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


Submitted: 16 November 2021
Accepted: 23 November 2021
Published: 20 December 2021
Abstract Views: 2771
PDF: 220
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Authors

Closed chest traumas are frequent consequences of falls in the elderly. The presence of concomitant oral anticoagulant therapy can increase the risk of post-traumatic bleeding even in cases of trauma with non-severe dynamics. There is limited information about the differences between vitamin K antagonists and direct oral anticoagulants in the risk of post-traumatic bleeding. To assess differences in the risk of developing intra-thoracic hemorrhages after chest trauma with at least one rib fracture caused by an accidental fall in patients over 75 years of age taking oral anticoagulant therapy. This study involved data from four emergency departments over two years. All patients on oral anticoagulant therapy and over 75 years of age who reported a closed thoracic trauma with at least one rib fracture were retrospectively evaluated. Patients were divided into two study groups according their anticoagulant therapy. Of the 342 patients included in the study, 38.9% (133/342) were treated with direct oral anticoagulants and 61.1% (209/342) were treated with vitamin K antagonist. A total of 7% (24/342) of patients presented intrathoracic bleeding, while 5% (17/342) required surgery or died as a result for the trauma. Posttraumatic intrathoracic bleeding occurred in 4.5% (6/133) of patients receiving direct oral anticoagulants and 8.6% (18/209) of patients receiving vitamin K antagonist. Logistic regression analysis, revealed no difference in the risk of intrathoracic haemorrhages between the two studied groups. Direct oral anticoagulants therapy presents a risk of post-traumatic intrathoracic haemorrhage comparable to that of vitamin K antagonist therapy.


Barker A, Cameron P, Flicker L, et al. Evaluation of RESPOND, a patient-centred program to prevent falls in older people presenting to the emergency department with a fall: A randomised controlled trial. PLoS Med 2019;16:e1002807. DOI: https://doi.org/10.1371/journal.pmed.1002807

Joyce M.F, Gupta A, Azocar R.J. Acute trauma and multiple injuries in the elderly population. Curr Opin Anaesthesiol 2015;28:145-50. DOI: https://doi.org/10.1097/ACO.0000000000000173

Reske-Nielsen C, Medzon R. Geriatric trauma. Emerg Med Clin North Am 2016;34:483-500. DOI: https://doi.org/10.1016/j.emc.2016.04.004

Demirhan R, Onan B, Oz B, Halezeroglu S. Comprehensive analysis of 4205 patients with chest trauma: a 10-year experience. Interact Cardiovasc Thorac Surg 2009;9:450-3. DOI: https://doi.org/10.1510/icvts.2009.206599

Marasco S, Lee G, Summerhayes R, Fitzgerald M, Bailey M. Quality of life after major trauma with multiple rib fractures. Injury 2015;46:61-5. DOI: https://doi.org/10.1016/j.injury.2014.06.014

Boris K, Forat S, Itmar A, et al. Increasing number of fractured ribs is not predictive of the severity of splenic injury following blunt trauma: an analysis of a National Trauma Registry database. Injury 2014;45:855-8. DOI: https://doi.org/10.1016/j.injury.2013.12.011

Dennis BM, Bellister SA, Guillamondegui OD. Thoracic trauma. Surg Clin North Am 2017;97:1047-64. DOI: https://doi.org/10.1016/j.suc.2017.06.009

Battle C, Hutchings H, Evans P.A. Risk factors that predict mortality in patients with blunt chest wall trauma: a systematic review and meta-analysis. Injury 2012;43:8-17. DOI: https://doi.org/10.1016/j.injury.2011.01.004

Battle C, Hutchings H, James K, Evans P.A. The risk factors for the development of complications during the recovery phase. Injury 2013;44:1171-6. DOI: https://doi.org/10.1016/j.injury.2012.05.019

Ahmed N, Yen-Hong K. Evaluating the outcomes of blunt thoracic trauma in elderly patients following a fall from a ground level: higher level care institution vs. lower level care institution. Eur J Trauma Emerg Surg 2021;47:955-63. DOI: https://doi.org/10.1007/s00068-019-01230-1

Čapov I, Peštál A, Reška M, et al. Assessment of thoracic trauma at the 1st Department of Surgery in Brno (1 January 2011 - 31 December 2015). Rozhl Chir Winter 2017;96:504-9.

