Category Archives: General

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).

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How To Keep Up With Your Literature

This short, 12 minute video shows you how to stay current with the literature in your field of expertise. It works for everyone in any discipline, and demonstrates a 5 step system that uses current technology to minimize time and maximize your learning.

My video is accompanied by a reference guide with details on the technique, as well as recommended hardware and software. Click here to download the pdf file.

This video is a sample of the type of content that will be presented at the Trauma Education: The Next Generation (TETNG) conference on September 5 in St. Paul, MN. All content presented at the conference will also have a downloadable reference guide. To view my post on that conference, click here.

For more information on TETNG, including live streaming and registration, click here.

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Trauma Education: The Next Generation

I’d like to share some exciting news about a trauma conference unlike any other! This is a total remodel of a conference we’ve put on annually in the Twin Cities for over a decade (Emergency Medicine and Trauma Update). We’re bringing it, kicking and screaming, into the digital age.

No more stodgy presenters reading from bullet-heavy PowerPoint slides! Away with the sore backside from sitting through an hour-long talk where the presenter goes over their time limit another 15 minutes!

The conference is now fast paced and to the point, with topics of interest to all trauma professionals (doctors, nurses, EMS, and anyone else who loves trauma). It consists of concise, 20 minute presentations interspersed with 5 minute videos of things you need to know. There are curbside consults, where we ask specialists the things you always wanted to. We’ll be taking questions for presenters from the audience and from Twitter using #TETNG13.

Here is a sample of some of the presentations:

  • Scott Weingart (EMCrit) joins us live from his studio in NYC, talking about finger thoracostomy
  • Michael McGonigal discusses why so much of what we think we know is wrong!
  • Felix Ankel talks about the future of trauma education
  • Field amputation, dislocated hip reduction, IO lines and more!

For those of you in the upper Midwest of the US, please join us live in St. Paul for this 4 hour program. It is located at the Minnesota History Center in a beautiful 300 seat auditorium. There is a fee to attend the live program to cover CME/CEU, food and parking. 

For those who cannot attend the live event, it will be streamed live on the internet beginning at 8am CST. Obviously, this is free but no CME/CEU’s will be offered. Park in your garage and get food from your own kitchen. 

And for anyone who just can’t tear themselves away from work on the morning of September 5, all content will be available for free on YouTube shortly after the conference.

For more information, and to register for the live event, go to 

Tomorrow, I’ll post instructions for testing your live streaming reception and a video of sample content. I’ll also provide instructions on how to receive the live stream closer to the meeting date.

Please feel free to email or comment with questions and suggestions!

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Trauma Centers: Optimal Resources vs Optimal Care

Since its inception, the trauma verification program for the American College of Surgeons has focused on standardizing the resources required by a hospital in order for it to become a trauma center. The book that contains the requirements for all levels of trauma center is even titled the “Optimal Resource Document.”

But is achievement of optimal resources enough? Numerous studies have shown that by adhering to these requirements and becoming a trauma center, trauma patient outcomes are improved and mortality is decreased. However, there is still considerable outcome variability across the same level of trauma centers to suggest that it might not be.

Trauma centers accomplish two things: providing a mostly standard set of at-the-ready resources, and providing care using these resources via a set of processes. Some of these processes have been codified by various organizations as practice guidelines. Are variations in the way these processes are implemented the reason for the observed variability in outcomes across trauma centers of the same level?

A paper by Shahid Shafi looked at compliance with standard trauma processes of care (T-POC) and the impact on outcome (mortality) in a single Level I trauma center in the US during a 3 year period. A total of 994 patients were studied. The authors focused on 25 process of care algorithms in 4 specific groups of common injury problems, including TBI, shock, pelvic fracture, and long bone extremity fracture.

The following interesting findings were noted:

  • 77% of the patients were eligible for at least one or more T-POC
  • Compliance with specific T-POCs varied from 10% to 99%
  • The best compliance rates (>90%) were achieved in only 3 T-POCs (blood transfusion for hypotension, intubation for low GCS, and laparotomy for GSW to the abdomen)
  • As judged by whether application of the various T-POCs actually occurred, half of the patients received only 60% of the care they needed
  • Increasing compliance with T-POCs by 10% decreased risk-adjusted mortality by 14%

Bottom line: Adoption of and adherence to standard process of care algorithms for various common clinical problems is the next step in the evolution of trauma care. Yes, a standard set of at-the-ready resources will still be required. But the verification and designation process for trauma centers will need to evolve to place more emphasis on not just having a collection of evidence based T-POCs, but on how uniformly and consistently they are properly applied.

Reference: Moving from “optimal resources” to “optimal care” at trauma centers. J Trauma 72(4):870-877, 2012.

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