Category Archives: Complications

Complications

Nausea In The Trauma Bay: Gastric Tube vs Anti-Emetic Drugs?

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Nausea and vomiting are common problems in trauma patients, particularly those in a trauma activation. Inciting factors include pain, a full stomach from food eaten before the event or blood swallowed after, or a reaction to pain medications. For years, trauma professionals reached for the lowly gastric tube to evacuate stomach contents to “solve” the problem.

But how many of you have seen a patient forcefully empty their stomach as soon as the tube touches the oropharynx? And of course, your patient is lying supine, so the vomitus goes straight up, then back down into their airway. And if their mental status is not quite right, they may aspirate, causing even bigger problems.

We’ve had antiemetic medications for a long time, some more effective than others. Only recently have we begun to rely on these as a first-line defense in the trauma resuscitation room. But do they work? Are they safer?

The University Medical Center Utrecht in the Netherlands looked at this problem. They changed their policy from inserting a gastric tube to administering antiemetics at the beginning of 2014. They studied their experience for the 6 months before and 6 months after the policy change. They inserted an orogastric (OG) tube preferentially before the switch and used ondansetron and/or metoclopramide after.

Here are the factoids:

  • A total of 1446 trauma patients were admitted during this period. After excluding patients who were intubated or did not complain of nausea, 453 were analyzed (30%)
  • 20% of patients who had an OG tube placed vomited vs only 3% receiving medication (significant)
  • After therapy, 14% of patients receiving an OG were still nauseated vs only 2% getting meds (also significant)
  • 3 patients vomited and aspirated after OG placement, and 1 developed a pneumonia. 2 patients became bradycardic and required medication administration, and one developed QT-prolongation

Bottom line: This is a relatively small, retrospective study. Furthermore, the choice of gastric tube route (oral) is a setup for gagging and vomiting. Nasogastric tubes are a bit less noxious, but can’t be inserted in all patients (see next week’s post). Even so, the use of antiemetics in trauma patients complaining of nausea seems like the kinder, gentler way to go. 

Which drug to use? Previous studies have shown that ondansetron 4mg is as effective as 8mg, and that it is about as effective as metoclopramide. There is also evidence that giving both is more effective than giving just one.

Gastric tubes are still important, particularly in the comatose patient. But since these patients are at risk for cribriform plate injury, only the oral route should be used.

Reference: Analysis of two treatment modalities for the prevention of vomiting after trauma: orogastric tube or antiemetics. Injury (accepted manuscript, in press) online 8 July 2017.

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Complications

More On Lead Poisoning And Retained Bullets

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Trauma professionals frequently have to leave bullets in patients. It is often more disruptive to go digging the projectiles out than to just leave them in place. But patients always want to know why and what the consequences might be.

In my last post, I discussed a very old paper on what we know about lead levels and retained bullets. Very recently, a meta-analysis was published that provides a better picture of this topic. They somehow managed to find over 2000 articles dealing with lead toxicity and bullets out there. But after someone had the pleasure of reviewing each of them, they found only 12 that had any meaningful or actionable information.

Here are the factoids:

  • All studies were observational (duh! It would be difficult to get your IRB to approve a study where patients were shot on purpose)
  • There were five cross-sectional studies, four case-control studies, and three prospective cohort studies
  • The studies were small, with a median of only 26 patients (range 15-120)
  • Eleven of the twelve studies showed an association with retained bullets and elevated blood lead levels
  • Three studies showed elevated blood levels if a fracture was present
  • The higher the number of retained fragments, the more likely lead levels were to be high
  • Higher lead levels were associated with retained fragments near a bone or joint
  • There were no good correlations with number of fragments and location vs actual lead toxicity

Bottom line: Even using meta-analysis, it is difficult to tease out meaningful answers to this question. That speaks to the low numbers of papers and their quality. However, this study does provide a little bit of guidance.

Retained bullet fragments are probably not a big worry in most patients. The bothersome cases are those where the fragments are in or near a bone or joint. And even though few patients actually developed lead toxicity, lead levels approaching 5 micrograms/dL can have physiologically significant negative effects. 

