What To Do About Upper Extremity DVT

August 19, 2011 The Trauma Pro Leave a comment

Deep vein thrombosis (DVT) is a potential problem for all trauma patients, primarily due to the small but real possibility of a resultant pulmonary embolism (PE). Many trauma programs have protocolized their evaluation and management of DVT, but this usually only involves clot in the lower extremities and pelvis. Unfortunately, up to 10% of DVT occurs in the upper extremities, and they are not usually addressed in the same fashion as lower extremity clot.

The American College of Chest Physicians has issued a number of recommendations for managing upper extremity DVT. This includes the use of anticoagulants in a similar manner as for lower extremities. These recommendations have varying literature support behind them, and it is not clear how well they apply to trauma patients.

Cedars Sinai Medical Center in Los Angeles has just published a paper that prospectively looks at the problem of upper extremity DVT in critically ill trauma and surgery patients. They used an existing protocol to screen and treat lower extremity DVT, but had no such algorithm for the upper extremity. A total of 1269 patients were treated in 2.5 years, and 862 patients were screened for DVT at least once.

They found 316 DVTs in 198 patients (115 lower extremity, 201 upper extremity). A total of 77 patients with upper extremity DVT met inclusion criteria by have at least one followup duplex ultrasound. Since no protocol existed, management was at the discretion of the individual attending physician. Important findings regarding upper extremity DVT were:

Most were nonocclusive (72%) and occurred in the internal jugular vein (52%)
The average diagnosis was made on hospital day 19
64% were associated with a central venous catheter, usually double or triple lumen. Removal of the catheter was predictive of improvement by the next duplex exam.
Pulmonary embolism occurred in 2.6%
Two thirds were treated with prophylactic or therapeutic anticoagulation
Anticoagulation did not lead to significant resolution by the final duplex exam

Bottom line: Trauma centers should develop a protocol for screening and treating upper extremity DVT. Anticoagulation may not be necessary, and specific criterial should be developed for its use. The patency and necessity for any central venous catheter associated with upper extremity DVT should be assessed, and preference given to moving or removing it.

Reference: The natural history of upper extremity deep venous thromboses in critically ill surgical and trauma patients: what is the role of anticoagulation? J Trauma 71(2):316-322, 2011.

Related posts:

General

Gallery August 18, 2011 The Trauma Pro Leave a comment

Pelvic Trauma Radiographs Demystified

Although we are becoming increasingly reliant on CT scans for diagnosis, plain old radiographs still have their place. This is especially true in pelvic imaging after trauma.

The most common pelvic radiograph obtained is the supine A-P view taken during trauma resuscitation. This image gives a quick and dirty look at the entire pelvis, from iliac crest to ischial tuberosity. The main areas of interest are the pubic symphysis and the SI joints, so if some of the periphery is cut off a repeat is not necessary prior to CT scan. This image helps predict the need for blood and pelvic compression devices.

If fractures are present, the orthopedic surgeons will generally request additional views in addition to the CT scan. The scan gives excellent detail, but the axial image slices are still not as good as a plain old radiograph in many cases.

Inlet and outlet views are used to get a better look at the pelvic ring. The inlet view opens the ring up into a big circle (or oval) and allows identification of fractures of the sacrum or displacement of the SI joints, as well as changes in the pubic symphysis. The outlet view shows any vertical displacements through the sacrum or SI joints well, and gives a better appreciation of some pubic fractures.

Judet views help demonstrate acetabular fractures by lining up the iliac wing with the xray tube. They can give additional information that the orthopedists use for determining operative or nonoperative management.

Rule of thumb: For major trauma patients, obtain an A-P pelvis radiograph if indicated by mechanism of injury or physical exam. Perform CT scan of the abdomen and pelvis if indicated. If a pelvic ring fracture is identified, obtain inlet and outlet radiographs before calling your orthopedic surgeon. If an acetabular fracture is seen, obtain Judet views before calling.

