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7th January 2022
The incidence of intrathoracic bleeding seen in an emergency department (ED) after elderly patients sustain a rib fracture due to a fall, is similar whether patients have been prescribed a direct oral anticoagulant (DOAC) or a vitamin K antagonist (VKA) such as warfarin. This was the conclusion of a study undertaken by researchers from the Department of Emergency Medicine, Hospital of Merano, Verona, Italy.
Falls are the leading cause of ED presentations in people aged 60 years and older, accounting for almost 50% of all incident injury presentations. Thoracic trauma which is associated with blunt or penetrating injury is a major cause of hospitalisation throughout the world and accounts for 10–15% of all traumas with 23.9% of these patients experiencing one or two rib fractures.
The incidence of intrathoracic bleeding after rib fractures remains uncertain and the extent to which any bleeding is associated with the type of anticoagulation taken is also unclear. For the present study, the researchers wanted to examine whether preinjury treatment with either VKAs or DOACs had an effect on the incidence of complications, such as bleeding, among elderly patients who experienced blunt thoracic trauma after a fall. They undertook a retrospective, observational study and included patients aged 75 years and older receiving oral anti-coagulants and who were found to have sustained at least one rib fracture due to a blunt chest trauma during their ED evaluation. Patients who trauma was caused by a car accident, who had a penetrating chest trauma, experienced severe changes in consciousness or who were haemodynamically unstable were excluded. Eligible patients were then divided into two groups: those taking a DOAC and those prescribed a VKA and both clinical and demographic data was collected for all patients. Regression analysis was used to determine which, if any clinical of demographic factors were associated with the risk of bleeding.
Over a 2-year period, 342 patients with a median age of 84 years (gender not reported) met the eligibility criteria for inclusion, of whom, 38.9% were treated with DOACs. There were a total of 24 (7%) of patients who presented with intrathoracic bleeding of which 17 (5%) required a surgical intervention or died because of their bleeding.
Overall, 4.5% of patients taking a DOAC developed intra-thoracic bleeding after rib fractures compared to 8.6% of those taking a VKA (p = 0.19). In addition, 4.5% of DOAC and 4.3% of VKA patients required surgery or died due to their bleed (p = 0.98).
Using regression analysis, the authors reported that the most significant factors associated with a bleed were age (p = 0.045), the presence of chronic heart failure (p = 0.046), chronic renal failure (p = 0.012), the number of rib fractures (p < 0.001), a high injury severity score (p < 0.001) and dangerous trauma dynamics (p < 0.001). Furthermore, none of these factors were affected by the type of anticoagulant taken.
Commenting on these results, the authors suggested that DOACs and VKAs presented a comparable risk for intra-thoracic bleeding, concluding that the risk of bleeding in the elderly prescribed anticoagulants and sustaining a non-severe trauma appeared to be low.
Turcato G et al. Safety and differences between direct oral anticoagulants and vitamin K antagonists in the risk of post-traumatic intrathoracic bleeding after rib fractures in elderly patients Emergency Care Journal 2021