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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.

General

Animals vs Cars: What To Do

October 21, 2021 The Trauma Pro Leave a comment

This is a bad time of year in much of the United States for striking animals on the road. In my part of the country, the deer are out in full force. Car vs animal can be challenging, and motorcycle vs animal is frequently deadly. What can our patients do to protect themselves?

Be especially vigilant when driving for the first few hours after sunset and just before sunrise. More animal activity occurs during these hours.
If one animal is spotted, look out for others.
Drive with high beams on as much as possible. In many animals, this will show reflections from their eyes. Some large animals, such as moose, don’t have glowing eyes.
Always where a seat belt in case an impact does occur.
If an animal is spotted, slow down quickly and blow the horn.

Most important! NEVER swerve or attempt to quickly change direction. This is one of the most common errors that results in serious injury or death. The driver swerves to avoid the animal and begins to leave the roadway. They then over-correct in the opposite direction, triggering a rollover. Always make gentle corrections, staying in the same lane.

For small animals, slowly adjust the steering wheel to straddle them with the wheels. For larger ones, try to plan the impact so it is in front of the unoccupied front passenger seat. If the seat is occupied, plan the strike in the middle of the hood. The idea is to keep the car occupants safe, but to assist with natural selection and remove the animal from the gene pool.

Abdomen

Do We Really Need To Admit Children With Low-Grade Solid Organ Injury?

October 18, 2021 The Trauma Pro Leave a comment

Over the years, we have slowly gotten wiser about solid organ injuries (SOI). Way back when, before CT and ultrasound, if there was a suspicion a patient had such an injury you were off to the operating room. We learned (from children, I might add) that these injuries, especially the minor ones, were not such a big deal.

However, we routinely admit adults and children with solid organ injury of any grade. Many centers have streamlined their practice guidelines so that these patients don’t spend very long in the hospital, but most are still admitted. A number of researchers from Level I pediatric centers in the US got together to see if this is really necessary.

They combed through 10 years worth of TQIP data for outcomes and timing of intervention in children with low-grade (grades 1 and 2) solid organ injury age 16 or less. Children with “trivial” extra-abdominal injuries were included to make the conclusions more generalizable. Penetrating injuries and burns were excluded, as were those with “risk of hemorrhage” or need for abdominal exploration for reasons other than the SOI. The risk of hemorrhage was defined as a pre-existing condition or other injury that made it more likely that a transfusion might be necessary for other causes.

Here are the factoids:

A total of 1,019 children with low-grade SOI (liver, kidney, or spleen) were enrolled in the study, and 97% were admitted
There was an even distribution across age groups. Many studies over-represent teenagers; this was not the case here.
Median LOS was 2 days, and a quarter were admitted to the ICU
Only 1.7% required an intervention, usually on the first hospital day (transfusion, angiography, or laparotomy)
Pediatric trauma centers did not perform any of the 9 angiographic procedures, and they only performed 1 laparotomy of the 4 reported

The authors concluded that practice guidelines should be developed for adult centers caring for children to decrease the number of possibly unnecessary interventions, and that it may be feasible to manage many children with low-grade SOI outside of the hospital.

Bottom line: This is an intriguing study. The admission length and silly restrictions like bed rest, NPO, and multiple lab draws are finally approaching their end. Although this paper does have the usual limitations of using a large retrospective database, it was nicely done and thoughtfully analyzed.

It confirms that adverse events in this population are very uncommon, and that adult centers are still too aggressive in treating children like adults. The recommendation regarding practice guidelines is very poignant and this should be a high priority.

Individual centers should determine if they have the infrastructure to identify low-risk children who have reliable families and live in proximity to a hospital with a general surgeon, or better yet, near a trauma center. Hopefully this study will help accelerate the adoption of such guidelines and practices, moving treatment for many children to the outpatient setting.

Reference: Hospital-based intervention is rarely needed for children with low-grade blunt abdominal solid organ injury: An analysis of the Trauma Quality Improvement Program registry. JTrauma 91(4):590-598, 2021.

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