All posts by TheTraumaPro

Spleen Vaccines: So Confusing! – Part 1

Earlier this year, there were a lot of television commercials for Prevnar 13, a 13-valent pneumococcal vaccine for immun-ocompromised or asplenic adults. And interestingly, I noticed that the CDC has added a recommendation that these patients receive this vaccination, followed by the original 23-valent vaccine (Pneumovax 23) 8 weeks later.

WTF? Patients with splenectomy (or significant angio-embolization) for trauma are considered functionally asplenic. And although the data for immunization in this group is weak, giving triple vaccinations with pneumcoccal, H. flu, and meningococcal vaccines has become a standard of care.

This was difficult enough already because there was debate around the best time to administer: during the hospital stay or several weeks later after the immune system depression from trauma had resolved. The unfortunate truth is that many trauma patients never come back for followup, and so don’t get any vaccines if they are not given during the hospital stay.

And then came the recommendation a few years ago to give a 5-year booster for the pneumococcal vaccine. I have a hard time remembering when my last tetanus vaccine was to schedule my own booster. How can I expect my trauma patients to remember and come back for their pneumococcal vaccine booster?

So what do we do with the CDC Prevnar 13 recommendation? If we add it, it means that we give Prevnar while the patient is in the hospital, and then hope they come back 8 weeks later for their Pneumovax. And then 5 years later for the booster dose. Huh?

Looking at the package insert, I read that Pneumovax 23 protects against 23 serotypes of S. Pneumo, which represent 85% of most commonly encountered strains out there. So it’s not perfect. Prevnar 13 protects against 13 serotypes, and there is no in-dication as to what percent of strains encountered are protected against.

So I decided to dig deeper and look at the serotypes included in each vaccine. They are shown in the chart below. The 23 bars with maroon in them (solid or striped) are Pneumococcal serotypes covered by Pneumovax 23. The 13 bars containing gray are ones covered by Prevnar 13. There is only one serotype in Prevnar 13 not covered by Pneumovax 23, serotype 6A. Unfortunately, it’s nearly impossible to find the prevalence of infections by serotype, and it varies geographically and over time anyway. So does cover-age of a single extra serotype by Prevnar 13 justify an additional vaccination and complicated administration schedule? Hmm.

It turns out that there is one significant difference between these two vaccines. Pneumovax 23 is a polysaccharide vaccine made up of fragments of polysaccharide from pneumococcus cell walls. Prevnar 13 is a “conjugated vaccine,” meaning that the polysaccharides are linked to a protein. This is thought to increase the immune system response to the vaccine.

(click for full-size graph)

The current CDC recommendations are listed below. In the old days, we just gave three vaccines before the patient left the hospital. Then the Pneumovax 23 booster was added at 5 years. Same for the meningococcal serogroup B booster at 4 weeks. Then the meningococcal conjugate vaccine (Menactra) came along and was added (with a booster at 8 weeks). Finally, Prevnar 13 was added with its own booster, and Pneumovax 23 was delayed for 8 weeks. Oh, and don’t forget the 5 year boosters for both Pneumovax 23 and the meningococcal conjugate vaccines. It has become very complicated.

(click for full-size chart)

In my next post, I’ll try to make sense of this mish-mash and offer some thoughts on how to decide what to do for your patients.

Early Mobilization In Solid Organ Injury

Traditionally, most centers keep their solid organ injury patients in bed and NPO for a period of time. I suspect that they feel that walking may cause the organ to break and require operation. And if they need emergency surgery, shouldn’t they have an empty stomach?

Now let’s think about this. The success rate of nonoperative management for liver and spleen injuries in properly selected patients is somewhere between 93% and 97%. It’s been years since I’ve had a failure while the patient was in my hospital. And since we treat about 200 of these per year, I will be starving and restricting ambulation in a lot of patients just in case that one failure occurs.

The group at LA County – USC recently published a prospective, observational study of their 20-month experience comparing early ambulation vs delayed ambulation after liver, spleen, or kidney injury. They admitted 246 patients with these injuries, but excluded those who couldn’t walk, walked out against medical advice, died, or underwent operative intervention or angiography.

