All posts by The Trauma Pro

Giving Vitamin D After Fracture: Helpful Or Not?

November 16, 2021 The Trauma Pro Leave a comment

The role of Vitamin D in fracture healing is well known. So, of course, trauma professionals have tried to promote Vitamin D supplementation to counteract the effects of osteoporosis. A meta-analysis of of 12 papers on the topic relating to hip and other non-vertebral fractures showed that there was roughly a 25% risk reduction for any non-vertebral fractures in patients taking 700-800 U of Vitamin D supplements daily.

Sounds good, right? So what about taking Vitamin D after a fracture occurs? Seems like it should promote healing, right? A large meta-analysis in an orthopedics journal looked at this very question.

Unfortunately, there was a tremendous variability in the interventions, outcomes, and measures of variance. All the authors could do was summarize individual papers, and a true meta-analysis could not be performed.

Here are the factoids:

81 papers made the cut for final review
A whopping 70% of the population with fractures had low Vitamin D levels
Vitamin D supplementation in hospital and after discharge did increase serum levels
Only one study, a meeting abstract which has still not seen the light of day in a journal, suggested a trend toward less malunions following a single loading dose of Vitamin D

Bottom line: Vitamin D is a great idea for people who are known to have, or are at risk for, osteoporosis and fractures. It definitely toughens up the bones and lowers the risk of fracture. However, the utility of giving it after a fall has not been shown. Of the 81 papers reviewed, none showed a significant impact on fracture healing. The only good thing is that Vitamin D supplements are cheap. Giving them may make us think that we are helping our patient heal, but it’s not.

What about the use of calcitonin for preventing future fractures? Find that in my next post!

References:

What is the role of vitamin D supplementation in acute fracture patients? A systematic review and meta-analysis of the prevalence of hypovitaminosis D and supplementation efficacy. J Orthopaedic Trauma 2016 Feb;30(2):53-63.
Fracture prevention with vitamin D supplementation: a meta-analysis of randomized controlled trials. JAMA 293(18):2257-2264, 2005.

Philosophy

What Is The Curbside Consult?

November 9, 2021 The Trauma Pro Leave a comment

Surgeons, I’m sure you’ve had an experience something like this at some point:

You happen to be wandering through the emergency department and one of your Emergency Medicine colleagues approaches you and says, “Hey, I ‘ve got this patient I’m seeing that I just want to run by you…”

How should you deal with this? They want a quick tidbit of information to help them decide what to do with the patient. Can they send them home, or should they “formally” consult you?

It’s important to look at the pros and cons of this practice. First the pros:

It’s direct. You’re right there. No phone calls, no paging.
It’s quick. Just a quick description of the problem, and a prompt answer. Then everyone can get on with their business.

But then there are the cons:

Situational accuracy. The consultee has not seen the patient, so the information they have been given was filtered through the consulter. Any number of cognitive biases are possible, so the real story may not be exactly as it seems.
Interpretation of the recommendation. Other cognitive biases are also possible as the consulter acts on and implements the recommendations of the consulter. Have they really been followed?
Lack of documentation. This is the biggest problem with a curbside consult. The consultee may act without documenting the source of the recommendation. Or, they may document that they spoke with Dr. Consultee. In either case, one or the other may be hung out to dry, so to speak.

Consider what happens if there is a complication in the care of that patient. There is no way to really determine what was said during that conversation a week or two years later. It boils down to recollections and may end up as a he said … she said situation. And in the worst case scenario, if such a case were to enter the medicolegal arena, there is no official record that any recommendation was made or followed. It’s a very easy case for the plaintiff’s attorney to prevail.

Those of you who have been following me for some time may be familiar with my Laws of Trauma. Originally, there were ten.

But the curbside consult leads to my new Eleventh Law of Trauma:

“Work not documented is work not done“

Bottom line: There is no such thing as a curbside consult! The consultee should say, “I’d better take a look at this patient, why don’t you officially consult me?”

In doing this, the consulter gets to use their own clinical and cognitive skills, and thus render a real opinion based on first hand experience. The consultee gets the most accurate recommendations possible, and they are noted in the record so there is no room for misinterpretation. And finally, there is good documentation from both that will stand up in a court of law if needed.

