated injuries are frequent and commonly present with hemodynamic instability or peritonitis. The aim of this paper is to present the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) duodenal, pancreatic, and extrahepatic biliary tree trauma management guidelines.

The e-merging e-pidemic of e-scooters.

INTRODUCTION: Since their release in 2017, standing electric motorized scooters (eScooters) have risen in popularity as an alternative mode of transportation. We sought to examine the incidence of injury, injury patterns, prevalence of helmet and drug and alcohol use in eScooter trauma. METHODS: This was a multi-institutional retrospective case series of patients admitted for injuries related to operation of an eScooter following the widespread release of these devices in September 2017 (September 1, 2017 to October 31, 2018). Demographics, drug and alcohol use, helmet use, admission vitals, injuries, procedures, hospital and intensive care unit length of stay (LOS), death, and disposition were analyzed. RESULTS: 103 patients were admitted during the study period, and monthly admissions increased significantly over time. Patients were young men (mean age 37.1 years; 65% male), 98% were not wearing a helmet. Median LOS was 1 day (IQR 1-3). 79% of patients were tested for alcohol and 48% had a blood alcohol level >80 mg/dL. 60% of patients had a urine toxicology screen, of which 52% were positive. Extremity fractures were the most frequent injury (42%), followed by facial fractures (26%) and intracranial hemorrhage (18%). Median Injury Severity Score was 5.5 (IQR 5-9). One-third of patients (n=34) required an operative intervention, the majority of which were open fixations of extremity and facial fractures. No patients died during the study. The majority of patients were discharged home (86%). CONCLUSION: eScooter-related trauma has significantly increased over time. Alcohol and illicit substance use among these patients was common, and helmet use was extremely rare. Significant injuries including intracranial hemorrhage and fractures requiring operative intervention were present in over half (51%) of patients. Interventions aimed at increasing helmet use and discouraging eScooter operation while intoxicated are necessary to reduce the burden of eScooter-related trauma. LEVEL OF EVIDENCE: Level IV.

Renal Trauma Classification and Management: Validating the Revised Renal Injury Grading Scale.

PURPOSE: To better characterize traumatic renal injury a revision to the 1989 American Association for the Surgery of Trauma renal injury scale was proposed in which grade IV includes all collecting system and segmental vascular injuries and grade V includes main renal hilar injury. We sought to validate the 2009 grading scale, emphasizing reclassifications between the 1989 and 2009 versions, and subsequent management. MATERIALS AND METHODS: Patient demographics and renal injury characteristics, computerized tomography imaging, radiology reports and subsequent management were recorded in a prospective trauma database. Multivariable logistic regression models for intervention were compared using 1989 and 2009 grades to evaluate which grading scale better predicted management. RESULTS: Of 256 renal injury cases 56 (21.9%) were reclassified using the revised 2009 scale, including 50 (19.5%) which were upgraded, 6 (2.3%) which were downgraded and 200 (78.1%) which were unchanged. Of grade III or higher cases management was nonoperative in 112 (78.9%), angioembolization in 9 (6.3%), nephrectomy in 9 (6.3%) and renorrhaphy in 12 (8.5%). Management was significantly associated with original and revised grades (chi-square p=0.02 and <0.001, respectively). Further, the multivariable model using the 2009 grades significantly outperformed the 1989 model. Radiology reports rarely included renal injury scales. CONCLUSIONS: Using the revised renal injury grading scale led to more definitive classification of renal injury and a stronger association with renal trauma management. Applying the revised criteria may facilitate and improve the multidisciplinary care of renal trauma.

The EGS grading scale for skin and soft-tissue infections is predictive of poor outcomes: a multicenter validation study.

INTRODUCTION: Over the last 5 years, the American Association for the Surgery of Trauma has developed grading scales for emergency general surgery (EGS) diseases. In a previous validation study using diverticulitis, the grading scales were predictive of complications and length of stay. As EGS encompasses diverse diseases, the purpose of this study was to validate the grading scale concept against a different disease process with a higher associated mortality. We hypothesized that the grading scale would be predictive of complications, length of stay, and mortality in skin and soft-tissue infections (STIs). METHODS: This multi-institutional trial encompassed 12 centers. Data collected included demographic variables, disease characteristics, and outcomes such as mortality, overall complications, and hospital and ICU length of stay. The EGS scale for STI was used to grade each infection and two surgeons graded each case to evaluate inter-rater reliability. RESULTS: 1170 patients were included in this study. Inter-rater reliability was moderate (kappa coefficient 0.472-0.642, with 64-76% agreement). Higher grades (IV and V) corresponded to significantly higher Laboratory Risk Indicator for Necrotizing Fasciitis scores when compared with lower EGS grades. Patients with grade IV and V STI had significantly increased odds of all complications, as well as ICU and overall length of stay. These associations remained significant in logistic regression controlling for age, gender, comorbidities, mental status, and hospital-level volume. Grade V disease was significantly associated with mortality as well. CONCLUSION: This validation effort demonstrates that grade IV and V STI are significantly predictive of complications, hospital length of stay, and mortality. Though predictive ability does not improve linearly with STI grade, this is consistent with the clinical disease process in which lower grades represent cellulitis and abscess and higher grades are invasive infections. This second validation study confirms the EGS grading scale as predictive, and easily used, in disparate disease processes. LEVEL OF EVIDENCE: Prognostic/Epidemiologic retrospective multicenter trial, level III.

