TRAUMA/EDITORIAL

Admit All Anticoagulated Head-Injured Patients? A MillionDollars Versus Your Dime. You Make the Call

James Li, MD

From Miles Memorial Hospital, Damariscotta, ME.

0196-0644/$-see front matterCopyright © 2012 by the American College of Emergency Physicians.doi:10.1016/j.annemergmed.2012.01.010

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[Ann Emerg Med. 2012;59:457-459]

A little more than 10 years ago, Garra et al1 reported thatanticoagulated patients with mild head injuries had no risk ofintracranial hemorrhage. Unfortunately, his conclusion waserroneous. Like quantum fluctuations in empty space, theabsence of brain injuries in his sample of 39 patients did notpreclude the presence of such injuries in reality.2

A few years ago, I signed a patient out to my partner, Arshad,after a long shift. The patient, anticoagulated for atrialfibrillation, had experienced a mild head injury and come to ourdepartment. I had already scanned his head and viewed thenormal results. I gave him some morphine because of theheadache he had as a result of his fall. The morphine relieved hisheadache and he fell asleep. He was waiting for a ride home.

Now Arshad is a physician who doesn’t spend a lot of timereviewing the literature. But he’s got the instincts of a fighterpilot. Despite Arshad’s knowing the patient had received a stiffdose of morphine, the patient’s somnolence bothered him. Soless than an hour after I had left, he ordered a second computedtomography (CT) scan. When the radiology resident refused toperform the scan, Arshad somehow overrode him and got itdone anyway. That decision saved my patient’s life. A fewminutes after the CT scan appeared on screen, the patient wason his way to the operating room for evacuation of a massivesubdural hematoma, one that had developed less than 3 hoursafter his normal initial CT result.

(I also owe Arshad my own life because, around the sametime, he seized 4 consecutive night shifts from me and put meon a plane to Paris, somehow knowing I would meet my futurewife. That’s the kind of guy he is.)

In between these 2 lifesaving events, our group published a2-center retrospective study reversing the conclusion by Garra etal1 that anticoagulated head-injured patients did not requirescanning.3 Our observation that many such patients would haveacute intracranial injuries was subsequently affirmed by at least5 other groups.4-8 The aggregated evidence now quantifies the

risk of acute intracranial hemorrhage in this population at 1 in 6 p

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Table 1), and clinical guidelines recommend head CT for allnticoagulated patients with head trauma.9-11

This is important information, particularly given that neitherhe New Orleans Criteria nor the Canadian CT Head Rulepplied to anticoagulated patients. (The Canadian studyxcluded them and the numbers from New Orleans were toomall to draw conclusions.) It also provides an example of howvidence can evolve to guide recommendations. Improving onnecdote, retrospective observations provide early measures on alinical question. This supplies incentive for better studies.rospective data provide credibility and are synthesized intoecommendations that promote improvements in our practice.

Nevertheless, clinical guidelines themselves often start theirives by anecdote. The 2002 European guideline on mildraumatic brain injury12 recommends that all anticoagulatedead-injured patients be admitted and receive 2 CT scans, one

nitially and a second after 24 hours. This suggestion wasualified by a grade C recommendation (ie, “clinicians mayrovide this service to selected patients depending on individualircumstances”) because it was largely based on a 1996 caseeport of 2 patients.13 Thus, for the past decade Europeanmergency physicians have been offering admission to theirnticoagulated head-injured patients, including those withinor trauma and normal initial CT scan results.In this issue of Annals, Menditto et al8 raise the level of

vidence supporting these European admission guidelines,rospectively measuring the rate of delayed intracranialemorrhage in a sample of anticoagulated head-injured patientsith normal initial CT scan results. During a 3-year period, 7 of7 anticoagulated patients who were rescanned after a mediannterval of 24 hours had new intracranial hemorrhages.

Menditto’s work was performed on the heels of an Italiantudy that found less risk.14 In 2010, Kaen et al14 found delayedemorrhages in 2 of 137 anticoagulated head-injured patients,sing similar methods. Thus, according to aggregated data fromoth studies, delayed hemorrhage may occur in about 1 in 25atients with normal initial CT scan results (Table 2).

These data raise the real question, Do such findings matter?y admitting more patients and ordering more CTs, do we

mprove outcomes? Or do we simply find more things that haveittle clinical importance? Indeed, in Menditto’s sample,8 only 1

atient needed craniotomy. In Kaen’s,14 none did.

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Admitting Anticoagulated Head-Injured Patients Li

On the other hand, we are talking about intracranialhemorrhages, something intrinsically deadlier than incidentallung nodules or bifid vertebrae. The fact that only 1 patientrequired neurosurgery should also be tempered by theknowledge that it took the discovery and evaluation of delayedhemorrhage in 9 patients to determine who neededintervention. This quandary should be familiar to us, for itapplies equally to patients with disorders as varied as myocardialinfarction, stroke, and appendicitis. If we knew who wouldbenefit from admission and who wouldn’t, we wouldn’t beadmitting them all.

That takes us to the question at hand. Do we really need toadmit all head-injured anticoagulated patients for serial CTscans? Indeed, the single patient needing evacuation of hissubdural hematoma was identified only after performing serialCT scans on 224 anticoagulated patients, all of whom wereadmitted for at least 24 hours after a normal initial CT scanresult.

That sounds expensive.To answer such questions, our colleagues in public health use

various measures to provide objective cost comparisons betweeninterventions. One such measure is the cost per year of lifesaved. Rather than putting a value on a person’s life, thismeasure shifts the value comparison to the intervention itself.

