All posts by TheTraumaPro

Enoxaparin And Pregnancy

Pregnant women get seriously injured, too. And pregnancy is an independent risk factor for deep venous thrombosis. We reflexively start at-risk patients on prophylactic agents for DVT, the most common being enoxaparin. But is it safe to give enoxaparin during pregnancy?

Studies have looked at drug levels in cord blood when the mother is receiving enoxaparin, and none has been found. No specific bleeding complications have been identified, either. So from the baby’s standpoint, administration is probably safe.

However, there are two other issues to consider. In a study looking at the use of enoxaparin for prophylaxis in women with a mechanical heart valve, 2 of 8 women (and their babies) died. Both suffered from clots that developed and blocked the valves. Most likely, the standard dose of enoxaparin was insufficient, so monitoring of anti-Factor Xa levels must be done.

The other problem lies in the multi-dose vial of Lovenox (Sanofi-Aventis). Each 100mg vial contains 45mg of benzyl alcohol, which has been associated with a fatal “gasping syndrome” in premature infants. The individual dose syringes do not have this preservative.

Bottom line: It is probably safe to give enoxaparin to pregnant women after trauma. However, it is unclear if the dose needs to be increased to achieve adequate prophylaxis. Only consider using this medication after consultation with the patient’s obstetrician, and use only the individual dose syringes. Otherwise fall back to standard subcutaneous non-fractionated heparin (even though it is a Category C drug by FDA; it is still considered the anticoagulant of choice during pregnancy).

Impact Of A Geriatric Trauma Service

I previously wrote about the impact of adding a hospitalist to the trauma service to improve care of geriatric trauma patients. Method Dallas Medical Center created a specific geriatric trauma service, which they called the G-60 service, in 2009. They published their data after one year of experience in 2012.

All patients 60 years of age and older with injuries <48 hours old were admitted to a specific hospital unit. All admitted patients were seen immediately by the trauma surgeon and a hospitalist. Other involved services included rehab, palliative care, PT and OT, pharmacy, nutrition, respiratory therapy, and social work, as needed. The hospitalist was also tasked with expedited clearance for surgical procedures.

Time-to-care goals included G-60 service activation and ED evaluation within 30 minutes, admission to the G-60 unit within 4 hours, operative procedures (if needed) within 36 hours, and discharge within 5 days if appropriate. Multidisciplinary rounds with the full complement of personnel were held twice weekly.

A total of 393 patients were admitted to the G-60 service over a period of one year. A control group of 280 patients from the year before implementation were used for comparison.

Here are the factoids:

  • Mechanism of injury was blunt 98% of the time, as expected. Most were falls, and the frequency increased from 68% to 75% after implementation of G-60.
  • ICU admission rate remained steady at about 20%
  • Significant time-to-care decreases were seen in all 4 categories. ED length of stay decreased by 2 hours, and time to OR decreased by more than half a day.
  • Hospital length to stay decreased from 7 to 5 days, and ICU LOS decreased from 5 to 3 days. Both were statistically and financially significant.
  • There were significant decreases in the incidence of complications, including UTI, renal failure, CHF, ventilator associated pneumonia, and respiratory failure.
  • There was no change in DVT or PE rates.

Bottom line: Implementation of a multidisciplinary trauma service that addresses the special problems of injured elderly patients improves outcomes, and would appear to save a lot of money. I have observed a very obvious age shift in the trauma population at my own trauma center, and I know quite a few other trauma medical directors who are seeing the same thing. We are all going to need to develop the equivalent of a G-60 service to improve outcomes and reduce the financial challenges of taking care of these patients. However, using age 60 as the threshold will miss a number of elders who might benefit. Frailty measures and common sense will need to be taken into account to make sure all appropriate patients can benefit from this type of service.

Reference: Geriatric trauma service: A one-year experience. J Trauma 72(1):119-122, 2012.

Adding A Hospitalist To The Trauma Service

Hospitals are increasingly relying on a hospitalist model to deliver care to inpatients on medical services. These medical generalists are usually trained in general internal medicine, family medicine, or pediatrics and provide general hospital-based care. Specialists, both medical and surgical, may be consulted when needed.

In most higher level trauma centers in the US (I and II), major trauma patients are admitted to a surgical service (Trauma), and other nonsurgical specialists are consulted based on the needs of the patients and the competencies of the surgeons managing the patients. As our population ages, more and more elderly patients are admitted for traumatic injury, with more and more complex medical comorbidities.

Is there a benefit to adding medical expertise to the trauma service? A few studies have now looked at this, and I will review them over the next few days. The Level I trauma center at Christiana Care in Wilmington, Delaware embedded a trauma hospitalist (THOSP) in the trauma service. They participated in the care of trauma patients with coronary artery disease, CHF, arrhythmias, chronic diseases of the lung or kidneys, stroke, diabetes, or those taking anticoagulants.

The THOSP was consulted on appropriate patients upon admission, or during admission if one of the conditions was discovered later. They attended morning and afternoon sign-outs, and weekly multidisciplinary rounds. A total of 566 patients with hospitalist involvement were matched to controls, and ultimately 469 patients were studied.

