Category Archives: General

Above-Knee vs Below-Knee DVT

Deep venous thrombosis (DVT) is a common problem in trauma patients. Many trauma centers have developed practice guidelines for beginning mechanical or chemoprophylactic measures as soon as practical in patients at risk. Some believe that below-knee and above-knee DVT are different, with those located below the knee posing a lower risk for propagation and pulmonary embolism. As always, we need to know, is it true?

The group at Oregon Health and Science University performed a retrospective review of six years of their experience with lower extremity DVT. They identified 308 patients who developed this complication and noted the following interesting findings:

  • Two thirds developed below-knee DVT, one third above-knee
  • Overall rate of pulmonary embolism (PE) was about 4% overall
  • PE occurred with equal frequency in below-knee vs above-knee DVT
  • The rate at which DVT resolved was no different in patients receiving prophylactic doses of enoxaparin vs therapeutic dosing
  • Below-knee DVT did not resolve faster than above-knee. Thus they are not more likely to resolve spontaneously

The point of looking for and giving enoxaparin and similar drugs in trauma patients is to avoid DVT, limit it’s progression, and prevent PE. This study showed that there really is no difference between below-knee and above-knee DVT, and that they should be treated similarly. Unfortunately, it also showed that prophylactic and therapeutic management worked equally as well. This is probably due to the fact that there are major differences across various types of trauma patients and that we still don’t know how to calculate the right dose of enoxaparin. However, we do have some tools to help us make a better guess. 

Bottom line: Trauma patients with any lower extremity DVT need to be treated, and enoxaparin is a common way to do this. Below-knee vs above-knee does not matter. If enoxaparin is used, just selecting a therapeutic dose (e.g. 1mg/kg bid) is not enough. Monitoring with anti-factor Xa levels or thromboelastogram (TEG) may help optimize effectiveness and reduce risk of PE.

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Reference: The effects of location and low-molecular-weight heparin administration on deep vein thrombosis outcomes in trauma patients. J Trauma 74(2):476-481, 2013.

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January TraumaMedEd Newsletter

The January newsletter is here! Click the image below or the link at the bottom to download. This month’s topic is Genitourinary, providing information on:

  • Initial management of bladder injury
  • How to do CT cystogram
  • Extraperitoneal bladder injury
  • Followup cystogram
  • Retrograde urethrogram in patients with a catheter in place
  • Renal injury grading update

Subscribers had the newsletter emailed to them on Tuesday. If you want to subscribe (and download back issues), click here.

Download the newsletter

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The Two-Sheet Trauma Trick

Hypothermia is always a concern in trauma patients. Even the simple act of completely exposing your patient in the trauma room facilitates it. How do trauma professionals balance the need to see everything with the equally important need to keep the patient warm?

The natural reaction is to cover them up. Sheets and warm blankets are the usual tools. But I always marvel that, as soon as the blanket goes on, there’s always a need to examine something or do some procedure. Look at a wound. Insert a urinary catheter. And every time this happens, the blanket comes off.

Here’s a clever way to deal with this problem. Don’t use just one sheet or blanket. Use two! Fold each one in half, so they are each half-length. Place one on the top half of the patient, the other at the bottom, overlapping slightly at the waist. If you need to look at an extremity, fold the blanket that covers it over from right to left (or left to right) to uncover just the area of interest. To insert a urinary catheter, just open the area at the waist, moving the top sheet up a little, the bottom down a little.

Bottom line: Keep your patient toasty! Use the two-sheet (or warm blanket) trick to avoid hypothermia. Remember, patient temperature begins to drop as soon as the clothes come off! And I don’t recommend the use of one-piece inflatable warming blankets (e.g. Bair Hugger) until the work in the ED is complete, because the whole thing has to be removed every time you need meaningful access to the patient.

Related posts:

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Trauma Care And HIPAA Demystified

HIPAA

There is a lot of confusion and misinformation out there regarding HIPAA (Health Insurance Portability and Accountability Act). This law was enacted in 1996 with the intent of protecting the health insurance benefits of workers who lose or change their jobs, providing standards for electronic health care transactions, and protecting a patient’s sensitive health information. This last part has caused much grief among trauma professionals.

It is commonplace for a trauma patient to require the services of many providers, from the initial prehospital crew, doctors and nurses at the initial hospital, yet another ambulance or aeromedical crew, professionals at a receiving trauma center, rehab or transitional care providers, and the patient’s primary physician to name a few. Unfortunately, because there can be significant financial penalties for violating the HIPAA privacy guidelines, providers are more likely to err (incorrectly) on the side of denying information to others outside their own institution.

All of the people mentioned above are considered “covered entities” and must abide by the HIPAA Privacy Rule. This rule allows us to release protected information for treatment, payment and “health care operations” within certain limits. The first and last items are the key provisions for most trauma professionals.

Treatment includes provision, coordination and management of care, as well as consultations and referrals (such as transferring to a trauma center). Think of this as the forward flow of information about your patient that accompanies them during their travels.

Health care operations include administrative, financial, legal and quality improvement activities. These quality improvement activities depend on the reverse flow of information to professionals who have already taken care of the patient. They need this feedback to ensure they continue to provide the best care possible to everyone they touch.

Bottom line: Trauma professionals do not have to deny patient information to others if they follow the rules. Obviously, full information must be provided to EMS personnel and receiving physicians when a patient is transferred to a trauma center. But sending information the other way is also okay when used for performance improvement purposes. This includes providing feedback to prehospital providers, physicians, and nurses who were involved in the patient’s care at every point before the transfer. The key is that the information must be limited and relevant to that specific encounter.

Feedback letters and forms, phone conversations and other types of communications for PI are fine! But stay away from email, which is not secure and is usually a violation of your institutional privacy policies.

Always consult your hospital compliance personnel if you have specific questions about HIPAA compliance.

Reference: HIPAA Privacy Rule

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