All posts by TheTraumaPro

DVT Prophylaxis At Home: Do Our Patients Do What They Are Told?

Deep venous thrombosis (DVT) is a big potential problem for many trauma patients, particularly those with orthopedic injuries. Patients at high risk are frequently given a prophylaxis regimen to take home after discharge while they are still at higher risk for clots. The particular choice of medication typically comes down to oral (warfarin or aspirin) vs injectable (low molecular weight heparin (LMWH)).

There is quite a bit of literature on patient compliance with their medication routines, or should I say noncompliance? The group at ShockTrauma in Baltimore evaluated how well orthopedic surgery patients adhered to their prescribed DVT prophylaxis schedule after discharge.

They conducted a randomized, prospective trial on all patients who underwent operative management of extremity or pelvic fractures. These patients were prescribed either oral low dose aspirin (81mg) or subcutaneous injections of LMWH (30mg bid). All completed a standardized 8-question tool to gauge their compliance with the medication regimen. Nicely, a power analysis was performed to identify the minimum number of patients needed to achieve statistical significance ( 126 total patients).

Here are the factoids:

  • Of 1450 potential patients undergoing operative fracture fixation, 329 were eligible for the study. All but 150 were excluded primarily due to no need for prophylaxis or inability to contact.
  • Overall adherence to the prophylaxis plan was fairly high, with 65% of patients having high adherence, 21% medium, and 20% low.
  • A quarter of the LMWH patients felt “hassled” by their regimen, while only 9% of the aspirin group did
  • LMWH prophylaxis was associated with low or medium adherence
  • Having to self-administer the prophylactic agent, being a male, and young was also associated with lower compliance

Bottom line: Interesting study. And unfortunately it suggests that our patients don’t always do what they are told, especially if they have to stick themselves with needles. So they may not be getting the prophylaxis we think they are. Furthermore, we’re not even sure if aspirin (or LMWH for that matter) make a difference in the incidence of death or major pulmonary embolism in these patients.

There are a lot of opportunities for mayhem in this study. A third of the enrolled patients were not even compliant with completing the survey. This is certainly a source of bias, and most likely suggests that the overall compliance rates would have been even lower if they had. 

Keep in mind the risk factors for compliance (age, sex, drug route) when deciding how and what to provide for DVT prophylaxis. Your patient may not be doing what you assume they are!

The March 2018 Trauma MedEd Newsletter Is Here!

Welcome to the current newsletter. In this one, I discuss the use of a “hybrid room” for trauma patients. Here are some of the things I cover:

  • What Is A Hybrid OR?
  • Why Use A Hybrid OR For Trauma?
  • Is The Hybrid OR For Trauma Useful?
  • Which Patients May Benefit From A Hybrid OR?
  • So You Want Your Own Hybrid Room?!

To download the current issue, just click here! Or copy this link into your browser: http://bit.ly/TME201803.

The Lucas CPR Device And Pregnancy

Here’s an image of the Lucas automated CPR device. Here’s a question for you: can you use the Lucas chest compression device in a pregnant patient?

The official company answer is “no.” Obviously, this is one those areas that is tough to get research approval on, and the number of pregnant patients who might need it is very small. So basically, we have little experience to go on.

That being said, the reality is that prehospital agencies can and do use it for these patients on occasion. There is only one published case report that I could find (see reference below). The thing that makes using this device a little more challenging is that, to optimize blood pressure, late term pregnant patients need to have the uterus rolled off of the vena cava. This means tipping the patient to her left.

As you can see from the picture above, the design of the Lucas makes this a bit difficult. However, it can be done, either by tipping the board the patient is on or wedging something under the right side of the back plate.

And as always, make sure that you adhere to your local policies and procedures, or have permission from your medical director to use this device in this particular situation.

Reference: Cardiac arrest and resuscitation with an automatic mechanical chest compression device (LUCAS) due to anaphylaxis of a woman receiving caesarean section because of pre-eclampsia. Resuscitation 68(1):155-159, 2005.

Trauma Mythbusters: Removing Bullets With Metal Instruments

I’ve heard this time and time again over the years. Don’t remove a bullet using metal forceps or a hemostat. Don’t drop it into a metal pan. Have you heard these, too? Is it true?

The idea is that rifling marks on the bullet that would help match it to a particular weapon may be damaged through mishandling, interfering with any criminal investigation.

So I decided to go to a reputable source. I asked a local police firearms and munitions expert the question. The result:

Myth busted! The amount of damage to the bullet due to handling with metal instruments is negligible and will not interfere with an investigation. Many of the bullets used in crimes are jacketed with copper or other metals, which are resistant to damage anyway. The surgeon would have to make an intentional effort to damage the bullet enough to interfere with a ballistics investigation. And I don’t recommend that anyway!

Finally! The Next MedEd Newsletter Is Coming! Trauma in the Hybrid Room

Well readers, I’ve been promising this for many months. And I’ve finally finished it! The next Trauma MedEd newsletter is ready!

A growing number of hospitals have a “hybrid OR.” This newsletter will answer all your questions about what it is, and what you can do in it. It can be a handy dandy tool for trauma cases, but there are a number of things you need to think about before you use it for the first time.

In this issue I’ll cover:

  • What exactly is a hybrid OR?
  • Why use one for trauma?
  • How useful is it, really?
  • What types of trauma cases can it be used for?
  • What do I need to think about before I use it for trauma?

As always, this issue will go to all of my subscribers first, this Saturday. If you are not yet one of them, click this link to sign up now and/or download back issues.

Unfortunately, non-subscribers will have to wait until I release the issue on this blog, about 10 days later. So sign up now!