Using the data from Menditto et al8 and Kaen et al,14 we cancalculate the cost to extend a patient’s life for 1 year accordingto the European recommendation of admitting and rescanningall anticoagulated head-injured patients. For US patients, thatcost comes to roughly $1 million (Table 3). In comparison,extending a patient’s life by a year with outpatient dialysis costs

Table 1. Risk of immediate intracranial hemorrhage in anticoag

Author Year Study Design

Garra1 1999 Retrospective, 1-centeLi3 2001 Retrospective, 2-centeIbañez4 2004 Prospective, 1-centerFabbri5 2005 Prospective, 1-centerCohen6 2006 Retrospective, 1-centeSmits7 2007 Prospective, 4-centerMenditto8 2012 Prospective, 1-centerSubtotalNumber needed to

treat*

CI, Confidence interval.*These numbers are raw integers.

Table 2. Risk of delayed intracranial hemorrhage in anticoagula

Author Year Study Design

Kaen14 2010 Prospective, 1-centerMenditto8 2012 Prospective, 1-centerSubtotalNumber needed to

treat*

*These numbers are raw integers.

one tenth as much. l

458 Annals of Emergency Medicine

Ironically, in Spain, where one of these studies took place,he same admission and serial scanning intervention costs much

d patients with mild head injuries.

Intracranial Hemorrhage/Sample % 95% CI

0/39 0 0–810/144 7 4–1327/126 21 15–3067/265 25 20–3110/50 20 11–3413/81 16 9–2619/116 16 10–25

158/896 18 15–206 5–7

atients with mild head injuries.

Intracranial Hemorrhage/Sample % 95% CI

2/137 1 0–67/87 8 4–169/224 4 2–8

25 13–50

able 3. Calculations for cost per year of life saved bymplementing European guidelines for admitting all head-njured anticoagulated patients for serial brain scans.*

ntervention Cost, $

tep 1. Average cost for noncontrast head CT scan15

nited States 464pain 117anada 65tep 2. Average cost for 24-h hospital admission15

nited States 3,612pain 470anada 340tep 3. Cost of 2 CT scans�24-h admission�224admissions needed to save 1 patient

nited States 1,016,960pain 157,696anada 105,280ther US-based interventions by cost per year of lifesaved, adjusted for 2011 dollars16

efibrillators in paramedic-staffed ambulances 612neumococcal vaccination in patients �65 y of age 3,454

soniazid therapy for patients with positive tuberculinskin test results

26,690

utpatient dialysis treatment 111,470olonoscopy screening in patients �40 y of age 141,300nnual mammogram in patients aged 40–49 y 298,300

Assumptions: Evacuation of a subdural hematoma is a surrogate marker for aife saved. The patient saved at aged 78 years lived 1 additional year, accordingo a mean life span for Italian men of 79 years.

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Li Admitting Anticoagulated Head-Injured Patients

the United States has major issues with medical value formoney, but that’s another discussion.

So what do we do? Despite the need for cost-effectiveness,our duty is to our individual patients, the ones immediatelyunder our care. Knowing that 1 in 6 anticoagulated head-injured patients is at immediate risk for intracranial hemorrhageis a good start. Regardless of cost analysis, that number neededto treat beats aspirin for infarction, antibiotics for lunginfections, rectal exams for trauma, and nasogastric tubes foranything. Bluntly put, every anticoagulated patient with a headinjury should still get scanned.

But what do we do with the patients who have normal initialscan results?

This exercise challenges our specialty to provide a solutionwhen other health systems might focus on costs or profitability.We know that a group of anticoagulated head-injured patientswith normal initial CT scan results will develop delayedbleeding. Some of these will require craniotomy. Although suchinformation might not compel change in the global health caresystem, it should be sufficient to compel change in the actionsof an individual emergency physician or department.

In our department, we check on our patients by telephonewhen their urine, throat, or blood culture results turn positive.Many departments have similar programs. Like many things wedo, this practice is grounded by anecdote, not evidence. Howmany calls do we make to save a single life? No one knows, butI bet it’s a big number.

Thus we spend a great deal of our time performing follow-upchecks despite the fact that no evidence yet demonstrates anoutcome benefit. Our motivation for doing so is based onsystemized habit, anecdote, and liability. (Case law persuasivelydemonstrates that not doing telephone follow-up is costly, butlaw is a long way from science.)

With this in mind, we are now presented with anoverwhelming reason to call back one category of patients: thehead-injured anticoagulated patient who’s been dischargedhome. Admission, as the Europeans recommend, addresses theneed but disregards the system. That need is high-qualityfollow-up. Hospitalization is a surrogate for this solution, but asothers have pointed out, “admission to the hospital does notguarantee skilled neurologic observation.”17

So here’s a solution that uses no surrogate, works everywhere,and integrates cost-effectiveness with patient outcomes: Just callthem. That’s right. Any anticoagulated head-injured patientwho is discharged from the ED gets a telephone call the nextday. It’s simple, it’s sensible, and it has a couple of prospectivestudies to support it. Patients who are confused, have worseningheadaches, or who just don’t feel right should be invited backfor a second CT.

Arshad would approve.

Supervising editor: Steven M. Green, MD

Funding and support: By Annals policy, all authors are required

to disclose any and all commercial, financial, and other

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elationships in any way related to the subject of this articles per ICMJE conflict of interest guidelines (see www.icmje.rg). The author has stated that no such relationships exist.

ublication date: Available online February 4, 2012.

ddress for correspondence: James Li, MD, E-mailamesli@remotemedicine.org.

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8. Menditto VG, Lucci M, Polonara S, et al. Management of minorhead injury in patients receiving oral anticoagulant therapy: aprospective study of a 24-hour observation protocol. Ann EmergMed. 2012;59:451-455.

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