All posts by TheTraumaPro

Delayed Intracranial Hemorrhage In Patients On Anticoagulants

A sizable portion of our population is taking one type of anticoagulant or another. Heck, even golf star Arnold Palmer and comedian Kevin Nealon are on Xarelto! Any trauma professional, and anyone who reads the package insert, knows that there is an increased risk of bleeding if they are injured while taking these drugs, whether it be warfarin or the new, novel anticoagulants.

But does the risk stop soon after injury? That is the presumption at many hospitals that initially treat these patients. They are seen in the ED, examined, scanned, and sent home if nothing is found. Is this a safe practice?

I have personally seen a patient who had an initially clean CT present within 12 hours after ED discharge with a catastrophic bleed and die. Yes, this is anecdotal, but I have talked to other trauma professionals with similar experiences. If this were just a minor complication, no big deal. But they died. Big problem for everyone involved.

So what does the literature say? Unfortunately, it consists of a collection of relatively small studies. Here are the collected factoids that I can glean from them:

  • Most are retrospective, observational studies 
  • Most are from a single hospital, which may miss readmissions to other facilities in the area
  • The delayed bleeding rate is about 0.5% to 1%
  • Some papers recommended discharging patients with a normal head CT and giving them instructions to return if new symptoms develop (this is what happened with my patient; what if they live alone or in a care center where these may not be recognized?!)
  • A few papers did identify patients needing neurosurgical intervention or who died
  • Immediate bleeds were more common with antiplatelet agents, delayed bleeds were more common with warfarin
  • I could find nothing that looked at this problem in patients taking novel anticoagulants like Pradaxa or Xarelto

Bottom line: The literature provides little guidance at this point. A good multi-institutional trial is needed to generate the numbers to tell us what to do. While we get around to this, I recommend that a selective brief observation (12 hrs) protocol be adopted. This protocol recognizes that subclinical bleeding may be present on initial presentation, and that a little more time is needed for it to declare itself.

Here is a link to our protocol. If the initial head CT is negative and the INR is less than 2.5, we will only discharge the patient if all of these criteria are true:

  • Age < 65
  • No skull fx
  • No new focal neurologic deficits
  • No soft tissue injury visible on CT (hematoma, laceration)
  • GCS = 15
  • No persistent vomiting
  • Brief TBI screen passed (Short Blessed Test, link here)

Most do not pass all of these, usually failing the age criterion. They are admitted for observation and neurologic monitoring for 12 hours, at which time the head CT is repeated. If it is still normal, then they can go home.

And although this protocol was designed with warfarin in mind, we apply it to patients taking novel anticoagulants like Pradaxa and Xarelto as well. We’ve had no epic fails yet, but I keep my fingers crossed!

Related posts:

References:

  • Management of minor head injury in patients receiving oral anticoagulant therapy: a prospective study of a 24-hour observation protocol. Ann Emerg Med 59(6):451-455, 2012.
  • Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and preinjury warfarin or clopidogrel use. Ann Emerg Med 59(6):460-468, 2012.
  • Delayed intracranial hemorrhage after blunt trauma: are patients on preinjury anticoagulants and prescription antiplatelet agents at risk? J Trauma 71(6):1600-1604, 2011.
  • Low risk of late intracranial complications in mild traumatic brain injury patients using oral anticoagulation after an initial normal brain computed tomography scan: education instead of hospitalization. Eur J Neurol 21(7):1021-1025, 2014.
  • Can anticoagulated patients be discharged home safely from the emergency department after minor head injury? J Emerg Med 46(3):410-417, 2014.
  • Patients with blunt head trauma on anticoagulation and antiplatelet medications: can they be safely discharged after a normal initial cranial computed tomography scan? Am Surg 80(6):610-613, 2014.

FAQ: Trauma Education – The Next Generation 9/17/15

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Why did you move the conference from the History Center?

Metropolitan State University is a little less expensive and, most importantly, they let you drink beverages in the auditorium. They have a new parking ramp as well. And it’s college, let’s all pretend we are young again.

Will I have colleagues from my department that I can support/heckle?

Of course! As it has been for the last two years, Emergency Medicine has been the majority contributor of in-kind faculty support for this conference.  Here’s who is contributing this year:

  • Dr. Robert LeFevere and his documentation tips and pitfalls
  • Dr. Ryan Bourdon helps you not trip up while taking care of the frail falling elderly patient
  • Dr. Charles Bruen is handling the pediatric airway and the little itty bitty tools needed for that – and that, my friends, is 0.25 hr of pediatric trauma CME!
  • Elise Haupt, PA-C and Martha Serbus, RN will be talking about “talking down” that agitated patient.
  • Dr. Rasimas from Tox & Psychiatry has got some back-up plans if the “talk down” didn’t work.
  • Dr. Alan Sazama is getting some serious screentime and hands-on education about ankle reduction and splinting.
  • Dr. Kevin Kilgore is in charge of the pre-show slides and break slides.  He’s got a small handful of decent pictures and teaching points, I’ve heard.
  • Dr. Michael Zwank is teaming up with Kris Norman, RN to make a little video about IV placement.
  • A couple of surprises
  • And you’ll see way, way too much of Jessie Nelson.

