Another Anticoagulant To Watch Out For

September 5, 2011 The Trauma Pro Leave a comment

In May, I wrote about a new direct thrombin inhibitor named dabigatran (Pradaxa). This drug appears beneficial for patients who need ongoing anticoagulation without the hassle of blood testing to check drug levels. The danger for trauma patients is that there is no antidote or rapid reversal possible. This means that significant traumatic bleeding, particularly in and around the brain, cannot be stopped! At Regions Hospital, we have seen a few patients on this drug, but luckily they have not had bleeding from trauma.

Late last month, Bristol-Myers Squibb and Pfizer announced that a new drug has shown very favorable results in preventing strokes in patients with atrial fibrillation (apixaban, Eliquis). Indeed, it cut the relatively low risk of stroke in half, compared to warfarin. It also had about a third fewer bleeding complications. It looks like it may also give dabigatran a run for its money.

This drug is a Factor Xa inhibitor, and also has no antidote other than time. There is some evidence that activated charcoal given orally within 3 hours of apixaban dosing may be somewhat helpful in reducing blood concentrations.

Trauma professionals need to be on the lookout for patients who use this drug. Any trauma patient who admits to being on a “blood thinner” needs to be questioned carefully to determine which one it is. If it is one of the newer drugs without an antidote, they need to be monitored continuously for signs of bleeding (read: ICU), especially if they have experienced head trauma.

Bottom line: Be on the lookout for these drugs. If any patients who have fallen are taking this drug (elderly, frequently intoxicated, etc.), contact their primary physician so that the risks vs benefits of continuing it can be considered.

References

Apixaban versus Warfarin in Patients with Atrial Fibrillation. NEJM Published online Aug 28, 2011
Eliquis prescribing information

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Gallery September 1, 2011 The Trauma Pro Leave a comment

Weird Trauma: Pruning Shears to the Head and Neck

This case made the national news yesterday, and I wanted to make a few comments on the ideal management of this type of injury.

An 86 year old Arizona man was trimming plants in his back yard and fell on his pruning shears. One of the handle grips pushed into his orbit and through his pharynx into his neck. How do you think through something like this?

First, always check vital signs. If the patient is hypotensive, they must go to the operating room. Even if vital signs are stable, ongoing bleeding necessitates an operation before anything else.

If vital signs are stable, then a road map showing vial structures is essential. The patient should be taken to CT so the exact position of the object can be determined. Any involved structures (carotid artery, esophagus) can be identified and a proper plan can be developed.

Then and only then can a stable patient be taken to the OR. Appropriate incisions should be placed so that key portions of the foreign object can be viewed as they are removed. In this case, incisions were made under his lip and into the maxillary sinus wall to monitor the removal process. The carotid artery had been cleared by CT. Once removed, any remaining bleeding can be addressed.

A final point: any problem like this that has the potential to involve the airway requires that a skilled anesthesiologist be present with appropriate airway management equipment, and the surgeon needs to have all equipment ready to place a tracheostomy on short notice.

This patient did well after removal and was treated with about 3 weeks of antibiotics for his sinus injuries. His inferior orbital wall was rebuilt, and overall he did well postoperatively. He is seriously reconsidering doing any gardening again.

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AAST 2011: Patients Evaluated But Not Transported By EMS

August 31, 2011 The Trauma Pro Leave a comment

Injured patients transported to the ED are just the tip of the iceberg. There are some patients who are evaluated by EMS, either at the scene or in their home, but never transported. These patients do not appear in any trauma registry and little information is known about how they do after their evaluation.

Stanford University reviewed county data and found 5,865 patients out of 69,000 who were evaluated by EMS but not transported (3 counties, 3 years of data). Over a quarter (29%) presented to an ED later and 92 were admitted (2% of the total). By linking available vital statistics data, at least 7 were found to have died.

