Many trauma centers insist on reinventing the wheel when it comes to policies and protocols. That’s why I like to share here. It’s so much easier to “borrow” from another center, tweak it until it works for yours, and save lots of time and effort.
Today, I’m sharing our adult “Adult Tranexamic Acid (TXA) in Trauma Patients” policy. The main points are:
Indications – adult trauma patient with enough blood loss to require transfusion or activation of the massive transfusion protocol
Timing – Only give if the injury was known to occur within 3 hours, not within 3 hours of arrival in your center
Dosing – a simple loading dose of 1 gram in 50cc saline give slow push, followed by another gram infused over 8 hours
Exclusion criteria – Although many are listed, the trauma team will only be able to find out about a few: use of anticoagulants, previous dosing of prothrombin complex concentrate (PCC) or Factor VIIa, and possibly the presence of subarachnoid hemorrhage if a CT has been obtained. If the infusion has already started when one of these criteria is identified, stop the infusion.
Suggestion: To keep your trauma professionals from forgetting this adjunct to resuscitation, consider putting a sign on your massive transfusion protocol coolers that says “Do You Need TXA?” And keep it in the med dispenser near/in your resuscitation rooms so you can get it quickly!
Most trauma professionals recognize the value of motorcycle helmets. I’ve written many articles here on the topic (see below). There is high quality evidence that helmets decrease severity of injury in motorcycle crashes (fewer severe brain injuries, higher survival, etc). And we also know from other studies that riders are not protecting their brain at the expense of their spine and torso.
In the 1970s, 47 of US states had enacted universal helmet laws. It wasn’t long after that the federal government lost its authority to penalize noncompliance. So you know what happened. Special interest groups began to weaken and/or repeal these laws, one by one. Now, although some form of helmet law still exists in 47 states, they apply universally to riders in only 19. In the other 26, only young riders, inexperienced ones, or those with insufficient insurance must wear helmets. But how would law enforcement know that when they see the average motorcyclist whizzing by? Which means that the number of riders wearing them has decreased markedly.
The hard part of doing studies to look at the impact of helmets vs no helmets is placing a specific value on a life. A group at the Medical College of Wisconsin in Milwaukee designed a study to use a specific statistical method to attack this problem. They looked at the the value that one places on a marginal change in their likelihood of death. Another way to look at it is the cost of reducing the average number of deaths by one. This is the Value of Statistical Life analysis.
Here are the factoids:
Cost and population information was obtained from a number of federal databases
Injury information was obtained from the National Trauma Databank
3951 motorcycle fatalities occurred during the one year study period
77% died at the scene, 10% in the ED, and 13% as inpatients
37% of riders did not wear helmets, but accounted for 69% of deaths
Helmet use increased survival in a crash by 50%
Costs for hospitalization and rehab (for survivors, obviously) were $5.5 billion for nonsurvivors vs $3.3 billion for survivors
The extra cost per fatality was about $800K
Therefore, (re)implementing universal helmet laws stands to save $2.2 billion per year
Bottom line: Enough numbers here to make your head spin. The $2.2 billion savings, along with a value of statistical life of $2.4 billion equals $4.6 billion in calculated gains. Obviously, the science appears more exact than it really is, but the numbers are large enough to confidently state that lots of money can be saved by simply wearing helmets. The hardest part of this is the human factor. Without legislation, people won’t wear helmets. And there are enough people that haven’t had to wear them, that they will lobby to keep it that way. Catch-22. The solution: prevention, although this will most likely be after the fact, when the patient is already injured and in the hospital. Do your part!
Ever wonder how interventional radiologists stop bleeding? They are very skilled in getting access to complicated areas of the arterial tree. Once they have located a bleeding point, they’ve got to plug it up with something.
Over the years, a wide variety of things have been used. They include blood clot, tiny metal or plastic spheres, superglue, and a variety of other creative things. One of the more recent additions is the metal coil.
On xray, these look like little pieces of piano wire in various shapes after they are inserted. But how do they work? They’re metal, and fairly smooth. How does that promote fast clotting?
The answer is more obvious when you look at one of these before it’s been inserted. Note the “fuzz”. These are synthetic fibers that are wrapped into the coil itself, and they are what actually promote clotting when the coil is in place.
Okay, once again here’s the x-ray of an unfortunate trauma patient:
Lets walk through the things I found so you can see how I knew:
The patient is a female – note the hook and eye clasps in the center of the image.
She is still on a backboard – there are parallel vertical lucencies on either side of the spine which are the longitudinal wood feet of old fashioned backboards (this image is 20 years old, before plastic was invented, haha)
She was stabbed with a long, professional cooking knife – apparent from the length and shape of the blade
The assailant was right handed – the blade was inserted into her left chest
The course of the knife is left to right, superior to inferior, and anterior to posterior – this is the typical trajectory from a right-handed assailant
She was unstable, either blood pressure or respirations – the patient has an ET tube, but no IV line yet
The patient was intubated, most likely due to hypotension and unresponsiveness – same as the last item
There is a moderate left hemothorax – the hemithorax is not completely opaque, so this is probably in the vicinity of a liter or so.
The mediastinum is shifted to the right – even though there may be slight rotation of the chest
A deep sulcus sign is present, either from a pneumothorax that is not easily visible, or from a large hemothorax – the shift and sulcus suggest that there is some tension physiology. Since the hemithorax is not opaque (not a massive amount of blood), there is probably a significant pneumothorax component.
Intra-abdominal and diaphragmatic injury is almost certain – from the depth and trajectory of the knife. It can’t miss everything!
A pulmonary contusion is present on the left – note the extra opacity surrounding the knife entry. This is bleeding into the lung parenchyma.
The stab enters the antero-lateral chest – if it were posterior or more lateral, the patient would be rotated off of it, or the arm would be abducted
It does not involve the arm or axilla – given the presumed entry into the chest at the base of the handle, it will be too far anterior to involve the arm or axilla
The patient needs a chest tube now – duh!
She must be taken to the OR immediately after the tube – double duh!!
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