Those people are great, but that’s not enough to fill 4 hours.  What else you got?

Yes, we have other specialties represented.  I’m not going to tell you the entire schedule. I need to keep some of the mystery alive, right? Got some Burn stuff, some Neurosurgery, some Ortho.  Even got a hospitalist to talk Palliative Care in Trauma.  And maybe, just maybe, that trauma patient does NOT need to be transferred here.

Hey, you’ve gotten all fancy (and cheap) in the past and had keynote speakers present from New York and Australia over that there internet thing.  Are you doing that again?

Yes, Virginia, we do have another live remote speaker.  I am continually surprised at the fact that we can talk someone into giving a live lecture in their closet talking to a microphone.  But we’ve done it again.  Dr. Brian Lin from California is talking.  He is the mastermind behind the website www.lacerationrepair.com (Closing the Gap: Wound Closure for the Emergency Practitioner).  

He comes highly recommended, and you may have heard him on EM:RAP. If his website is any guide, I’m assuming they’ll be some great pictures.  If you fix wounds, you want to see this.  

Can I get CME/CEU credits?

Yep, if you show up.  Watching live remotely? Also yes, if you register and pay a $49 fee. Watching it later? I’m going to go with maybe for now.  We had talked about some quiz questions to allow for credit, but I don’t know the status of that now. The person who does know is on a well-deserved vacation (I can be needy).  If you definitely want the credit, come to the conference!

What if I’m working/post-nights/pre-eve/super tired/need to watch the kids/out of town/haven’t showered in a week, etc?

Watch it remotely!  Go to www.tetng.org on the day of the conference. Click the link that will be there. That will take you to: 

https://livestream.com/accounts/3687220/events/4331857

Warning: You may not get to see Kevin Kilgore’s break slides. You can watch it later in its entirely or wait for us to break it into manageable chunks.  Or get the handouts on the website and read them.

What exactly were you doing at the Happy Gnome in St. Paul last Friday?

I don’t want to discuss that. You’ll have to come to the conference and find out.  

Best Of: Finding Rib Fractures On Chest XRay

A lot of people have been viewing and requesting this post recently. 

Here’s a neat trick for finding hard to see rib fractures on standard chest xrays.

First, this is not for use with CT scans. Although chest CT is the “gold standard” for finding every possible rib fracture present, it should never be used for this. Rib fractures are generally diagnosed clinically, and they are managed clinically. There is little difference in the management principles of 1 vs 7 rib fractures. Pain management and pulmonary toilet are the mainstays, and having an exact count doesn’t matter. That’s why we don’t get rib detail xrays any more. We really don’t care. Would you deny these treatments in someone with focal chest wall pain and tenderness with no fractures seen on imaging studies? No. It’s still a fracture, even if you can’t see it.

So most rib fractures are identified using plain old chest xray. Sometimes they are obvious, as in the image of a flail chest below.

But sometimes, there are only a few and they are hard to distinguish, especially if the are located laterally. Have a look at this image:

There are rib fractures on the left side side on the posterolateral aspects of the 4th and 5th ribs. Unfortunately, these can get lost with all the other ribs, scapula, lung markings, etc.

Here’s the trick. Our eyes follow arches (think McDonald’s) better than all these crazy lines and curves on the standard chest xray. So tip the xray on its side and make those curves into nice arches, then let your eyes follow them naturally:

Much more obvious! In the old days, we could just manually flip the film to either side. Now you have to use the rotate buttons to properly position the digital image.

Final exam: click here to view a large digital image of a nearly normal chest xray. There is one subtle rib fracture. See if you can pick it out with this trick. You’ll have to save it so you can manipulate it with your own jpg viewer. 

Related posts:

August Newsletter Released!

The August newsletter is now available! Click the link below to download. This month’s topic is “Potpourri”, a bunch of random stuff of interest.

In this issue you’ll find articles on:

  • Crowdfunding medical research
  • McSwain’s rules of patient care
  • What if you don’t have TEG for trauma?
  • REBOA: All it’s cracked up to be?
  • Treating headache after TBI

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

Click here to download newsletter.

Air Embolism From an Intraosseous (IO) Line

IO lines are a godsend when we are faced with a patient who desperately needs access but has no veins. The tibia is generally easy to locate and the landmarks for insertion are straightforward. They are so easy to insert and use, we sometimes “set it and forget it”, in the words of infomercial guru Ron Popeil.

But complications are possible. The most common is an insertion “miss”, where the fluid then infuses into the knee joint or soft tissues of the leg. Problems can also arise when the tibia is fractured, leading to leakage into the soft tissues. Infection is extremely rare.

This photo shows the inferior vena cava of a patient with bilateral IO line insertions (black bubble at the top of the round IVC).

During transport, one line was inadvertently disconnected and probably entrained some air. There was no adverse clinical effect, but if the problem is not recognized and the line is not closed properly, there could be.

Bottom line: Treat an IO line as carefully as you would a regular IV. You can give anything through it that can be given via a regular IV: crystalloid, blood, drugs. And even air, so be careful!