Here are the factoids:

  • There were 36 patients in the early ambulation group (<24 hours) and 43 late ambulators (>24 hours)
  • There were no complications in the early group, and three in the late group (one readmission, two developed pseudoaneurysm that required embolization)

Bottom line: This is a very small study, but it dove-tails with my personal experience. We removed activity restrictions and NPO status from our solid organ protocol two years ago and have not noted any complications while in the hospital.

Reference: Safety of early ambulation following blunt abdominal solid organ injury: A prospective observa-tional study. Am J Surg 214(3):402-406, 2017.

Overwhelming Post-Splenectomy Infection (OPSI)

Most trauma professionals have heard of OPSI, but few have ever seen it. The condition was first described in splenectomized children in 1952. Soon after, it was recognized that this infection occurred in asplenic adults as well.

OPSI is principally due to infection by encapsulated organisms, those with a special polysaccharide layer outside of the bacterial wall. This layer is only weakly immunogenic, and confers protection from the normal immune mechanisms, particularly phagocytosis. However, these bacteria are more easily identified and removed in the spleen.

OPSI may be caused by a number of organisms, the most common being Strep. pneumonia, Haemophilus influenza, and meningococcus. For this reason, the standard of care has been to administer vaccines targeting the usual organisms to patients who have lost their spleen.

How common is OPSI? A recent paper from Gernany reviewed comprehensive data from 173 intensive care units over a 2-year period. Here are some of the more interesting factoids:

  • 2,859 ICU beds were screened, but the number of unique patients was not given. This is very disappointing because incidence cannot be calculated!
  •  52 cases of OPSI occurred
  •  Only half of the patients had received vaccines
  •  Pneumococcus was the most common bacterium (42%). There were no H. Flu or meningococcal infections.

Bottom line: Yes, OPSI exists and can occur in your asplenic patients. It is uncommon enough that you and your colleagues will probably never see a case. But proper vaccination remains important. Papers consistently show that we are collectively not very good at ensuring that our splenectomized patients receive all their vaccines, ranging from only 11-50%. We collectively need to make better efforts to provide them to our at-risk patients.

Reference: Overwhelming Postsplenectomy Infection: A Prospective Multicenter Cohort Study. Clin Infec Diseases 62:871-878, 2016.

The October 2019 Trauma MedEd Newsletter Has Been Released!

Here’s the most recent newsletter that was released at the end of October; the topic is Potpourri.

In this issue, I cover:

  • Femoral Traction And Open Fractures
  • Nursing: My Doc Won’t Listen!
  • Zones Of The Retroperitoneum
  • CT After Laparotomy For Penetrating Trauma

To download the current issue, just click here! Or copy this link into your browser: http://bit.ly/TME201910

The next newsletter will be released to subscribers at the end of November. I’ll release it to everyone else via this blog in December, so subscribe now if you want it sooner! Click this link right away to sign up now and/or download back issues.

Got a suggested theme for later issues? Just let me know what you’d like to read about by emailing or leaving a comment here.

Inserting an NG Tube (Not an NC Tube)!

On occasion (but not routinely) trauma patients need to have their stomach decompressed. The reflex maneuver is to insert a nasogastric (NG) tube. However, this may be a dangerous procedure in some patients.

Some patients may be at risk for a cribriform plate fracture, and blindly passing a tube into their nose may result in a nasocerebral (NC) tube (see picture). Immediate and profound neurologic decompensation usually occurs. This is a neurosurgical catastrophe, and the outcome is uniformly dismal. It generally requires craniectomy to remove the tube.

The following patients are at risk:

  • Evidence of midface trauma (eyebrows to zygoma)
  • Evidence of basilar skull fracture (raccoon eyes, Battle’s sign, fluids leaking from ears or nose)
  • Coma (GCS<8)

If you really need the tube, what can you do? If the patient is comatose, it’s easy: just insert an orogastric (OG) tube. However, that is not an option in awake patients; they will continuously gag on the tube. In that case, lubricate a curved nasal trumpet and gently insert it into the nose. The curve will safely move it past the cribriform plate area. Then lubricate a smaller gastric tube and pass it through the trumpet.