Oral anticoagulation for stroke prevention in patients with chronic cardiac arrhythmias is well established, and warfarin remains the most common medication in use for this purpose. Newer oral direct thrombin inhibitors such as Dabigatran are approved in the United States, Europe, Australia, and Japan, and their use is growing. Platelet inhibition for a number of cardiovascular and vascular indications is also well established with widespread use of aspirin and Clopidogrel, often in combination. Clearly, polytrauma patients with medication-induced coagulopathy are at an increased risk of hemorrhage, and a large retrospective survey of the California Office of Statewide Planning and Development database over a 14 year period revealed a two fold increase in all-cause mortality following a ground-level fall in elderly patients (age >65) who take oral anticoagulants [33]. Patients with traumatic brain injury are most at risk for the rapid development of life-threatening complications and in the same survey, 31.6 % of those taking oral anticoagulants died with head injury as compared to 23.8 % of patients not anticoagulated. Even patients with injuries limited to fractures, however, can be impacted by delays to surgical reduction, longer hospital stays, and higher rates of disposition to rehabilitation or nursing facilities [34]. Based primarily on work done by Ivascu and colleagues [35, 36], the EAST practice management guidelines committee was able to offer recommendations based on Class III scientific evidence (retrospectively collected data): [37]

Transfusion of thawed fresh-frozen plasma (FFP) and the administration of parenteral vitamin K remain first line therapies for the reversal of the effects of warfarin. The use of FFP in the case of bleeding complications or emergency surgery, however, can be time-consuming and poorly tolerated in elderly patients with limited cardiopulmonary reserve. An appealing alternative is the prothrombin complex concentrate which contains human plasma-derived prothrombin and coagulation factors VII, IX, and X (vitamin K-dependent). These lyophilized products (Kcentra/Beriplex and Octaplex) are standardized to potency, unlike FFP, and can be rapidly administrated at low volumes. Several other plasma-derived coagulation factor concentrates exist (e.g., fibrinogen, antithrombin), and their use, particularly when combined with the rapid diagnostic accuracy of rotational thromboelastometry point-of-care testing, allows a more specific targeting of coagulation deficiencies. As a result, newer treatment algorithms are emerging that could considerably reduce the use of allogeneic blood products [38].

Nearly one third of individuals over the age of 65 will undergo an inpatient surgical procedure during the year before their death [39]. Many of these procedures fall within the scope of acute care surgery, polytrauma, or fracture fixation. Increasingly, these patients present to the hospital with advanced directives, such as a Living Will or Healthcare Power of Attorney, that include “Do Not Resuscitate” (DNR) orders. According to data from the Health and Retirement Study, over two-thirds of people aged 60 and above had an advanced directive at the time of their death in 2010, an increase of more than 50 % over the previous decade [40]. In the emergency care setting, interpreting advanced directives and DNR orders can be complicated. Although they may be specific for listing limitations (e.g., no cardiac compressions, endotracheal intubation, advanced airway management, or defibrillation), they are often vague as to application (e.g., in the event of a terminal illness, or no reasonable hope of functional recovery). The administration of anesthesia alone will expose patients to practices and procedures that might be viewed as “resuscitation.” Additionally, operative interventions and anesthesia may subject patients to new and potentially reversible risks of cardiopulmonary arrest. Policies that automatically suspend DNR orders or other treatment limitations prior to surgery are no longer recommended by the American College of Surgeons or American Society of Anesthesiologists [41, 42]. Rather, a policy of “required reconsideration” is felt to be more appropriate. This process should involve a candid discussion with the patient or the patient’s representative that outlines intraoperative and perioperative risks associated with the surgical procedure as well as an approach for potentially life-threatening problems. Any clarifications of or modifications to the patient’s directives should be documented in the medical record and communicated to other members of the health care team.