Head

The Second Head CT In Patients Taking DOACs

November 5, 2021 The Trauma Pro Leave a comment

Direct oral anticoagulant drugs (DOACs) are here to stay. When they were first released, I was very concerned with our inability to reverse them. I feared that we would have a rash of our elders presenting with severe head bleeds that we could do nothing about.

Well, that has not materialized. In fact, it appears that the probability of serious bleeding is more likely with our old reversible workhorse drug, warfarin.

But we are still spooked by DOACs. Nearly every center that has a practice guideline for managing patients with TBI on blood thinners includes a repeat CT scan after a given time interval. This is typically 6, 12, or even 24 hours.

Given the evolving safety profile of DOACs, is this even necessary? The surgical group at the Henry Ford Wyandotte Hospital in Michigan performed a retrospective registry review for their Level III trauma center. They reviewed the data for all adult patients who had suspected or confirmed blunt head trauma (any mechanism), were taking a DOAC, and received at least one CT scan.

Here are the factoids:

There were 400 patients with 498 encounters (yes, 15% came back with another TBI)
Patients were elderly (mean age 76) and nearly evenly split by sex
Fall was the most common mechanism (97%)
The first scan was negative in 96% of patients;12% of them did not have a repeat scan
Of the 420 patients who had a second scan, 418 were negative (99.5%). The two with positive scans were discharged uneventfully.
There were no differences based on specific DOAC, presenting GCS or mechanism

Bottom line: This is a relatively small, single institution study. However, it does appear that the authors have a large population of elderly patients suffering falls. This paper suggests that, indeed, a second scan may not be necessary. This parallels data from my own hospital. But to be on the safe side, keep an eye out for bigger, multi-institutional studies to be sure.

Reference: The utility of a second head CT scan af-ter a negative initial CT scan in head trauma patients on new direct oral anticoagulants (DOACs). Injury, article in press, June 13, 2021.

Resuscitation

Are You A TXA Believer, Or TXA Hesitant?

November 2, 2021 The Trauma Pro Leave a comment

I’ve visited several hundred trauma centers over the past 25 years, and recently I’ve begun to appreciate that there are two camps when it comes to the use of tranexamic acid: the TXA believers and the TXA hesitant.

There have been a number of large studies that seem to suggest a benefit with respect to survival from major hemorrhage, particularly if given soon after injury (CRASH-2, MATTERs). This drug is dirt cheap and has been around a long time, so it has a clearly defined risk profile.

However, many of those hesitant to use it point to the possibility of thromboembolic events that have been sporadically reported. Several years ago, I did my own literature review and found that the number of thrombotic events from TXA was nearly identical to that of transfusing plasma.

JAMA Surgery just published a large systematic review, meta-analysis, and meta-regression that sought to examine the association between thromboembolic events (TE) in patients of any age and involving all medical disciplines, not just trauma.

The anesthesia group at the University Hospital Frankfurt in Germany did a systematic search of the Cochrane Central Register of Controlled Trials, as well as MEDLINE, for randomized controlled trials involving TXA. They covered all published studies through December 2020.

The authors adhered to standard guidelines for con-ducting reviews and meta-analysis (PRISMA). They specifically searched for outcomes involving TEs, such as venous thromboembolism, myocardial infarction or ischemia, limb ischemia, mesenteric thrombosis, and hepatic artery thrombosis. They also tallied the overall mortality, bleeding mortality, and non-bleeding mortality.

Here are the factoids:

• A total of 216 eligible trials were identified that included over 125,000 patients

• Total TEs in the TXA group were 1,020 (2.1%) vs 900 (2.0%) in the control group

• Studies at lowest risk for selection bias showed similar results

Bottom line: The authors concluded that IV TXA, irrespective of the dose, does not increase the risk of thromboembolic events. Period.

Hopefully, this is the final study needed to convince the TXA hesitant that it is safe to administer. They may still argue the efficacy, but at less than $100 per vial it is becoming impossible to ignore.

Reference: Association of Intravenous Tranexamic Acid
With Thromboembolic Events and Mortality A Systematic Review, Meta-analysis, and Meta-regression. JAMA Surgery 156(6):3210884, 2021.

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