Incidence of intracranial bleeding in seniors presenting to the emergency department after a fall: A systematic review

Wit, Kerstin de; Merali, Zahra; Kagoma, Yoan K.; Mercier, Éric

doi:10.1016/j.injury.2019.12.036

Cited by 27 publications

(17 citation statements)

References 28 publications

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“…In the validation of the NEXUS head CT rule, 8.9% of patients older than 65 years (331 of 3705 patients) had a clinically significant injury on CT. 14 The incidence of ICH we found is similar to that of a 2020 systematic review that reported a 5% incidence of ICH in patients older than 65 years who had a fall. 15 A meta-analysis of 4080 patients on anticoagulants (98.3% on warfarin) and with head injuries reported an 8.9% incidence of ICH, which is similar to the 8.2% incidence of ICH we found in patients on warfarin. 5 Unique ED visits for head injury n = 82 431…”

Section: Discussionsupporting

confidence: 68%

Intracranial hemorrhage after head injury among older patients on anticoagulation seen in the emergency department: a population-based cohort study

Grewal

Atzema

Austin

et al. 2021

CMAJ

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alls resulting in a head injury are common among older adults. 1,2 Advanced age and anticoagulation are thought to be associated with an increased risk of intracranial hemorrhage (ICH) after a head injury. [3][4][5] With the aging population and increasing use of anticoagulants, older patients on anticoagulation are commonly seen in the emergency department after a head injury. The Canadian CT Head Rule suggests that patients presenting to the emergency department with a minor head injury who are older than 65 years should undergo head imaging to rule out ICH. 6 This clinical decision tool did not include patients on anticoagulation; however, a clinical policy from the American College of Emergency Physician suggests computed tomography (CT) imaging for these patients. 7 Before 2010, warfarin, a vitamin K antagonist, was the oral anticoagulant used most commonly in North America. Since then, direct oral anticoagulants (DOACs) have been approved for various indications including treatment of venous thromboembolism, prevention of venous thromboembolism after arthroplasty, and stroke prophylaxis in patients with atrial fibrillation. Unlike warfarin, DOACs either directly inhibit clotting factors II (e.g., dabigatran) or X (e.g., apixaban, rivaroxaban, edoxaban). Although more expensive than warfarin, DOACs are attractive alternatives

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Section: Discussionsupporting

confidence: 68%

Intracranial hemorrhage after head injury among older patients on anticoagulation seen in the emergency department: a population-based cohort study

Grewal

Atzema

Austin

et al. 2021

CMAJ

Self Cite

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“…7,8 A systematic review by de Wit et al identi ed a pooled incidence of 5.2% from 11 studies which speci cally looked at patients aged 65 years or above who presented to the ED following a fall. 9 Although our study speci cally selected only patients from RACF (and could potentially represent a more frail cohort at risk for ICH than those reported elsewhere) our ndings appear comparable, with yields of 3.7% in the pre-implementation period and 5.6% during the post implementation period, with the latter possibly being attributable to the more targeted scanning strategy as a result of the intervention. A low baseline yield within this sub-population of ED attendees could, however, also be affected by a potentially greater tendency for RACF residents to be referred to hospital following a fall compared to patients who self-present from the community.…”

Section: Discussionsupporting

confidence: 49%

Impact of the Canadian CT Head Rule Supplemented by the Original Published Minimum Inclusion Criteria to Assist Emergency Department Clinicians’ Assessment of Patients Presenting Post Fall From Residential Aged Care: a Retrospective Audit