The risk of delayed intracranial hemorrhage with direct acting oral anticoagulants after trauma: A two-center study.

BACKGROUND: The aim of this study was to characterize the risk of a delayed intracranial hemorrhage (ICH) in trauma patients on direct-acting oral anticoagulants (DOACs). METHODS: Patients on DOACs admitted to two Level I Trauma Centers between 2014 and 2017 were reviewed. Only patients with a negative admission CT brain were included. The primary outcome was a delayed ICH. RESULTS: Overall, 249 patients were included. The median age was 81 years with 82% undergoing a repeat CT. Three patients developed a delayed ICH (1.2%). One developed an ICH after receiving tissue plasminogen activator for a cerebrovascular accident after two negative CTs. Excluding this patient, the incidence dropped to 0.8%. None required neurosurgical intervention. CONCLUSION: For patients at risk for a TBI who are on DOACs, repeat cross-sectional imaging of the brain when the initial imaging is negative is not necessary. A period of clinical observation may be warranted.

Laboratory measures of coagulation among trauma patients on NOAs: results of the AAST-MIT.

BACKGROUND: Warfarin is associated with poor outcomes after trauma, an effect correlated with elevations in the international normalized ratio (INR). In contrast, the novel oral anticoagulants (NOAs) have no validated laboratory measure to quantify coagulopathy. We sought to determine if use of NOAs was associated with elevated activated partial thromboplastin time (aPTT) or INR levels among trauma patients or increased clotting times on thromboelastography (TEG). METHODS: This was a post-hoc analysis of a prospective observational study across 16 trauma centers. Patients on dabigatran, rivaroxaban, or apixaban were included. Laboratory data were collected at admission and after reversal. Admission labs were compared between medication groups. Traditional measures of coagulopathy were compared with TEG results using Spearman's rank coefficient for correlation. Labs before and after reversal were also analyzed between medication groups. RESULTS: 182 patients were enrolled between June 2013 and July 2015: 50 on dabigatran, 123 on rivaroxaban, and 34 apixaban. INR values were mildly elevated among patients on dabigatran (median 1.3, IQR 1.1-1.4) and rivaroxaban (median 1.3, IQR 1.1-1.6) compared with apixaban (median 1.1, IQR 1.0-1.2). Patients on dabigatran had slightly higher than normal aPTT values (median 35, IQR 29.8-46.3), whereas those on rivaroxaban and apixaban did not. Fifty patients had TEG results. The median values for R, alpha, MA and lysis were normal for all groups. Prothrombin time (PT) and aPTT had a high correlation in all groups (dabigatran p=0.0005, rivaroxaban p<0.0001, and apixaban p<0.0001). aPTT correlated with the R value on TEG in patients on dabigatran (p=0.0094) and rivaroxaban (p=0.0028) but not apixaban (p=0.2532). Reversal occurred in 14%, 25%, and 18% of dabigatran, rivaroxaban, and apixaban patients, respectively. Both traditional measures of coagulopathy and TEG remained within normal limits after reversal. DISCUSSION: Neither traditional measures of coagulation nor TEG were able to detect coagulopathy in patients on NOAs. LEVEL OF EVIDENCE: Level IV.

Improving life expectancy: A 'broken neck' doesn't have to be a terminal diagnosis for the elderly.

BACKGROUND: Elderly patients with cervical spine fractures require optimal care. Treatment with a cervical collar or halo instead of surgical fixation may increase mortality. This investigation intends to describe the life expectancy after injury and evaluate the impact of surgical intervention on mortality. METHODS: Patients ≥65 years, with traumatic cervical spine fractures without cord injury were identified in the 1995-2009 California Office of Statewide Health and Planning database. Those with halo placement or surgical spine fixation were identified. Primary outcome was death, studied at the initial admission, 30 days, 1 year, and the entire study period. Univariate and multivariate regressions were performed to identify predictors of death. Kaplan-Meier survival curves were used to describe life expectancy after injury. RESULTS: 10 938 patients were identified. Mortality rate was 10% during the initial admission, 28% at 1 year and 50% during the entire study period. A halo was placed in 14% of patients and 12% underwent surgical fixation. Mortality rates during the initial admission were 11% for patients without an intervention, 7% with halo placement and 6% with surgical fixation; at 1 year, these increased to 30%, 26% and 19%, respectively. At 1 year, more than one in four patients above 75 years of age will die.At 1 year spine fixation, female gender and admission to a trauma center predicted a lower risk of death at 1 year (OR 0.59, 0.68; p<0.001 and OR 0.89; p=0.02, respectively). Having a complication, fall mechanism, and traumatic brain injury (OR 1.84, 1.33, 1.37; p<0.001, respectively) were predictors of a higher risk of death. Halo use had no impact on death at 1 year (OR 0.98; p=0.77). DISCUSSION: Mortality rates after cervical spine fracture in the elderly is high. Surgical fixation is associated with improved survival; remaining true after adjusting for age and comorbidities; suggesting that surgical fixation may improve outcomes in the elderly. LEVEL OF EVIDENCE: Level IV.