Storlarski AE, Miller CP, Ata A, et al. Outcomes of preinjury anticoagulation in patients with traumatic rib fractures. Am J Surg 2019;217:29-33. DOI: https://doi.org/10.1016/j.amjsurg.2018.06.007

Levy JH, Spyropoulos AC, Samama CM, Douketis J. Direct oral anticoagulants: new drugs and new concepts. JACC Cardiovasc Interv 2014;7:1333-51. DOI: https://doi.org/10.1016/j.jcin.2014.06.014

Febres LMS, Manteca JC. Direct oral anticoagulants in the treatment of venous thromboembolic disease. Ann Vasc Surg 2017;42:337-50. DOI: https://doi.org/10.1016/j.avsg.2017.01.010

Kim HM, Choi E, Park CS, et al. Effectiveness and safety of non-vitamin K antagonist oral anticoagulants in octogenarian patients with non-valvular atrial fibrillation. PLoS One 2019;14:e0211766. DOI: https://doi.org/10.1371/journal.pone.0211766

von Heymann C, Rosenthal C, Kaufner L, Sander M. Management of direct oral anticoagulants-associated bleeding in the trauma patient. Curr Opin Anaesthesiol 2016;29:220-8. DOI: https://doi.org/10.1097/ACO.0000000000000294

Turcato G, Zannoni M, Zaboli A, et al. Direct oral anticoagulant treatment and mild traumatic brain injury: Risk of early and delayed bleeding and the severity of injuries compared with vitamin K antagonists. J Emerg Med 2019;57:817-24. DOI: https://doi.org/10.1016/j.jemermed.2019.09.007

Grandone E, Ostuni A, Tiscia GL, et al. Management of patients taking oral anticoagulants who need urgent surgery for hip fracture. Semin Thromb Hemost 2019;45:164-70. DOI: https://doi.org/10.1055/s-0039-1678718

Stöllberger C. Drug interactions with new oral anticoagulants in elderly patients. Expert Rev Clin Pharmacol 2017;10:1191-202. DOI: https://doi.org/10.1080/17512433.2017.1370369

Turcato G, Zaboli A, Zannoni M, et al. Risk factors associated with intracranial bleeding and neurosurgery in patients with mild traumatic brain injury who are receiving direct oral anticoagulants. Am J Emerg Med 2021;43:180-5. DOI: https://doi.org/10.1016/j.ajem.2020.02.046

Battle C, Hutchings H, Bouamra O, Evans PA. The effect of pre-injury anti-platelet therapy on the development of complications in isolated blunt chest wall trauma: a retrospective study. PLoS One 2014;9:e91284. DOI: https://doi.org/10.1371/journal.pone.0091284

Feeney JM, Neulander M, DiFiori M, et al. Direct oral anticoagulants compared with warfarin in patients with severe blunt trauma. Injury 2017;48:47-50. DOI: https://doi.org/10.1016/j.injury.2016.08.016

Spinola M.B, Riccardi A, Minuto P, et al. Hemorrhagic risk and intracranial complications in patients with minor head injury (MHI) taking different oral anticoagulants. Am J Emerg Med 2019;37:1677-80. DOI: https://doi.org/10.1016/j.ajem.2018.12.003

Cipriano A, Pecori A, Bionda AE, et al. Intracranial hemorrhage in anticoagulated patients with mild traumatic brain injury: Significant differences between direct oral anticoagulants and vitamin K antagonists. Intern Emerg Med 2018;13:1077-87. DOI: https://doi.org/10.1007/s11739-018-1806-1

Turcato, G., Zaboli, A., Tenci, A., Ricci, G., Zannoni, M., Scheurer, C., Wieser, A., Maccagnani, A., Bonora, A., & Pfeifer, N. (2021). 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, 17(4). https://doi.org/10.4081/ecj.2021.10284

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