Recommendation: If your patient has a retained bullet fragment near a bone or joint, or they have “multiple” retained fragments (no good definition of this), they should have blood lead levels measured every three months for a year. If the level is rising, and certainly if it reaches the 5μ/dL level, attempts should be made to remove the fragments.

Reference: Lead toxicity from retained bullet fragments: A systematic review and meta-analysis. J Trauma 87(3):707-716, 2019.

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Complications

Can Lead Poisoning Occur After A Gunshot?

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This is a fairly common question from victims of gunshots and their families. As you know, bullets are routinely left in place unless they are superficial. It may cause more damage to try to extract one, especially if it has come to rest in a deep location. But is there danger in leaving the bullet alone?

One of the classic papers on this topic was published in 1982 by Erwin Thal at Parkland Hospital in Dallas. The paper recounted a series of 16 patients who had developed signs and symptoms of lead poisoning (plumbism) after a gunshot or shotgun injury. The common thread in these cases was that the injury involved a joint or bursa near a joint. In some cases the missile passed through the joint/bursa but came to rest nearby, and a synovial pseudocyst formed which included the piece of lead. The joint fluid bathing the projectile caused lead to leach into the circulation.

The patients in the Parkland paper developed symptoms anywhere from 3 days to 40 years after injury. As is the case with plumbism, symptoms were variable and nonspecific. Patients presented with abdominal pain, anemia, cognitive problems, renal dysfunction and seizures to name a few.

Bottom line: Any patient with a bullet or lead shot that is located in or near a joint or bursa should have the missile(s) promptly and surgically removed. Any lead that has come to rest within the GI tract (particularly the stomach) must be removed as well. If a patient presents with odd symptoms and has a history of a retained bullet, obtain a toxicology consult and begin a workup for lead poisoning. If levels are elevated, the missile must be extracted. Chelation therapy should be started preop because manipulation of the site may further increase lead levels. The missile and any stained tissues or pseudocyst must be removed in their entirety.

Granted, this is a very old paper. Over the years, a few papers on the topic have popped up from time to time. In my next post, I’ll review a meta-analysis on this topic that was published just last year.

Reference: Lead poisoning from retained bullets. Ann Surg 195(3):305-313, 1982.

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Complications

Vasopressin In Hemorrhagic Shock?

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Since almost forever, the use of pressors in hemorrhagic shock has been frowned upon. One of my mentors used to ask me, “Is your trauma patient losing norepinephrine?” My opinion was that the bag of vasopressor was only valuable for the crystalloid it was dissolved in. Even the ATLS course recommended against the use of these drugs in hemorrhagic shock.

While visiting a trauma center earlier this year, I encountered a case in which vasopressin was used in the treatment of one of these patients. When I questioned the program leadership, they provided a research paper and a white paper promoting its use.  As I always do when shown something I disagree with, I asked for the source material so I could review it myself. This is the only way to learn new tricks, and I want to share with my readers what I found.

The group at the University of Pennsylvania performed a randomized, double-blind, placebo-controlled clinical trial (in 2019) on the use of arginine vasopressin (AGP) to determine if it decreased the number of blood products transfused during resuscitation. The study took five years and included adults who received at least six units of any blood product within 12 hours of injury. Moribund patients (CPR, resuscitative thoracotomy) were excluded, as were patients with renal or coronary artery disease, and those with TBI requiring neurosurgical intervention.

A total of 100 patients were randomized, 49 to the AVP group and 51 to the placebo group. AVP dosing consisted of a bolus of 4 IU followed by an infusion of 0.04 IU/min until hemorrhage was controlled. Once this occurred, the infusion was titrated from 0 to 0.04 IU/min to maintain MAP > 65 torr. The primary outcome was the total volume of transfused blood, and secondary outcomes included the volume of crystalloid administered, vasopressor requirements, complications, and 30-day mortality.

Here are the factoids:

  • Patients were young (27 years) and typically male (93%), with 79% penetrating trauma
  • At 48 hours, patients who were given AVP received significantly less blood products (1.4L vs 2.9L), but the same amount of crystalloid (9.9L vs 11L)
  • Mortality (12% for both groups) and complications were similar between the groups (55% AVP vs 64% placebo)
  • Strangely, venous thrombosis was lower in the AVP group (11% vs 34%)

The authors concluded that the use of AVP in hemorrhagic shock resulted in a decrease in the volume of transfused blood products. They recommended further studies to determine if there were survival or complication avoidance benefits.

