Aspirin is of great value in preventing cardiovascular events and is commonly used.(2, 4) In the management of trauma patients, the bleeding tendency related to aspirin should be a major concern. However, if the injury patterns or injured organs are not specified, the evaluation of the effect of preinjury aspirin intake on bleeding risk would be fuzzy. The treatment modalities are somewhat diverse among various target organs in trauma. Careful reviews for specific body regions are necessary. For instance, it is difficult to manage ICH in the presence of platelet dysfunction or coagulopathy since one can neither use packing to apply pressure to the brain parenchyma nor employ angioembolization. Thus, the influence of aspirin on brain injury would not be the same as that on blunt abdominal trauma.
Literature reviews have reported that patients with preinjury aspirin have mortality rates comparable to those of nonaspirin controls.(15–17) Ferraris et al. reported that bleeding risk is not increased in antiplatelet-treated patients presenting with trauma. The researchers regarded the result as less potent platelet inhibition while using aspirin monotherapy.(1) For patients with head injury, aspirin monotherapy would not influence the risk of ICH, the need for surgical interventions or the mortality rate.(18–20) There is no strong evidence showing the benefit of reversing platelet function by transfusion in traumatic ICH patients.(21–24) Regarding non-head injuries, the available studies have reported that aspirin does not increase overall mortality or the need for blood transfusions.(15–17, 25) Regarding chest trauma, one series demonstrated that antiplatelet or anticoagulation drugs did not increase the complications of hemothorax in blunt chest wall trauma.(26) On the other hand, regarding pelvic fractures, Christy et al. found that antiplatelet therapy was associated with increased blood transfusions but not mortality or morbidity.(27) Therefore, it remains controversial whether preinjury aspirin might increase the difficulty of hemostasis.
Practically, patients sustaining trauma insults are relatively younger and healthy. The incidence of APAC use is low, which yields insufficient case numbers to conduct such research. Therefore, to date, most studies that address the impact of APAC on trauma are small case series. In the current population-based study, liver or spleen injuries were focused upon in a nationwide patient population, which can reflect the real-world situation. In addition, the current study excluded all other APAC drugs and dealt with aspirin only. Thus, the influence of aspirin could be clearly evaluated. The current study revealed that preinjury aspirin use does not increase the need for hemostatic interventions for blunt hepatic or splenic injuries. Indeed, multiple abdominal organ involvement and severity of trauma per se may be the major determinants for angioembolizations or operations. Regarding surgical treatments specifically, patients with preinjury aspirin intake did not require more operations than the PSM control group. It seems that nonoperative management can be safely performed in these patients. Furthermore, the amount of blood transfusion was similar between the preinjury aspirin and control groups without affecting the prognosis. Though not direct evidence, this has suggested that aggressive reversal of functional platelets by transfusions would not be beneficial in blunt abdominal trauma. Based on this study, the current treatment algorithm for blunt hepatic or splenic injuries would be applicable to patients with preinjury aspirin use, and this could be fundamental evidence for trauma treatment in the growing population of individuals taking aspirin.
In patients with chronic diseases, each APAC drug has its own characteristics, and combination use is also common. A large diversity exists among the selections of APAC drugs, including APAC monotherapy only or combination prescription. Understanding the features of each drug and each combination may be valuable for daily practice. Aspirin plays a fundamental role in such medications. Measurement of platelet and coagulation function could be a method. Attempts have been made to utilize laboratory examinations to quantify platelet function and predict clinical outcomes for trauma patients. However, the ability of various assays to detect preinjury aspirin use or predict clinical outcomes has remained controversial.(6, 28, 29)
There were several limitations of the study. First, information on patient compliance with the medication was not accessible in the database. Second, the dosage of aspirin and the degree of platelet inhibition were not assessed. Further investigation can be carried out to determine the effects of dosage and the degree of platelet inhibition. Last, the current study did not evaluate all intra-abdominal organs. The liver and spleen were the most commonly involved organs in blunt abdominal trauma and presented with hemorrhage. Injuries to the pancreas, bowel and mesentery, bladder, and diaphragm would pose problems other than bleeding. Kidneys are retroperitoneal structures and should be discussed separately.