Lee

Beavers

Pham

et al. 2022

Preprint

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Background A large number of CT brain (CTB) scans are ordered in the ED for older patients with a confirmed or possible head strike but no ongoing symptoms of a head injury. This study aimed to evaluate the effect of the Canadian CT head rule supplemented by the original published minimum inclusion criteria to assist clinician assessment of the need for CTB following minimal trauma fall in patients presenting from residential aged care facilities (RACF) to a major metropolitan emergency department (ED). Methods This study was conducted as a pre- and post-intervention retrospective audit. The intervention involved implementation of a decision support tool to help clinicians assess patients presenting to the ED following a fall. The tool integrated the Canadian CT Head Rule (CCHR) in conjunction with a simplified set of inclusion criteria to help clinicians define a minimum threshold for a “minor head injury”. Outcome data pertaining to CT brain ordering practices and results were compared over symmetrical 3-month time periods pre- and post-intervention in 2 consecutive years. Results The study included 233 patients in the pre-intervention arm and 241 in the post-intervention arm. Baseline demographics and clinical characteristics were similar in both groups. There was a 20% reduction in the total number of CTB scans ordered following tool implementation, with 134 (57.0%) scans in the pre-intervention group and 90 (37.3%) in the post-intervention group (p < 0.01). The diagnostic yield in the pre- and post-intervention groups was 3.7% and 5.6% respectively (p = 0.52). No variation was observed in medical management between groups, and no patients in either group underwent neurosurgical intervention. Conclusions Use of the CCHR supplemented by the original published minimum inclusion criteria appeared to safely reduce the number of CTB scans performed in RACF residents presenting to an ED after a fall, with no associated adverse outcomes. A larger study across multiple centres is required to determine widespread efficacy and safety of this tool.

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“…In the medically compromised population, impaired mobility, sight, and stability often lead to injuries due to falls and traffic accidents. On the basis of studies describing the impact of anticoagulant use on brain injuries [ 13 , 14 , 15 , 16 ], we assumed that riders of E-bikes and P-scooters who used anticoagulants would have higher rates of morbidity and hospitalization than riders who did not [ 13 , 14 , 15 , 16 ]. However, the results show no such effect of anticoagulant use.…”

Section: Discussionmentioning

confidence: 99%

“…The widespread use of direct oral anticoagulants has outpaced research efforts to establish their effects in patients with bleeding traumatic injuries [ 15 ]. Most of the available studies focused on intracranial hemorrhage without assessing the need for hospital admission [ 13 , 14 , 15 , 16 ].…”

Section: Introductionmentioning

confidence: 99%

Impact of Comorbidities on Hospitalization for Injuries in Riders of Electric Bikes and Powered Scooters: A Retrospective Cross-Sectional Study

et al. 2022

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Background and Objectives: Injuries associated with electric bikes (E-bikes) and powered scooters (P-scooters) have increased yearly worldwide. We aimed to evaluate the impact of pre-existing comorbidities on the probability of hospitalization for injuries in riders of E-bikes and P-scooters. Materials and Methods: A retrospective cross-sectional study design was used. The cohort included patients referred to the emergency department (ED) of a tertiary medical center in 2014–2020 for injuries sustained while riding an E-bike or P-scooter. Data were collected from the medical files on demographics, clinical characteristics including pre-existing comorbidities and permanent use of medications, and injury characteristics. Findings were compared between patients referred for hospitalization from the ED and patients discharged home. Results: Of the 1234 patients who met the inclusion criteria, 202 (16.4%) had a prior medical condition and 167 (13.5%) were taking medication on a permanent basis. A significant relationship was found between hospitalization and having a medical condition (𝜒2(1) = 9.20, p = 0.002) or taking medication on a permanent basis (𝜒2(1) = 6.24, p = 0.01). Hospitalization for injuries was more likely in patients with a comorbidity (27.8%) than those without a comorbidity (15.5%), and in patients who were on permanent drug therapy (22.2%) than in patients who were not (12.9%). Surprisingly, anticoagulant intake specifically had no effect on the probability of hospital admission. Conclusions: Patients with comorbidities have a higher incidence of hospitalization for E-bike- and P-scooter-associated injuries. Therefore, physicians may take into account comorbidities for the effective management of this patient group’s injuries.

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Incidence of intracranial bleeding in seniors presenting to the emergency department after a fall: A systematic review

Cited by 27 publications

References 28 publications

Intracranial hemorrhage after head injury among older patients on anticoagulation seen in the emergency department: a population-based cohort study

Intracranial hemorrhage after head injury among older patients on anticoagulation seen in the emergency department: a population-based cohort study

Impact of the Canadian CT Head Rule Supplemented by the Original Published Minimum Inclusion Criteria to Assist Emergency Department Clinicians’ Assessment of Patients Presenting Post Fall From Residential Aged Care: a Retrospective Audit

Impact of Comorbidities on Hospitalization for Injuries in Riders of Electric Bikes and Powered Scooters: A Retrospective Cross-Sectional Study

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