Category Archives: Complications

TXA Hesitancy: Part II

March 13, 2026 The Trauma Pro Leave a comment

In my last post, I reviewed a huge systematic review and meta-analysis of the use of tranexamic acid (TXA) by all medical disciplines using it. There were more than 125,000 cases included, and the incidence of thrombotic complications in TXA vs non-TXA patients was exactly the same, at about 2%.

Our orthopedic surgery colleagues have been using TXA to reduce bleeding in their cases for decades. There is nothing close to the degree of “TXA hesitancy” in orthopedic surgeons than I see in surgical practices across trauma centers. What do the orthopods know that we don’t?

Trauma orthopedic groups in Malta and the UK published a paper in which they performed a systematic review and meta-analysis of the use of TXA in hip fracture surgery. They focused on randomized, controlled trials published after 2010. A standard approach was used in the analysis, which looked specifically at the impact of IV TXA on transfusion requirements in surgery. Only adults were studied, and eligible studies compared TXA with a placebo or TXA, with no TXA.

Here are the factoids:

Out of 85 studies initially identified, only 13 met all criteria
Across these trials, a total of 1194 patients were enrolled
The need for blood transfusion was reduced by more than 50% when the transfusion threshold was Hgb 8g/dl, which was highly statistically significant
When a higher transfusion threshold was used (between 8-10 g/dl Hbg), the risk reduction was only 23%, which was not significant
The incidence of thrombotic events was identical for the TXA and no-TXA groups

Bottom line: This paper presents more high-quality evidence that the use of TXA in surgically induced injury (hip fracture repair) significantly reduces the need for transfusion in the group with the most blood loss.

However, as with any meta-analysis, the results are only as good as the quality of the individual papers. There were differences in how the TXA was given. It was also not possible to separate out the results from the various types of hip surgery performed. And obviously, these are not major, multi-trauma patients.

Most TXA hesitant surgeons are either concerned with the efficacy of TXA or the potential risks. This paper shows that, overall, TXA is effective in these patients despite the mix of doses and delivery timing. And it clearly shows that the risk for thrombotic complications was identical to that of not giving it.

We have a cheap, effective tool to reduce the need for blood transfusion (read “blood loss”) in trauma patients that has a totally neutral risk profile for thrombosis. We all need to ask ourselves, “Why are we not using it?”

Reference: The Use of Tranexamic Acid in Hip Fracture Surgery — A
Systematic Review and Meta-analysis . J Orthop Trauma, 36(2):e442-3448, 2022.

Complications

TXA Hesitancy: Part I

March 10, 2026 The Trauma Pro Leave a comment

I’ve visited several hundred trauma centers over the past 25 years, and recently I’ve begun to appreciate that there are two tribes when it comes to the use of tranexamic acid: the TXA believers and the TXA hesitant.

There have been several large studies that suggest a survival benefit from major hemorrhage, particularly when given soon after injury (CRASH-2, MATTERs). This drug is dirt cheap and has been around a long time, so it has a clearly defined risk profile.

However, many of those hesitant to use it point to the possibility of thromboembolic events that have been sporadically reported. Several years ago, I conducted my own literature review and found that the number of thrombotic events with TXA was nearly identical to that with plasma transfusion.

JAMA Surgery published a large systematic review, meta-analysis, and meta-regression last year that examined the association between thromboembolic events (TE) in patients of any age and across all medical disciplines, not just trauma.

The anesthesia group at the University Hospital Frankfurt in Germany did a systematic search of the Cochrane Central Register of Controlled Trials, as well as MEDLINE, for randomized controlled trials involving TXA. They covered all published studies through December 2020.

The authors adhered to standard guidelines for conducting reviews and meta-analysis (PRISMA). They specifically searched for outcomes involving TEs, such as venous thromboembolism, myocardial infarction or ischemia, limb ischemia, mesenteric thrombosis, and hepatic artery thrombosis. They also tallied the overall mortality, bleeding mortality, and non-bleeding mortality.

Here are the factoids:

A total of 216 eligible trials were identified that included over 125,000 patients (!)
Total TEs in the TXA group were 1,020 (2.1%) vs 900 (2.0%) in the control group
Studies at the lowest risk for selection bias showed similar results

Bottom line: The authors concluded that IV TXA, irrespective of the dose, does not increase the risk of thromboembolic events. Period.

In my next post, I’ll describe an even more recent systematic review and meta-analysis in orthopedic patients. Our orthopedic colleagues have been using this drug successfully for hip surgery for decades. Let’s see what they think.

Reference: Association of Intravenous Tranexamic Acid With Thromboembolic Events and Mortality: A Systematic Review, Meta-analysis, and Meta-regression. JAMA Surgery 156(6):3210884, 2021.

Complications

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

January 27, 2026 The Trauma Pro Leave a comment

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.

Complications

More On Lead Poisoning And Retained Bullets

September 26, 2025 The Trauma Pro Leave a comment

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.

Complications

Can Lead Poisoning Occur After A Gunshot?

September 23, 2025 The Trauma Pro Leave a comment

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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