General

Gallery August 17, 2011 The Trauma Pro Leave a comment

Compression Of The Fractured Pelvis With A Sheet

Fractures of the posterior pelvis are notorious for their potential to bleed. Here are some tips to use if you encounter a trauma patient with an unstable pelvis and want to slow down the bleeding in the ED.

First, figure out what type of pelvic fracture it is. You will probably be able to do this using physical exam and a simple A-P radiograph. Push down hard on the anterior superior iliac spines to see if the pelvis moves. If so, the patient has an anterior-posterior compression type fracture, and you will likely see diastasis of the pubic bones on the xray. These are amenable to compression maneuvers discussed here.

If the pelvis collapses with lateral compression of the iliac wings, then the patient has a lateral compression fracture and compression maneuvers should not be used. Similarly, if a vertical shear is seen on the xray, do not use compression maneuvers.

There are several pieces of equipment available to help compress the pelvis:

Commercial pelvic compression product (e.g. T-Pod). These are convenient but pricey.
MAST trousers – just inflate the abdominal compartment, not the legs. But who has these laying around any more?
Sheet – cheap and quick. Very effective if used properly.

To apply a sheet, it needs to be folded into a narrow band no more than 12 inches high. It should be passed under the patient’s legs and moved upwards. It must be centered over the greater trochanters. This will apply proper pressure, but will not cover the lower abdomen (think laparotomy) or the genitalia (think urinary catheter). Cross the ends of the sheet over as shown above, with one person holding the cinch point while the sheet is secured. This can be carried out with a knot or plastic clamps. Metal clamps will degrade CT or angiographic imaging and should not be used. The sheet should be left in place for the shortest period of time possible, as skin breakdown can occur.

The picture above on the left shows a sheet that is folded too wide (difficult to get enough tension, and covers the good stuff) and uses metal towel clips. The picture on the right shows the proper technique.

General

Gallery August 16, 2011 The Trauma Pro Leave a comment

Orbital Compartment Syndrome

Sure, you’ve heard about all the other compartment syndromes: leg, thigh, forearm, buttock, and abdomen to name a few. But how about a compartment syndrome of the orbit?

This isn’t your usual muscular compartment problem, although the basic concept is the same. The eye is surrounded by rigid bones or relatively stiff soft tissue (the eyelid, believe it or not). Any extra tissue or blood added to this compartment dramatically raises the pressure in the area, which is readily conducted to the eye itself. This rapidly results in:

Severe eye pain
Decreased extraocular movements, which may result in diplopia
Proptosis
Decreased visual acuity
Increased intra-ocular pressure (>40 torr)
Slow pupillary response

This syndrome should be confirmed rapidly and is one of the few true ophthalmologic emergencies. A lateral canthotomy and cantholysis should be carried out to make the lower lid freely mobile, decompressing the compartment (see diagram). This procedure is not for the faint of heart, but should be familiar in any ED where an ophthalmologist is not readily available. Urgent followup with an eye specialist is mandatory.

General

Timed PI Audit Filters: When Does The Clock Start?

August 15, 2011 The Trauma Pro Leave a comment

Several of the performance improvement (PI) audit filters typically used at trauma centers include a time parameter. These include:

Craniotomy > 4 hrs
Laparotomy > 4 hrs
OR for open fracture > 8 hrs
Compartment syndrome > 2 hrs

The question that needs to be asked is: 2 or 4 or 8 hours after what?

There are several possible points at which to start the clock:

Arrival in the ED
When the diagnosis is made
When the decision to operate occurs

The answer is certainly open to interpretation. Here is my opinion on it:

The purpose of a PI filter is to measure system performance. There are a myriad of system problems that can delay taking a patient to the OR. These include care delays in the ED, delays in getting or interpreting diagnostic tests, delays in contact or response for consultants, delays in diagnosis, delays in OR scheduling or availability, and more. Does it make sense to limit the evaluation of your system by setting one of the later decision points as your start time?

Bottom line: I recommend starting the audit filter clock at the time of patient arrival in the ED. This enables the PI program to evaluate every system that can possibly enable or impede your patient’s progress to the OR.

Home of the Trauma Professional's Blog