Bottom line: Patients who are evaluated by EMS but ultimately not transported to a hospital may have unsuspected problems. The mortality is very low (0.14%) but these may represent preventable deaths. It is not practical to force everyone to go to the ED. However, it should be cost-effective to at least make a followup call the next day on these select patients to see if they should be urged to get further evaluation in the ED.

Reference: The forgotten trauma patient: outcomes for injured patients evaluated by EMS but not transported. AAST 2011 Annual Meeting, Oral Paper 46.

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AAST 2011: CT Evaluation of Penetrating Neck Trauma

August 30, 2011 The Trauma Pro Leave a comment

In the old days, stab injuries to Zone 2 in the neck meant a trip to the operating room. Then it became acceptable to evaluate stable patients with this injury via endoscopy, angiography and a swallow study. Most chief residents didn’t have the patience for this and opted for OR anyway. CT now promises to simplify the evaluation process, rolling these studies into one fast and simple one.

USC+LAC and the University of Maryland directed a prospective multicenter study that looked at the sensitivity and specificity of using CT angiography of the neck to evaluate penetrating injuries.All patients underwent a structured physical examination of the neck. If hard signs of injury to the vascular tree or aerodigestive tract were present, they were immediately taken to OR (6%). Nearly all of these patients had an injury that required repair. If they had no signs, they were merely observed (51%). None had a missed injury.

The remaining 159 patients had a positive exam (minor oozing, small stable hematoma) underwent CT angio of the neck (54% stabs, 42% gunshots, 4% other). The majority were in Zone 2 (41%), but 24% were in Zone 3, 21% in Zone 1, and 14% crossed multiple zones. Overall sensitivity was 100% and specificity was 97%. CT angio was nondiagnostic in 3 patients due to missile fragment artifact.

Bottom line: CT angio of the neck is a fast and accurate exam that can be used in stable patients with an abnormal physical exam but no hard signs of injury. This fits my bias, and we have already been using the scanner this way for stabs. I would now recommend cautiously extending its use for select gunshots as well.

Hard signs of neck injury:

Unstable vital signs
Large, expanding, or pulsatile hematoma
Active bleeding
Air bubbling
Voice or airway disturbance
Hematemesis / hemoptysis
Thrill / bruit
Neurologic deficit

Reference: Evaluation of multidetector computed tomography for penetrating neck injury: a prospective multicenter study. AAST 2011 Annual Meeting, Oral Paper 61.

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AAST 2011: Autopsy Reports and Performance Improvement

August 29, 2011 The Trauma Pro Leave a comment

Autopsy reports have traditionally been used as part of the trauma performance improvement (PI) process. They are typically a tool to help determine preventability of death in cases where the etiology is not clear. Deaths that occur immediately prior to arrival or in the ED are typically those in which most questions arise.

The American College of Surgeons Trauma Verification Program includes a question on what percentage of deaths at a trauma center undergo autopsy. Low numbers are usually discussed further, and strategies for improving them are considered. But are autopsies really that helpful?

A total of 434 trauma fatalities in one state over a one year period were reviewed by a multidisciplinary committee and preventability of death was determined. Changes in preventability and diagnosis were noted after autopsy results were available. The autopsy rate was 83% for prehospital deaths and 37% for in-hospital deaths. Only 69% were complete autopsies; the remainder were limited internal or external only exams.

Addition of autopsy information changed the preventability determination in 2 prehospital deaths and on in-hospital death (1%). In contrast to this number, it changed the cause of death in about 40% of cases, mostly in the prehospital deaths.

Bottom line: From a purely performance improvement standpoint, autopsy does not appear to add much to determining preventability of death. It may modify the cause of death, which could be of interest to law enforcement personnel. I would still recommend obtaining the reports for their educational value, especially for those of you who are part of training programs.

Reference: Dead men tell no tales: analysis of the utility of autopsy reports in trauma system performance improvement activities. AAST 2011 Annual Meeting, Paper 63.

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