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Suivi des recommandations sur la prise en charge des traumatisés crâniens légers sous anticoagulants et antiagrégants plaquettaires dans un service d’urgence

Adherence to guidelines for management of minor head injury in patients receiving anticoagulants or antiplatelets in an emergency department

  • Article Original / Original Article
  • Published:
Annales françaises de médecine d'urgence

Résumé

Objectif

La Société française de médecine d’urgence a émis en 2012 des recommandations formalisées d’experts (RFE) sur la prise en charge des traumatismes crâniens légers (TCL). L’objectif principal de notre étude était d’évaluer, chez les patients traumatisés crâniens légers définis par un score de Glasgow compris entre 13 et 15 et sous anticoagulants (AC) ou antiagrégants plaquettaires (AAP), l’adhésion à ces recommandations dans notre service et d’analyser les facteurs influençant une prise en charge conforme ou non conforme. L’objectif secondaire était de réaliser une description de la prise en charge et du devenir de cette population.

Méthode

Étude rétrospective monocentrique sur un an, incluant tous patients adultes sous AC ou AAP ayant présenté un TCL se présentant aux urgences. Ont été étudiés les caractéristiques des patients, leur devenir à J30 en termes de décès intra-hospitalier et de réhospitalisation et les facteurs associés à l’application ou la non-application des recommandations.

Résultats

Cent soixante-quinze patients inclus. Une tomodensitométrie cérébrale (TDMc) a été réalisée chez 97 % des patients en un temps conforme dans 60 % des cas, des anomalies ont été retrouvées chez 20 patients (11 %). Cent pour cent des patients sous antivitamine K (AVK) ont eu un dosage de l’international normalized ratio (INR). La durée de surveillance clinique a été conforme dans 47 % des cas. Deux patients (1 %) sont décédés et deux patients (1 %) ont été ré-hospitalisés à J30 pour cause neurologique. Les facteurs associés à une réalisation de TDMc hors délais étaient : un sexe masculin : OR=3,24 (IC 95 % : [1,07–10,83] ; p=0,04), un traitement par AVK : OR=76,3 (IC 95 % : [2,9–154,1], p=0,01) ou par anticoagulants oraux directs : OR=148,39 (IC 95 % : [7,1–266], p=0,003). Étaient associées à une durée de surveillance conforme : des anomalies à la TDMc : OR=0,08 (IC 95 % : [0,01–0,8], p=0,05) et une hospitalisation post-urgence : OR=0,02 (IC 95 % : [0,01–0,2], p=0,001).

Conclusion

L’application stricte des RFE reste perfectible dans notre service. Cependant, le niveau de preuve des études sur ce thème est discuté. Une mise à jour des RFE nous paraît nécessaire pour préciser la prise en charge de cette population particulière de patients.

Abstract

Aim

In 2012, the French society for emergency medicine issued guidelines for the management of minor head injuries (MHI) with a Glasgow coma scale between 13 and 15. The primary end-point of our study was to evaluate the adherence to these guidelines in our department and to analyze factors influencing a management in conformity or not in patients with MHI treated by anticoagulants (AC) or antiplatelets (AP) agents. The secondary end-point was to provide a description of the management and the becoming of this population.

Procedure

A one-year retrospective monocentric study, including all adult patients treated by AC or AP who presented a MHI coming to emergency department. Characteristics of patients, their becoming at 30 days in terms of intra-hospital mortality and re-hospitalization, and the factors associated with the application or non-application of guidelines were studied.

Results

175 patients included. A CT-scan (CT) was performed in 97% of patients in a congruent time in 60% of cases; abnormalities were found in 20 patients (11%). One hundred percent of patients treated by anti-vitamin K (AVK) had an international normalized ratio measure. The duration of clinical monitoring was congruent in 47% of cases. Two patients (1%) died and two patients (1%) were re-hospitalized within 30 days for neurological reasons. Factors associated with an out-of-delay CTachievement were: male: OR= 3.24 (95%CI: [1.07–10.83], p= 0.04), treatment by AVK: OR= 76.3 (95%CI: 2.9–154.1), p= 0.01) or by direct oral anticoagulants: OR= 148.39 (95% CI [7.1–266], p= 0.003). CT anomalies: OR= 0.08 (95% CI [0.01–0.8], p= 0.05) and post-emergency hospitalization: OR= 0.02 (95% CI: [0.01–0.2], p= 0.001) were associated with a congruent monitoring period.

Conclusion

Strict application of guidelines can be improved in our department. However, levels of proof of studies on this topic are discussed. An update of guidelines seems to be necessary to clarify the management of this particular population of patients.

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Authors and Affiliations

  1. Pôle urgences, centre hospitalier du Forez, 42605, Montbrison, France

    J. Cucuel, Y. Chouhab, P. Parsis, C. Forestier & M. Martinez

  2. Imagerie médicale, centre hospitalier du Forez, 42605, Montbrison, France

    R. Mohammedi

  3. Réseau d’urgence ligérien Ardèche Nord (REULIAN), centre hospitalier Le Corbusier, 42700, Firminy, France

    R. Spiga, A. Redjaline & M. Martinez

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  1. J. Cucuel
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  2. R. Spiga
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  6. C. Forestier
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  8. M. Martinez
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Correspondence to M. Martinez.

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Cucuel, J., Spiga, R., Mohammedi, R. et al. Suivi des recommandations sur la prise en charge des traumatisés crâniens légers sous anticoagulants et antiagrégants plaquettaires dans un service d’urgence. Ann. Fr. Med. Urgence 7, 291–298 (2017). https://doi.org/10.1007/s13341-017-0785-6

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  • DOI: https://doi.org/10.1007/s13341-017-0785-6

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