Delayed Bleeding: The Silent Risk for Seniors

Drs Robert Glatter, Christina L. Shenvi, and Richard D. Shih discuss delayed intracranial hemorrhage among older patients taking preinjury anticoagulants who present with blunt head trauma.
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-TRANSCRIPT-
Robert D. Glatter, MD: Hi. I'm Robert Glatter, medical advisor for Medscape Emergency Medicine. Today, we'll be discussing the results of a new study published in The Journal of Emergency Medicine, looking at the incidence of delayed intracranial hemorrhage among older patients taking preinjury anticoagulants who present to the emergency department (ED) with blunt head trauma.
Joining me today is the lead author of the study, Dr Richard Shih, professor of emergency medicine at Florida Atlantic University. Also joining me is Dr Christina Shenvi, associate professor of emergency medicine at the University of North Carolina (UNC) Chapel Hill, with fellowship training in geriatric emergency medicine.
Welcome to both of you.
Richard D. Shih, MD: Thanks, Rob.
Christina L. Shenvi, MD, PhD, MBA: Thanks. Pleasure to be here.
ICH Study Methodology
Glatter: It's a pleasure to have you. Rich, this is a great study and targeted toward a population we see daily in the emergency department. I want you to describe your methodology, patient selection, and how you went about organizing your study to look at this important finding of delayed intracranial hemorrhage, especially in those on anticoagulants.
Shih: This all started for our research team when we first read the 2012 Annals of Emergency Medicine paper. The first author was Vincenzo Menditto, and he looked at a group of patients that had minor head injury, were anticoagulated, and had negative initial head CTs.
There were about 100 patients, of which about 10 of them did not consent, but they hospitalized all these patients. These were anticoagulated, negative-first head CTs. They hospitalized the patients and then did a routine second CT at about 24 hours. They also followed them for a week, and it turned out a little over 7% of them had delayed head CT.
We were wondering how many delayed intracranial hemorrhages we had missed because current practice for us was that, if patients had a good physical exam, their head CT was normal, and everything looked good, we would send them home.
Because of that, a number of people across the country wanted to verify those findings from the Menditto study. We tried to design a good study to answer that question. We happen to have a very large geriatric population in Florida, and our ED census is very high for age over 65, at nearly 60%.
There are two Level I trauma centers in Palm Beach County. We included a second multicenter hospital, and we prospectively enrolled patients. We know the current state of practice is not to routinely do second CTs, so we followed these patients over time and followed their medical records to try to identify delayed bleeding. That's how we set up our methodology.
Is It Safe to Discharge Patients With Trauma After 24 Hours?
Glatter: For the bulk of these patients with negative head CTs, it's been my practice that when they're stable and they look fine and there's no other apparent, distracting painful trauma, injuries and so forth, they're safe to discharge.
The secondary outcome in your study is interesting: the need for neurosurgical intervention in terms of those with delayed intracranial hemorrhage.
Shih: I do believe that it's certainly not the problem that Menditto described, which is 7%. There are two other prospective studies that have looked at this issue with delayed bleeding on anticoagulants. Both of these also showed a relatively low rate of delayed bleeding, which is between like 0.2% and 1.0%. In our study, it was 0.4%.
The difference in the studies is that Menditto and colleagues routinely did 24-hour head CTs. They admitted everybody. For these other studies, routine head CT was not part of it. My bet is that there is a rate of delayed bleeding somewhere in between that seen in the Menditto study and that in all the other studies.
However, talking about significant intracranial hemorrhage, ones that perhaps need neurosurgery, I believe most of them are not significant. There's some number that do occur, but the vast majority of those probably don't need neurosurgery. We had 14 delayed bleeds out of 6000 patients with head trauma. One of them ended up requiring neurosurgery, so the answer is not zero, but I don't think it's 7% either.
Glatter: Dr Shenvi, I want to bring you into the conversation to talk about your experience at UNC, and how you run things in terms of older patients with blunt head trauma on preinjury anticoagulants.
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