Monthly Archives: January 2016

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EAST 2016: Lower Mortality In Patients Taking Newer Oral Anticoagulants vs Warfarin

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How not to write your abstract! The full title is this:

Trauma Patients on New Oral Anticoagulation Agents Have Lower Mortality Than Warfarin

Now let’s look at what it really says. This was a retrospective trauma registry review from a single Level I trauma center. Over a 14 month period, 275 of 1994 admitted patients were on anticoagulants.

Here are the (misleading) factoids and my comments:

  • Patients on warfarin had a higher mortality (13%) than those on new oral agents (NOA) (6%). (I can’t duplicate the statistical significance calculation)
  • Patients taking any anticoagulant were admitted to an ICU more often (44-50% vs 36%). (Duh! This just shows their usual practice, nothing new)
  • Patients on warfarin were more statistically likely to receive prothrombin complex concentrate. (Double duh! Because it doesn’t work for NOAs?)
  • The authors pointed out a trend toward more NOA use in this graph. (Really? It goes from 11 to 14 with wide monthly variations!)
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Bottom line: This is why it’s so important to read the entire abstract and think about the stats. And ultimately, it’s even more important to read the whole paper! They don’t always say what you think they say!

Reference: Trauma patients on new oral anti-coagulation agents have lower mortality than those on warfarin. EAST 2016 Oral abstract #24.

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EAST 2016: Scene Time And Mortality

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The old “scoop and run” vs “stay and play” debate has gone on for years. It would seem to be intuitive that trauma patients, who should be assumed to be bleeding to death, would do better with shorter prehospital times and quicker transport to definitive care. 

However, several studies have not shown worse outcomes in the “stay and play” patients. Once again, mortality is a very crude indicator of “worse” outcomes, and may not be a good enough measure. Nonetheless, the debate continues to rage. A group at the University of Pittsburgh used the Pennsylvania Trauma Registry to review a huge number of EMS transports, looking at mortality as the measure of interest.

Recognizing that total prehospital time can be influenced by delays in specific phases (response, scene, or transport), they analyzed the impact of problems in each. If one particular phase represented more that 50% of the total prehospital time, it was considered a delay. Logistical regression was used to match patients to try to control for any confounding issues.

Here are the factoids:

  • Over 164,000 records with prehospital times were reviewed over a 14 year period.
  • There was a statistically significant increase in mortality if the scene time phase was prolonged.
  • No differences in mortality were noted with longer response or transport times.
  • Prolonged extrication and intubation had a tendency to prolong scene time, and were independently associated with higher mortality.
  • Lengthy scene time without extrication or intubation was not associated with higher mortality.

Bottom line: This registry-based study has helped us to slice and dice the prehospital time issue a little bit better. As with other studies, the times themselves may not necessarily be the problem. It’s what is causing the delay that matters. Extrication and intubation tend to indicate sicker trauma patients, but they are also somewhat unavoidable. Prehospital trauma professionals will need to focus on tools and exercises that save time during these critical interventions.

Reference: Not all prehospital time is equal: influence of scene time on mortality. EAST 2016 Oral abstract #9, resident research competition.

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EAST 2016: (F)utility of CPR In Hemorrhagic Shock

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Ahh, another (f)utility study. Does it work, or doesn’t it? And yes, I know. It’s another animal study. But it may give us a glimpse of where we are really going with this. 

A team at the University of Tennessee – Knoxville devised a dog experiment to study how well performing CPR works in critically hypovolemic animals. They used three groups of dogs that received a severe shock insult: hemorrhage until loss of pulse, then waiting for 30 minutes in that pulseless state. At that point, one of three interventions was performed for 20 minutes.

One group received CPR only, another group underwent CPR plus fluid administration, and the last group got fluids only. 

Here are the factoids:

  • The insult to all three groups was similar.
  • Vital signs and lab studies were similar in the CPR+fluid and fluid only groups.
  • The CPR only group had significantly lower mean arterial pressures and higher pulse rates than the other CPR+fluid and fluid only groups.
  • Ejection fraction was lower in the CPR only group, and it also had a higher incidence of end organ damage. 
  • Two of the six dogs in the CPR only group died before the end of the study.

Bottom line: Tread with caution here. It makes sense that pounding on an empty tank won’t do much. But this study doesn’t exactly prove this. Only the vital signs measurements were significantly different. All other results are just trends in this very small study. And finally, dogs are (obviously) different than people, in their physiology and their chest wall shape. This can certainly make a difference, and does not mean that we should abandon CPR in humans in hemorrhagic shock.

Reference: Utility of CPR in hemorrhagic shock, a dog model. EAST 2016 Oral abstract #8, resident research competition.

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January Trauma MedEd Newsletter Released!

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Welcome to the current newsletter. This is the second of two issues that will give quick analyses of some of the better oral and poster abstracts that will be presented at the 2016 Annual Scientific Assembly this month. Here’s the scoop on what’s inside:

  • How Long Does VTE Risk Last In TBI?
  • Measuring Volume Status Using Jugular Ultrasound
  • (F)utility Of Antibiotic Use In Facial Fractures
  • Use Of Scribes To Increase Charge Capture
  • Nursing Interruptions In The SICU
  • Pain And Tourniquet Efficacy

Subscribers received the newsletter last Sunday night. If you want to subscribe to get early delivery in the future (and download back issues), click here.

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