Here are the factoids:

  • Addition of the THOSP resulted in a 1 day increase in hospital length of stay
  • Trauma readmissions decreased significantly from 2.4% to 0.6%
  • The number of upgrades to ICU status doubled, but ICU LOS remained the same
  • Mortality decreased significantly from 2.9% to 0.4%
  • The incidence of renal failure decreased significantly
  • Non-significant decreases in cardiovascular events, DVT/PE and sepsis were also noted
  • There was no difference in the number of medical specialty consults placed (cardiology, endocrinology, neurology, nephrology)

Bottom line: This paper shows some positive impact, along with some puzzling mixed results. The decrease in mortality and many complications is very positive. Was the increase in ICU transfers due to a different care philosophy in medical vs surgical personnel? And the failure to decrease the number of specialty consults was very disappointing to me. I would expect that having additional medical expertise on the team should make a difference there.

Was the THOSP really “embedded” if they were not involved in the regular daily rounds? In this case, they were present only for handoffs and for weekly multidisciplinary rounds. I believe that having them on the rounding team daily would be of huge benefit, allowing the surgeons and hospitalists to learn from each other. Plus, there should be a benefit to the residents in a Level I center, helping them broaden their ability to care for these complicated patients.

Tomorrow: The G-60 Geriatric Trauma Service 

Reference: Embedding a trauma hospitalist in the trauma service reduces mortality and 30-day trauma-related readmissions. J Trauma 81(1):178-183, 2016.

What’s The Best Pelvic Binder? Part 2

Yesterday, I detailed some pelvic binders commonly available in the US. Today, I’ll go through the (little) science there is regarding which are better than others.

There are a number of factors to consider when choosing one of these products. They are:

  • Does it work?
  • Does it hurt or cause skin damage?
  • Is it easy to use?
  • How much does it cost?

It’s difficult to determine how well binders work in the live, clinical setting. But biomechanical studies can serve as a surrogate to try to answer this question. One such cadaver study was carried out in the Netherlands a few years ago. They created one of three different fracture types in pelvis specimens. Special locator wires were placed initially so they could measure bone movement before and after binder placement. All three of the previously discussed commercial binders were used.

Here are the factoids:

  • In fracture patterns that were partially stable or unstable, all binders successfully closed the pelvic ring.
  • None of the binders caused adverse displacements of fracture fragments.
  • Pulling force to achieve complete reduction was lowest with the T-POD (40 Newtons) and highest with the SAM pelvic sling (120 Newtons). The SAM sling limits compression to 150 Newtons, which was more than adequate to close the pelvis.

So what about harm? A healthy volunteer study was used to test each binder for tissue pressure levels. The 80 volunteers were outfitted with a pressure sensing mat around their pelvis, and readings were taken with each binder in place.

Here are the additional factoids:

  • The tissue damage threshold was assumed to be 9.3 kPa sustained for more than 2-3 hours based on the 1994 paper cited below.
  • All binders exceeded the tissue damage threshold at the greater trochanters and sacrum while lying on a backboard. It was highest with the Pelvic Binder and lowest with the SAM sling.
  • Pressures over the trochanters decreased significantly after transfer to a hospital bed, but the Pelvic Binder pressures remained at the tissue damage level.
  • Pressures over the sacrum far exceeded the tissue damage pressure with all binders on a backboard and it remained at or above this level even after transfer to a bed. Once again, the Pelvic Binder pressures were higher. The other splints had similar pressures.

And finally, the price! Although your results may vary due to your buying power, the SAM sling is about $50-$70, the Pelvic Binder $140, and the T-POD $125.

Bottom line: The binder that performed the best (equivalent biomechanical testing, better tissue pressure profile) was the SAM sling. It also happens to be the least expensive, although it takes a little more elbow grease to apply. In my mind, that’s a winning combo. Plus, it’s narrow, which allows easy access to the abdomen and groins for procedures. But remember, whichever one you choose, get them off as soon as possible to avoid skin complications.

References:

  • Comparison of three different pelvic circumferential compression devices: a biomechanical cadaver study. JBJS 93:230-240, 2011.
  • Randomised clinical trial comparing pressure characteristics of pelvic circumferential compression devices in healthy volunteers. Injury 42:1020-1026, 2011.
  • Pressure sores. BMJ 309(6959):853-857, 1994.

What’s The Best Pelvic Binder? Part 1

Several products for compressing the fractured pelvis are available. They range from free and simple (a sheet), to a bit more complicated and expensive. How to decide which product to use? Today, I’ll discuss the four commonly used products. Tomorrow, I’ll look at the science.

First, let’s dispense with the sheet. Yes, it’s very cheap. But it’s not easy to use correctly, and more difficult to secure. Click here to see my post on its use.

There are three commercial products that are commonly used. First is the Pelvic Binder from the company of the same name (www.pelvicbinder.com). It consists of a relatively wide belt with a tensioning mechanism that attaches to the belt using velcro. One size fits all, so you may have to cut down the belt for smaller patients. Proper tension is gauged by being able to insert two fingers under the binder.

Next is the SAM Pelvic Sling from SAM Medical Products (http://www.sammedical.com). This device is a bit fancier, is slimmer, and the inside is more padded. It uses a belt mechanism to tighten and secure the sling. This mechanism automatically limits the amount of force applied to avoid problems with excessive compression. It comes in three sizes, and the standard size fits 98% of the population, they say.

Finally, there is the T-POD from Pyng Medical (http://www.pyng.com/products/t-podresponder). This one looks similar to the Pelvic Binder in terms of width and tensioning. It is also a cut to fit, one size fits all device. It has a pull tab that uses a pulley system to apply tension. Again, two fingers must be inserted to gauge proper tension.

So those are the choices. Tomorrow, I’ll go over some of the data and pricing so you can make intelligent choices about selecting the right device for you.