148 Preinjury Antithrombotic Therapy and the Elderly TBI Patient

Abstract

Methods We performed a retrospective analysis of elderly TBI patients (>=65 years) with evidence of brain hemorrhage on computed tomography (CT) scan at our institution from 2006-2010. Patient demographics, injury severity, clinical course, length of stay, and disposition were collected. Statistical analyses were performed to compare groups and identify predictors of mortality, complication, infection, neurosurgical intervention, and hemorrhage progression. Results 1552 patients were identified with 543 aspirin only (AO), 97 clopidogrel only (CO), 218 warfarin only (WO), 193 clopidogrel/aspirin (CA), and 501 patients on no antithrombotic medication (NAT). Significant differences existed in abbreviated injury score (AIS) (p=0.012), Glasgow Coma Scale (GCS) score (p=0.013), and Marshall score (p<0.001) at time of presentation. Blood products were administered to reverse coagulopathy in 77.3% of patients. After adjusting for covariates, including medication reversal, antithrombotic use was associated with increased mortality (p=0.03); WO use conferred greater odds of mortality than preinjury use of antiplatelet agents (OR 2.53, p=0.003), which did not influence mortality (p=0.622). Rates of neurosurgical interventions (p=0.677) did not differ between groups. Survivor subset analysis demonstrated that CT-identified hemorrhage progression was not associated with preinjury antithrombotic therapy, nor were rates of complication or infection development, hospital/ICU LOS, ventilator days, or discharge disposition. When stratifying for severe and moderate TBI only, use of antithrombotics did not affect outcomes. Conclusions Preinjury use of warfarin, but not antiplatelet medications, influences survival in elderly patients admitted with TBI. Hemorrhage progression, neurosurgical interventions, and morbidity are not affected. The importance of antithrombotic therapy seems to lie in its impact on initial injury severity, which, in turn, is predictive of increased morbidity and mortality. Learning Objectives By the conclusion of this session, participants should be able to: 1) describe the importance of particular risk factors for poor outcomes amongst elderly TBI patients, 2) discuss, in small groups, potential options for identifying particular at-risk subsegments of this demographic and optimizing their care, and 3) identify strategies to limit wasteful healthcare expenditures in this population.