Improving outcomes in elderly emergency medicine patients: Directions in geriatric emergency medicine

INTRODUCTION: The number of elderly patients on blood thinning agents has increased dramatically in the last 20 years, creating increased health risk in trauma situations. For this reason, a thorough evaluation of the literature and a study of patient demographics will assist in further delineating the problem and targeting appropriate interventions.;MANUSCRIPT I: Improving Outcomes in Geriatric Emergency Medicine Patients Following Head Trauma: A Review of the Literature.;BACKGROUND: An increasing use of anticoagulant and antiplatelet agents in elderly patients has contributed to increased morbidity and mortality in this population. This risk is exemplified in trauma scenarios, particularly those involving head injury.;OBJECTIVES: To perform an in depth literature review encompassing the research that has been performed to date regarding the management of head trauma in elderly patients on blood-thinning agents.;METHODS: An English-language search was performed using MEDLINE and the keywords ANTICOAGULANT, ANTIPLATELET, WARFARIN, ASPIRIN, PLAVIX, and GERIATRIC, ELDERLY, and TRAUMA, HEAD TRAUMA, FALLS, and HEAD CT, REVERSAL AGENTS. Over 600 articles were found, and these were further narrowed using combinations of the above. Articles were selected based on relevance to emergency medicine and trauma surgery.;RESULTS: Relevant articles are summarized below. The majority of relevant articles were published in emergency medicine and trauma journals with a minority within medical and geriatric subspecialty periodicals. Coumadin was the most widely-studied anticoagulant agent, with fewer articles identified containing aspirin and plavix-related research.;DISCUSSION: Patients on Coumadin have an increased morbidity and mortality in head trauma and generalized trauma scenarios. Aspirin and plavix have a less significant impact, although research remains to be done. Reversal of blood thinning agents with blood products remains a mainstay of treatment, especially the administration of FFP for patients on Coumadin, and the timing and efficacy of follow-up imaging studies remains to be determined.;MANUSCRIPT II: Demographics of Elderly Falters on Blood-thinning Agents Presenting to Large Urban Emergency Department.;BACKGROUND: Falls are an increasing problem among elderly patients on blood thinning agents. Assessment of demographic factors associated with patients who fall may be helpful in determining what interventions can be implemented to decrease and prevent the morbidity and mortality associated with this sensitive population.;METHODS: All patients seen in the ER and evaluated with CT scan for minor head trauma during the time period January, 2008, through January 2010, comprised the initial population. Patients discharged from the ER and patients under the age of 85 were excluded from this initial analysis. Patients were divided into whether or not they were on a blood-thinning agent, and the patients on aspirin, plavix, or Coumadin, or a combination of the three, were compared and contrasted in this initial analysis.;RESULTS: The majority of elderly fallers are female. Mechanism of injury is most commonly trip and fall. Morbidity, in the form of intracranial hemorrhage, appears to be higher for those patients on aspirin, although further research is needed to delineate the significance of these findings. Blood products are administered most frequently in those patients who are expected to undergo a surgical procedure. Discharge disposition quite uniformly is to a higher level of care from admitting social status.;DISCUSSION: No universal guidelines exist for managing patients on blood thinning agents in spite of the fact that they appear to be at increased risk of injury following falls. Further assessment of the demographic characteristics of this population may assist in the development of protocols to more appropriately manage this sensitive population.