Ground Level Fall, Who Do You Call? Appropriate Trauma for Ground-Level Falls on Anticoagulants

Introduction

While most trauma activations are based on mechanism or physiologic parameters, many centers incorporate specific risk factors (e.g., anticoagulant use) to upgrade lower-energy mechanisms. To address concerns about delays in diagnosing and treating traumatic intracranial hemorrhage in high-risk patients, our hospital revised its trauma activation criteria in December 2018. The update designated all anticoagulated patients with evidence of an injury above the clavicles as partial trauma team activation, ensuring an automatic response from the attending trauma surgeon and trauma surgery resident team. We hypothesized that early involvement of the trauma surgery team would be associated with a decrease in the time to critical intervention.

Methods

This is a single-center retrospective cohort study evaluating all ground-level falls on therapeutic anticoagulation or nonacetylsalicylic acid antiplatelet agents with evidence of an injury cephalad to the clavicles that were included in our institutional trauma registry from the beginning of 2014 to the end of 2019. The analysis examined injury incidence and the timeliness of interventions.

Results

Seventy-seven percent of the cohort had minor or no injuries and 38.4% were discharged from the emergency department. The most frequent nonminor injuries were intracranial hemorrhages (9.2%, n = 88), extremity fractures (10.9%, n = 104), and spine fractures (5.6%, n = 53). An emergent intervention was performed in 1.8% of patients (n = 17). After revising the activation criteria, time to computed tomography imaging decreased (average 76.4 ± 63.4 versus 36.8 ± 57.0 min, P < 0.0001); however, time from arrival to intervention for intracranial hemorrhage did not significantly decrease (average 281.5 ± 205.8 versus 230.7 ± 96.5 min, P = 0.36).

Conclusions

Given the low likelihood of urgent or emergent interventions that only a trauma surgeon can perform, trauma surgery team involvement in caring for this anticoagulated low-energy mechanism cohort may not represent an appropriate allocation of center resources. Rather than activating the trauma surgery team, a more selective approach is warranted to mitigate costs, decrease unnecessary charges, and optimize hospital resources. Emergency department protocols for expedited imaging and the rapid involvement of appropriate specialists may be more appropriate than a higher activation level.