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Abstract

Introduction: Nonoperative management (NOM) of solid organ injury is commonly practiced; however data is limited in the geriatric population. The hypothesis is that failure of NOM is common in the geriatric population, due to elderly patients on preinjury anticoagulant and antiplatelet agents due to comorbidities. Methods: This is a retrospective analysis of 10 years of geriatric trauma patients that sustained solid organ injury at a single 591 bed trauma center that sees an above average amount of geriatric trauma. Inclusion criteria include age ≥ 65 years old, having sustained trauma, and solid organ injury. Data was collected from the Trauma One database and chart review which included demographics, comorbidities, transfusions, preinjury anticoagulants, associated injuries and outcomes. Results: Thirty-six geriatric trauma patients were identified across a 10 year period with a mean age of 77.7 years and 58.3% males. Medical comorbidities included hypertension (61%), coronary artery disease (30%) and diabetes (16%). The mechanisms of injury were all blunt: fall from standing (50%), motor vehicle related (27.8%) and fall from height (22.2%). The organs injured included spleen (61.1%), adrenal (27.8%), kidney (25.0%) and liver (22.2%), which includes 8.8% patients with multiple organs injured. The most common associated injuries were rib fractures (66.7%), lower extremity fracture (27.8%), spine injury (19.4%), head injury (13.9%), and pelvic fracture (11.1%). Overall, 19.4% of the patients preinjury were on aspirin, 16.7% on clopidogrel, 16.7% on warfarin and none on dabigatran. All patients were managed in the Surgical Intensive Care Unit with appropriate invasive and noninvasive monitoring. The transfusion of blood products was common, with 47.2% requiring transfusion of packed red blood cells, 63.9% receving fresh frozen plasma and 8.3% receiving platelets. NOM was successful in 74.9% of patients, which includes 5.5% receiving an angioembolization. 25% of patients required surgery, with 19.4% of the operations immediate, and 5.5% were delayed in response to failure of NOM. Of the failures, one was for a spleen, and the other a liver injury. Of the 7 patients requiring emergent surgery, 5 were on no anticoagulation, one was on warfarin, and the other on both aspririn and clopidogrel. Of the 2 delayed failures of NOM, one was on no anticoagulant or antiplatelet agents, and the other was on warfarin. The mean length of stay was 11.4 days. Overall mortality was 13.8%. Conclusions: Despite a high rate of preinjury anticoagulant use, NOM can be safely accomplished in the geriatric population with appropriate supportive care in the critical care setting. Outcomes are consistent with previous studies in younger patient populations. Preinjury exposure to anticaogulation is not an absolute contraindication to a nonoperative approach in this high risk population. As a group, a high rate of transfusion is observed, particularly of fresh frozen plasma.