Following is a comment I received about one reader’s experience with this drug. Why don’t we just set some hard parameters or age limits on the use of such drugs? I’ll provide the opposing view tomorrow.
“So far, one clinical trauma experience- 70+ yo male cut his fingers working with a model airplane engine; on dabigatran. Blood loss nearly 1 L., no control of bleeding w. 2 hours of tourniquet time. Required microvascular ligation of digital vessels. Impressively powerful anticoagulant.
You have to be aware of dosing times to know how long anti-coag effect is likely to endure. Lab tests of little help. No demonstrated efficiacy of Factor VIIa or PCC; in fact, PCC has been shown not to help in one trial. It is effective with Xarelto, though.
Our blood bank stays up at night worrying about this drug, with good reason, since we do our own collections.
Clinicians prescribing this drug should look at bleeding risk scoring systems (HEMORR2HAGE, HAS-BLED) as well as the CHADS2 score before deciding to use this drug.
I suspect it will be ultimately replaced by the Factor Xa inhibitors.
N.B- New Zealand has been reporting a myriad of bleeding issues with this drug. Since it is a relatively closed system, their experience should be a bellweather.”
Trauma Program Director
Click here to download a reference sheet for dabigatran reversal.
Time for a little philosophy today.
“If a tree falls in a forest and no one is around, does it make a sound?”
There is a clinical corollary to this question in the field of trauma:
“If an injury exists but no one diagnoses it, does it make a difference (if there would be no change in treatment)?”
Here’s an example. On occasion, my colleagues want to order diagnostic studies that won’t make any clinical difference, in my opinion. A prime example is getting a chest CT after a simple blunt assault. A plain chest xray is routine, and if injuries are seen or the physical exam points to certain diagnoses, appropriate interventions should be taken. But adding a chest CT does not help. Nothing more than the usual pain management, pulmonary toilet, and an occasional chest tube will be needed, and those can be determined without the CT.
Trauma professionals need to realize that we don’t need to know absolutely every diagnosis that a patient has. Ones that need no treatment are of academic interest only, and can lead to accidental injury if we look for them too hard (radiation exposure, contrast reaction, extravasation into soft tissues to name a few). This is how we get started on the path to “defensive medicine.”
Bottom line: Think hard about every test you order. Consider what you are looking for, what you might find, and if it will change your management in any way. If it could, go ahead. But always consider the benefits versus the potential risks, or what I call the “juice to squeeze ratio.”
- George Berkeley, A Treatise Concerning the Principles of Human Knowledge, 1734, section 45.
- paraphrased by William Fossett, Natural States, 1754.
The ED is a fast-paced environment where things must happen quickly at times. This makes it a ripe environment for errors. A recent study looked at one possible way of decreasing the number of medication errors in a Level I trauma center.
A prospective observational study was carried out in the ED, where pharmacists were on duty and attended all trauma activations for 10 hours each day. No pharmacist was present the rest of the time. The potential errors that were identified consisted of any of the following:
- medication ordered but not given
- medication given but not ordered
- delay in administration
Nearly 700 patient encounters were evaluated, with about one third seen when the pharmacist was present, and two thirds when they were away (makes sense given their coverage hours). The demographics of the patient groups were the same.
There was a huge difference in the number of medication errors! Only 6 errors (3%) occurred when pharmacists were present, but 137 occurred (30%) when they were not. An odds-ratio calculation showed that medication errors were 13.5 times more likely to occur on shifts when pharmacists were not present in the ED.
Bottom line: It’s helpful to have another set of eyes, not focused on the patient’s injuries, looking after critical medications. The error rate is so much lower with a pharmacist present that it must be cost effective to provide them 24/7. Time for another study!
Reference: On-site pharmacists in the ED improve medical errors. Am J Emerg Med Jun 10, 2011 (epub ahead of print).
Field Amputation for Trauma, Part 4
We’ve covered all the prep for field amputation over the past 3 days. Now, it’s time to do it. What equipment is needed? There are two principles: figure it all out in advance, and keep it simple.
It is crucial that the trauma program design and assemble equipment and drug packs in advance, otherwise critical equipment may not make it to the field. The pack needs to be conveniently located, have fresh instruments and batteries for the equipment, and should have essential anesthetics included. A sample list is available here, and I encourage you to modify it to suit your needs.
Paralytics, sedatives and analgesics are essential. I prefer vecuronium, midazolam and fentanyl, but there are many other choices. I would discourage the use of propofol because it is difficult to titrate outside the hospital and may contribute to hypotension.
The patient must be intubated prior to starting the procedure. This airway may be difficult due to patient positioning, so be prepared to perform a surgical airway. Finally, don’t assume that your patient will be nicely positioned supine. Rescue workers may need to support the patient (or you) if he or she is in an awkward position.
Finally, don’t assume that you will accompany the patient (and possibly their limb) back to the hospital. Based on the specific aircraft used, there may not be room available. You may return by ground transportation or another aircraft. That’s why your backup surgeon needs to be mobilized!
We’ve discussed the numbers behind and indications for performing field amputation for trauma. Now it’s time to look at the logistics. There are two main considerations here: getting to the scene, and staying safe.
Getting there includes an obvious problem: what happens when the trauma surgeon leaves the hospital? During the daytime, other surgeons may be available, although they may have elective procedures or other tasks to keep them busy. At night it becomes more of an issue, as they may be the only surgeon available for the hospital. Once involved in the field amputation process, they may be unavailable for hours.
The easiest solution is to utilize the backup trauma surgeon. All Level I and II centers must have one. There are two possibilities here: the trauma surgeon leaves and the backup proceeds to the hospital for coverage (if in-house), or the backup surgeon is transported leaving the on-call surgeon to manage as usual.
The choice is up to the trauma program, but this is an issue that needs to be thought out in advance. The best solution takes geography into consideration. Since most transports to the scene will be made by helicopter, it is easier to use the trauma center’s helipad to pick up the on-call surgeon. If an in-house surgeon is not used, consideration must be given to the nearest safe landing zone and this may mean that an out-of-house surgeon would have to travel to the hospital for pick-up.
Once on scene, the surgeon must ascertain that the area of the incident is safe. This is important for the well being of the patient, the rescue crews and the patient. If the scene cannot be made safe, it is not possible to render care, even if the patient is in grave trouble.
Bottom line: The trauma program must think through these details in advance and develop a policy for who goes to the seen and how. And safety for all is of paramount importance.
Tomorrow I’ll discuss equipment and drugs needed for this procedure.