Category Archives: General

Papers To Change Our Practice 1: Tranexamic Acid

The first paper I’ll be presenting on Friday at the Penn Reunion deals with tranexamic acid (TXA). This drug works differently than the quick clotting agents out there. It’s an antifibrinolytic, so it actually prevents clot breakdown. It has been approved by the FDA for use in hemophiliacs undergoing dental work and for menorrhagia. Thrombotic complications have been described, so it cannot be used with prothrombin complex concentrate or recombinant activated factor VII.

The most recent and best known study on TXA is the CRASH-2 study. It was extremely well designed and included over 20,000 patients in hospitals spanning 40 countries. The study design has survived serious scrutiny. They found that TXA use in trauma patients reduced the relative risk of death by 9% (from 16% to 14.5%). The risk of death specifically from bleeding was reduced by 15%. And use of TXA in the most severely injured patients, those who would die of bleeding on the day of randomization, was reduced by 20%. CRASH-2 suggested that TXA was of most benefit when given within 3 hours of injury and in patients with a systolic pressure less than or equal to 75 torr. There were no adverse events or differences in thrombotic events, including deep venous thrombosis.

Bottom line: TXA has been shown to be effective, safe and inexpensive (about $200 for treatment using retail pricing). It is the only drug that has been shown to reduce all-cause mortality from bleeding in a high quality trial. And it only needs to be used in 67 major trauma patients before one life will be saved. It has already been adopted by some hospitals in both the US and the UK. Trauma centers should begin to think about incorporating this important drug into their initial treatment protocols now. HOWEVER: Since it is not FDA approved in the US, we may have to wait a little longer here to start using it in earnest. And think about the possibilities when EMS can start giving it in the field!

Reference: Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 2010;376:23–32.

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25th Reunion Of The Penn Trauma Program

I’m traveling to Philadelphia this week to celebrate the 25th anniversary of the trauma program at the University of Pennsylvania. I am one of the three founding surgeons and have been asked to speak at the academic forum portion of the program. I’ll be talking about three papers that should have changed our practice.

For the remainder of the week I’ll be writing about those three papers. They involve the use of an agent that helps control bleeding, radiation exposure in trauma imaging, and the use of technology developed outside the field of medicine to treat trauma patients.

Tune in as I work my way through those important studies. And on Friday, I’ll be tweeting any important or interesting info presented at the academic forum.

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Could Be A Urethral Injury, But The Catheter’s Already In?

You’re seeing a trauma patient, probably a transfer from somewhere else. Either they told you there “may have been” some blood at the tip of the urethra, or maybe you see it smearing the outside of a urinary catheter that’s already in place! How do you proceed from here?

First, try not to get into that situation. Make sure that everyone on your team knows that gross blood at the meatus, male or female, means urethral injury until proven otherwise. If it’s not gross blood, it could be that the patient was incontinent and has hematuria from other causes. The fear with passing a catheter across a urethral injury is that it may convert a partial tear to a complete one. Reconstruction and complications from the latter are far more serious.

But the catheter is there. What to do?

First, leave the catheter in place. You must assume that the injury is present, and you need to rule it in or rule it out in order to decide what to do with the catheter. If the injury is not really there, then you can remove the catheter when indicated. If it really is present, then the urethral injury is being treated appropriately.

Next, do a urethrogram. I’ve previously described how to do it here, but the technique I describe is only appropriate for uncatheterized patients. The technique must be modified to use thin contrast and a method to inject alongside the catheter. To do this, fill a 20-30cc syringe with contrast (Ultravist or similar liquid) and put an 18 gauge IV catheter on the tip (no needles, please). Slide the IV catheter alongside the urinary catheter, clamp the meatus with your fingers, pull the penis to the side and inject under fluoroscopy. The contrast column will not be as vivid as with a regular urethrogram because it is outlining the urinary catheter, so there is less volume.

If the contrast travels the length of the urethra and enters the bladder without leaking out into soft tissue, there is no injury. If there is contrast leakage, stop injecting and plan to call a urologist.

Finally, be on the lookout for associated injuries. Urethral injuries are frequently found in patients with anterior pelvic fractures and perineal injuries.

Related post:

Link: blood at the urethral meatus (Atlas-Emerg-Medicine.org.ua from McGraw-Hill)

Thanks to JP for suggesting this topic!

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The better is the enemy of the good

From the poem “The Prude Woman” by Voltaire, 1772.

This adage is particularly important in medicine. Every test and treatment we order has an upside (hopefully) that will reveal something or make our patient better. Unfortunately, we tend to ignore the inescapable downsides, which include cost and unanticipated consequences. These consequences are the discomfort, side effects, and dangers that come with any medical intervention. And in some cases, the results of an unneeded test may be in error or show some red herring that leads us on a wild goose chase of other interventions that compound the danger.

Bottom line: All trauma professionals need to think about everything they do to a patient, especially the risks they will inflict and the benefits that might accrue. Consider how it will influence your care. Will anything that is revealed change what you do? If not, you don’t need it. And your patient certainly doesn’t need the costs and hidden dangers that go along with it.

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When Can Your Trauma Patient Stop Taking Warfarin?

I admit it. I read trauma and surgery literature, not medical literature. Imagine my surprise when a fellow physician (internist) told me that there is an objective system for helping us figure out whether anticoagulation is needed for atrial fibrillation. “CHADS2” he said. Am I the last trauma surgeon on earth to hear about this?

CHADS2 is a validated scoring system for predicting stroke risk in people with atrial fibrillation. There are 5 components as follows:

  • C – congestive heart failure – 1 point
  • H – hypertension (treated or untreated) – 1 point
  • A – age >= 75 – 1 point
  • D – diabetes mellitus – 1 point
  • S2 – history of stroke or TIA – 2 points

Stroke risk is directly correlated to the number of points scored. So based on that the recommendations are:

  • Score = 0: low risk, no therapy needed or just take aspirin
  • Score = 1: moderate risk, aspirin or oral anticoagulant
  • Score >= 2: moderate to high risk, take oral anticoagulant

Bottom line: Evaluate every trauma patient on anticoagulation to see if they really need to keep taking it. If it’s for a one-time episode of DVT or PE that happened years ago, they should be able to stop. If it’s for a-fib, check their CHADS2 score and work with their primary care provider to see if they could take aspirin or nothing. Factor in a history of frequent falls or car crashes as well.

Related posts: 

Reference: Selecting patients with atrial fibrillation for anticoagulation: stroke risk stratification in patients taking aspirin. Circulation 110 (16): 2287–92, 2004.

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