Bottom line: Surprise! This is a very high-quality study, and I’m surprised I missed it five years ago. It provides compelling evidence to support the use of vasopressin in patients with hemorrhagic shock. The authors speculate that this pressor may overcome the vasoplegia that may occur in late-stage shock. Although this is more common in septic shock, it can also occur with massive hemorrhage.

There have been further studies, mainly meta-analyses, that provide additional support for this work. To date, no studies have been powered to show improvements in survival or complications. 

This work is strong enough on its own that it should be okay to modify your practice based on it. The State of Arkansas has generated a white paper that promotes the use of AVP in any patient who requires MTP activation. Although this indication differs from the six-unit requirement in this research paper review, it is more likely to be remembered if implemented at the start of the MTP. This is very similar to the administration of TXA, which should also be considered at the beginning of the MTP.

However you choose to do it, here is the algorithm:

  • Give a 4 IU bolus of AVP
  • Immediately begin a 0.04 IU/min infusion
  • Once hemorrhage has been definitively controlled, titrate to a mean arterial pressure > 65 using 0-0.04 IU/min
  • Stop after 48 hours

References:

  • Effect of Low-Dose Supplementation of Arginine Vasopressin on Need for Blood Product Transfusions in Patients With Trauma and Hemorrhagic Shock: A Randomized Clinical Trial. JAMA Surg. 2019 Nov 1;154(11):994-1003. doi: 10.1001/jamasurg.2019.2884. PMID: 31461138; PMCID: PMC6714462.
  • Arkansas White Paper: Arkansas Trauma System Evidence-Based Guidelines for Use of Vasopressin in Shock (click to download)
  • Effects of Vasopressin Receptor Agonists during the Resuscitation of Hemorrhagic Shock: A Systematic Review and Meta-Analysis of Experimental and Clinical Studies. J Pers Med. 2023 Jul 16;13(7):1143. doi: 10.3390/jpm13071143. PMID: 37511756; PMCID: PMC10381354.

Shout-out to Lindsay Graves, the TPM at Baptist Hospital in Little Rock, who shared this work with me.

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Complications

Giving Vitamin D After Fracture: Helpful Or Not?

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The role of Vitamin D in fracture healing is well known. So, of course, trauma professionals have tried to promote Vitamin D supplementation to counteract the effects of osteoporosis. A meta-analysis of 12 papers on the topic, relating to hip and other non-vertebral fractures, showed a roughly 25% risk reduction for any non-vertebral fractures in patients taking 700-800 IU of Vitamin D supplements daily.

Sounds good, right? So what about taking Vitamin D after a fracture occurs? Seems like it should promote healing, right? A large meta-analysis published in an orthopedic journal examined this very question.

Unfortunately, there was a tremendous variability in the interventions, outcomes, and measures of variance. The authors were limited to summarizing individual papers, and a proper meta-analysis could not be conducted.

Here are the factoids:

  •  81 papers made the cut for final review
  • A whopping 70% of the population with fractures had low Vitamin D levels
  • Vitamin D supplementation in hospital and after discharge did increase serum levels
  • Only one study, a meeting abstract which has still not seen the light of day in a journal, suggested a trend toward fewer malunions following a single loading dose of Vitamin D

Bottom line: Vitamin D is an excellent idea for people who are known to have, or are at risk for, osteoporosis and fractures. It definitely toughens up the bones and lowers the risk of fracture. However, the utility of giving it after a fall has not been shown. Of the 81 papers reviewed, none showed a significant impact on fracture healing. The only good thing is that Vitamin D supplements are cheap. Giving them may make us think that we are helping our patient heal, but it’s not. 

What about the use of calcitonin for preventing future fractures? Find that in my next post!

References:  

  • What is the role of vitamin D supplementation in acute fracture patients? A systematic review and meta-analysis of the prevalence of hypovitaminosis D and supplementation efficacy. J Orthopaedic Trauma 2016 Feb;30(2):53-63.
  • Fracture prevention with vitamin D supplementation: a meta-analysis of randomized controlled trials. JAMA 293(18):2257-2264, 2005.
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