Objective
Oral anticoagulant (OAC) use increases the risk of death in conditions like hemorrhagic stroke, trauma, and traumatic brain injury. Early identification of OAC use is critical for timely interventions to mitigate hemorrhage risk and improve survival. We aimed to identify emergency medical services (EMS) care characteristics associated with patients using an OAC.
Methods
We analyzed prehospital data (2018–2020) from the ESO Data Collaborative, focusing on adult (≥18 years) 911 EMS calls. The administered OACs were warfarin, dabigatran, rivaroxaban, and apixaban. We compared EMS call characteristics, patient demographics, response times, and interventions between OAC and non-OAC users. We used univariate logistic regression to identify independent predictors of OAC use.
Results
Of 16,244,550 adult 911 EMS events, 906,575 involved OAC users (56 of 1,000 calls). Those using OAC were older (73.6 years vs. 56.9 years) and more often from nursing homes or long-term care facilities (17.0% vs. 9.2%) but less likely to have trauma (14.7% vs. 18.1%) or cardiac arrest (1.2% vs. 1.4%). The most common EMS primary clinical impressions for OAC users were chest pain (7.4%), altered mental status (7.3%), injury (6.5%), abdominal pain (4.3%), and brain injury (2.8%).
Conclusion
OAC users accounted for 1 in 18 adult EMS encounters. Specific patient and call characteristics were associated with OAC use. These findings should be incorporated into EMS training to facilitate recognition and appropriate management of OAC-related emergencies.

Objective
This study aimed to investigate the relationship between abnormal intracranial findings on brain computed tomography and antiplatelet or anticoagulant use in patients with nontraumatic headache in the emergency department (ED).
Methods
This was a single-center prospective observational study of patients admitted to the tertiary ED with complaints of nontraumatic headache between May 1, 2016 and September 1, 2016. Anticoagulant or antiplatelet drug use by the patient was recorded. Brain computed tomography (CT) results were categorized into two groups, abnormal results (CT positive) and no pathologic results (CT negative), and compared. The CT positive group included any pathological signs in the brain and the negative group was considered a normal read. A logistic regression analysis was used for evaluating the association of antiplatelets and anticoagulants with abnormal CT findings.
Results
Of the 837 patients with nontraumatic headaches, 157 (18.8%) patients who underwent brain CT scanning were included. The mean age of the patients was 44.4±16.7 years. Eighty-eight (56.1%) of the patients were women. Of the 29 (18.4%) patients using antiplatelets or anticoagulants, 16 (55.2%) were in the CT positive group. There was a statistically significant difference between both groups in terms of drug use compared to the CT negative group (P<0.001). Factors affecting CT results were examined in logistic regression analysis and a statistically significant difference was found in the detection of positive results in antiplatelet or anticoagulant drug users (adjusted odds ratio, 2.478; 95% confidence interval, 1.006–6.102; P=0.048).
Conclusion
The use of antiplatelets or anticoagulants in patients admitted to the ED with nontraumatic headache is associated with an increased risk of abnormal intracranial results in brain CT.

Objective
Four-factor prothrombin complex concentrate (4F-PCC) was approved by the US Food and Drug Administration in 2013 for management of severely bleeding patients on warfarin therapy. We describe use of 4F-PCC at a large, suburban academic center.
Methods
We retrospectively reviewed all patients receiving 4F-PCC from its introduction through 2016 at a large level 1 trauma center. Clinical and demographic data were obtained, including indications for anticoagulation and antiplatelet agents, comorbidities, concomitant medications, etiology and site of bleeding, as well as disposition, length of stay, mortality, and thrombotic events.
Results
One hundred eighty-four patients received 4F-PCC. Mean age was 72 years; 40.8% were female. Indications for 4F-PCC administration included: active bleeding (74%), reversal prior to a procedure (14%), and elevated international normalized ratio (12%). Warfarin was the most common concomitant medication (71.1%). Most patients were receiving anticoagulation for atrial fibrillation (63%). Concomitant treatments for bleeding included vitamin K (58.2%), packed red blood cells (50%), fresh frozen plasma (38%), and platelets (26.1%), amongst others. Median length of hospital stay was 8.4 days. Nine patients (4.9%) developed thrombosis within 90 days of 4F-PCC. Mortality was 24.5%, with notably higher rates amongst those who received 4F-PCC for off-label indications (19.1% on-label mortality vs. 37.7% off-label mortality on chi-square analysis, P=0.01).
Conclusion
This study demonstrates that 4F-PCC is being utilized for indications other than the reversal of warfarin-induced coagulopathy. Further investigation is warranted to determine the efficacy and safety of 4F-PCC for these potential indications.