Category Archives: General

Tranexamic Acid and Trauma

I recently received a request to write about tranexamic acid (TXA) and trauma patients. There is a lot of interest in this agent, especially in the military, and there are some good, recent papers to review.

Tranexamic acid works differently than the quick clotting agents out there. It is an antifibrinolytic, so it actually prevents clot breakdown. It has been approved by the FDA for use in hemophiliacs undergoing dental work and for menorrhagia. Thrombotic complications have been described, so it cannot be used with prothrombin complex concentrate or recombinant activated factor VII.

The most recent and best known study on TXA is the CRASH-2 study. It was extremely well designed and included over 20,000 patients in hospitals spanning 40 countries. The study design has survived serious scrutiny. They found that TXA use in trauma patients reduced the relative risk of death by 9% (from 16% to 14.5%). The risk of death specifically from bleeding was reduced by 15%. And use of TXA in the most severely injured patients, those who would die of bleeding on the day of randomization, was reduced by 20%. There were no adverse events or differences in thrombotic events, including deep venous thrombosis.

Bottom line: TXA has been shown to be effective, safe and inexpensive (about $200 for treatment using retail pricing). It is the only drug that has been shown to reduce all-cause mortality from bleeding in a high quality trial. It has already been adopted by some hospitals in both the US and the UK. CRASH-2 suggested that TXA was of most benefit when given within 3 hours of injury and in patients with a systolic pressure less than or equal to 75 torr. Trauma centers should begin incorporating this important drug into their initial treatment protocols now. However, since it’s not FDA approved in the USA, we will need to wait a while and watch everybody else.

Final thought: Will this eventually be started by EMS?

Reference: Tranexamic acid for trauma patients: a critical review of the literature. J Trauma 71(1):S9-S14, 2011.

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Guidelines for Consultants to the Trauma Service

Trauma surgeons often rely on consultants to assist in the care of their patients. Orthopedic surgeons and neurosurgeons are some of the more frequent consultants, but a variety of other surgical and medical specialists may be needed. I have found that providing a set of guidelines to consultants helps to ensure quality care and provide good communication between caregivers and patients / families.

We have disseminated a set of guidelines to our colleagues, and I wanted to touch on some of the main points. You can download the full document using the link at the bottom of this post.

In order to deliver the highest quality and most cost-effective care, we request that services we consult do the following:

  • Please introduce yourself to our patient and their family, and explain why you are seeing them.
  • Although you may discuss your findings with the patient, please discuss all recommendations with a member of the trauma service first. This avoids patient confusion if the trauma team chooses not to implement any recommendations due to other patient factors you may not be aware of.
  • Document your consultation results in writing (paper or EMR) in a timely manner.
  • If additional tests, imaging or medications are recommended, discuss with the trauma service first. We will write the orders or clear you to do so if appropriate, and will discuss the plan with the patient.
  • We round at specific times every day and welcome your attendance and input.
  • Please communicate any post-discharge instructions to us or enter in the medical record so we can expedite the discharge process and ensure all followup visits are scheduled.

Bottom line: A uniform “code of behavior” is important! Ensuring good patient communication is paramount. They need to hear the same plans from all of their caregivers or else they will lose faith in us. One of the most important lessons I have learned over the years is that you do not need to implement every recommendation that a consultant makes. They may not be aware of the most current trauma literature, and they will not be familiar with how their recommendations may impact other injuries. 

Click here to download the full copy of the Regions Hospital Trauma Services consultant guidelines.

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Financial Triage (Wallet Biopsy) and Transfer to Trauma Centers

A significant amount of volume coming in to Level I and Level II trauma centers is transferred from other hospitals. Occasionally, concerns are raised that some hospitals “cherry pick” the patients, retaining those who are insured and transferring those who are not. If this is true, it has the potential to undermine the entire trauma transfer system by delaying and impeding patient care and by financially damaging the higher level trauma centers. A few single state or single health care system studies have been performed, and some of them have suggested that the uninsured were more likely to be transferred to high level trauma centers.

The group at Parkland looked at a national sample using the National Trauma Databank, and compared the insurance status of patients transferred to Level I and II centers to those retained at Level III and IV centers. Overall, most patients (83%) were insured. At first glance, transferred patients were significantly more likely to be uninsured (18% vs 14%). However, they were also more seriously injured and more likely to have multiple injuries. When adjusted for these differences, the transferred patients were no more likely to be uninsured than the others.

Bottom line: There does not appear to be any concerted effort nationally to inappropriately transfer uninsured injured patients to high level trauma centers. The perception arises because the uninsured have a tendency toward higher risk behaviors that may result in serious injury.

However, it is possible that cherry picking may occur on occasion at the local level. If you are a trauma director experiencing this phenomenon, the best course of action is to speak directly to the director at the referring hospital. Politely discuss your perceptions and offer to see if there is anything you can do to help with their triage process. Frequently, letting them know you are aware of the pattern causes them to improve their transfer decision making.

Reference: Financial triage in transfer of trauma patients: a myth or a reality. Am J Surg 198(3):e35-e38, 2009.

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Brain Injury and Chemical Prophylaxis for DVT

Deep venous thrombosis (DVT) and its complications are recognized and common problems in trauma patients, particularly those with traumatic brain injury (TBI). We know that giving chemical prophylaxis like heparin and low molecular weight heparin (LMWH) reduces the risk. Unfortunately, trauma professionals (and neurosurgeons in particular) are reluctant to give it after acute TBI for fear of making intracranial hemorrhage worse.

Froedtert Hospital in Milwaukee modified their protocol for TBI patients to allow chemical prophylaxis to start 24 to 48 hours after a 24 hour followup CT that showed no progression of any bleeding. Therefore, prophylaxis could be started 48 to 72 hours after injury. They used subq heparin three times daily, or LMWH twice daily. All others received mechanical prophylaxis and were screened twice weekly by duplex ultrasound. The chemical prophylaxis group was not screened routinely. 

A total of 812 patients were studied, half of whom received early prophylaxis per protocol. The average Abbreviated Injury Score for the head in these patients was 3.4, which represents fairly serious injury. There was a significant decrease in the incidence of DVT in the chemical prophylaxis group (1% vs 3%). More intriguing, there was a lower rate of injury progression in this group as well (3% vs 6%), although not quite statistically significant.

Bottom line: Although this is a small and retrospective study, it was well designed and relatively large compared to most other similar work. It shows that use of chemical prophylaxis works in patients with serious TBI, and appears to be safe. Similar protocols should be considered by trauma program multidisciplinary operations committees to further systematize this process. 

Reference: Safety and efficacy of prophylactic anticoagulation in patients with traumatic brain injury. J Am Coll Surg 213:148-154, 2011.

Related post: Does interrupting DVT prophylaxis increase risk for it?

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Portable CT Scanning For Trauma Patients

I recently had the opportunity to see a portable head CT scanner in action, the CeroTom by NeuroLogica (Danvers, MA). Today, I’ll give my thoughts on this new technology.

There are 3 major considerations when evaluating portable CT scanning:

  • Patient safety, always at the forefront
  • Usefulness, also know as image quality
  • Financial viability

From a safety standpoint, portable scanning can decrease (but not eliminate) the safety hazards associated with transporting a critically ill patient out of the ICU. Road trips are associated with misplaced/displaced lines, tubes and monitors about 15% of the time. These are lifelines in some patients, and even momentary disruptions can be life-threatening. Some patients are on levels of support so high they are not transportable, so portable scanners offer an opportunity to get diagnostic imaging that would not be available otherwise.

Clinical performance is on par with standard scanners. Resolution is lower, but the diagnostic accuracy and reliability are not different compared to fixed scanners.

From a financial standpoint, use of the portable scanner works as well. The Cleveland Clinic deployed a CereTom scanner a few years ago and found that the unit paid for itself in 6.9 months. For you financial types, the internal rate of return was 169% and the 5-year expected economic benefit was $2.6 million.

Bottom line: This new piece of technology offers significant benefits to patients in the ICU who may otherwise not be able to get imaging due to safety reasons. It can also be employed in the OR on anesthetized patients, which can assist with diagnosis in patients with both abdominal injuries requiring immediate operation and concomitant head injury.

Practical notes: The CereTom is an 8-slice scanner with a 25cm field of view. The patient is moved onto a scan board which supports the head while it is moved slightly off the top of the bed to accommodate the scanner. Current scanner cost is $450,000 and attachment packages for hospital beds are $7,000. One CT technologist can operate the unit, which takes about 5 minutes to set up and 15 minutes to scan. All lines, tubes and monitors must be (carefully) moved to the side of the bed so the scanner can fit over the top.  

References:

  • The economic and clinical benefits of portable head/neck CT imaging in the intensive care unit. Radiology Manage 30(2):50-54, 2008.
  • Review of portable CT with assessment of a dedicated head CT scanner. Am J Neuroradiol 30:1630-1636, 2009.

I have no financial interest in Neurologica, Inc.

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