Category Archives: General

Q&A: Prothrombin Complex Concentrate

December 15, 2011 The Trauma Pro Leave a comment

An anonymous user recently asked about decision-making with regard to anticoagulation reversal. Specifically, they were interested in using prothrombin complex concentrate (PCC) vs activated Factor VII (FVIIa). I’ve done a little homework on this question, and am going to include some information on the use of fresh frozen plasma (FFP), too.

Unfortunately, there’s not a lot of good data out there comparing the three. Enthusiasm for using FVIIa is waning because it is extremely expensive and the risk/benefit ratio is becoming clearer with time (more risk and less benefit than originally thought). PCC is attractive because it provides most of the same coagulation factors as FFP, but with far less volume. However, it is very expensive, too.

What to do? One of the best papers out there comes from the UK, where they looked at the cost effectiveness of PCC vs FFP in warfarin reversal. They reviewed a year’s worth of National Health Service patients from the standpoint of what it costs to gain a year of life after hemorrhage. They found that the cost was £1000-£2000 per life-year, and £3000 per quality adjusted life-year. This was more cost effective than using FFP. Unfortunately, I do not have access to the full text to review the details.

PCC has only been compared to FFP in the treatment of hemophilia, so it’s not possible to draw any conclusions. The course of therapy for perioperative management of hemophiliacs is lengthy (meaning hideously expensive), and there was a cost-savings seen ($400,000)! Since we use only short duration therapy in trauma patients, the savings will be far less.

Bottom line: PCC is probably as effective as FFP, with less risk of volume overload. It is probably more cost effective as well. As the population of people that are placed on warfarin ages and becomes more susceptible to volume overload from plasma infusions, I think that PCC is going to become the reversal agent of choice. Use of Factor VIIa will continue to wane. However, someone needs to do some really good studies so we don’t get suckered.

Reference: Modeling the cost-effectiveness of prothrombin complex concentrate compared with fresh frozen plasma in emergency warfarin reversal in the United Kingdom. Clinical Therapeutics 32(14):2478-2493, 2010.

General

Gallery December 13, 2011 The Trauma Pro Leave a comment

Dealing With Shotgun Wounds

Shotgun wounds are uncommon but potentially disabling or deadly. Here are some basics for dealing with them.

Most people only think about the shot that comes out of the shotgun shell and its effects. While this certainly causes a problem, this foreign body is only a part of it. And it can be challenging to pick them out surgically. However, there are two other foreign bodies that become an issue: the wad, and other material on or around the patient (clothing, pieces of a door, etc).

Look at the diagram above on the left. The wad is a plastic cup that holds the shot and helps the exploding powder charge propel it out of the shell (see sample pictures on the right). If the shotgun is fired at relatively close range, the wad can enter the patient’s wound. It is usually found near the surface and is easily recognized. Be sure to look for it when removing clothing and dressings from your patient.

Any debris from the patient’s surroundings will end up deep to the wad. It is usually centrally located in the wound, and may penetrate as deep as the shot. I once found a piece of coat fabric in the middle of an abscess that formed months after the shooting.

Management of these wounds requires general anesthesia and patience. The soft tissue injury is always worse than it appears, and make take up to 3 days to fully declare itself. I recommend debriding all obviously devitalized tissue and then placing a negative pressure dressing (if possible) to help reduce tissue edema.

All easily found shot should be removed during the initial operation. Deeply embedded particles will either scar in place or migrate to the surface. If all dead tissue is removed, infection is not that common. Inspection of all vital structures, especially blood vessels, should be performed at that time. Remember, due to the velocity and force involved, arteries may appear completely normal on the outside but have significant intimal interruption.

The patient should return to the OR every other day until all tissue die-back has stopped. Final closure or reconstruction can be considered at that time.

General

Gallery December 12, 2011 The Trauma Pro Leave a comment

Determining The Age Of Bruises

On occasion, you may encounter a patient who has bruising and wonder how old the injuries are. Or there may be several bruises and you would like to know if they occurred at different times. This becomes especially important when dealing with injured children in whom there is a suspicion of abuse.

Bruising occurs when blood leaks from blood vessels into the skin and subcutaneous tissues. If the skin and soft tissues are firm, bruising is not as apparent. In areas where the skin and soft tissues are loose, such as the peri-orbital areas and scrotum, bruising is visible early and may be extensive. The elderly tend to bruise easily because both the skin and subcutaneous tissue are very thin and friable.

A predictable series of color changes occurs with most bruises. During the acute phase, the color is usually reddish and the area may be raised and tender. After about 2 days, the color turns purple and any swelling usually disappears. Over the next week, the color changes to green and yellow as the heme metabolizes. Finally, the color fades and by two weeks most evidence of the injury is gone.

The table above is a key to estimating bruise age. However, this is not an exact science! A number of studies have been performed showing that examiners given photographs of bruises of various ages were not terribly accurate. Fresh and intermediate bruises were identified fairly accurately, but not so for older bruises.

The trauma professional may find it helpful to use these guidelines when trying to decide if there are both fresh and older bruises present. This may indicate that an older adult may be suffering from frequent falls, or that a child needs to be evaluated for abuse.

Reference: Estimation of the age of bruising. Arch Dis Childhood 74:53-55, 1996.

General

Gallery December 6, 2011 The Trauma Pro Leave a comment

There will not be a scheduled post today or tomorrow. We are undergoing an American College of Surgeons reverification visit for our adult and pediatric Level I trauma centers today. Things are a bit busy, but I’ll resume on Thursday!

General

Yes, Smoking is Bad!

December 5, 2011 The Trauma Pro Leave a comment

Everybody knows that smoking is bad. But how often have you stopped by to see one of your trauma patients and have been told “they’re out smoking?” Well, it turns out it’s bad for their injuries as well.

A German group looked at the effects of smoking on healing of a “simple” tibial fracture. They looked at 103 patients who underwent treatment for an isolated tibial shaft fracture at a trauma center. Patients with more complicated problems like extension into a joint, open fracture (Gustilo III), or significant soft tissue injury were excluded.

Patients were divided into non-smokers and smokers (including previous smokers). A total of 85 patients were studied, and there were roughly half in each group. The nonsmoking group experienced no delayed or non-unions of their fractures. The smoking group reported 9 delayed unions and 9 non-unions in 46 patients! As expected, time off work and eventual functional outcome was worse as well.

Bottom line: The exact mechanism for impairment of fracture healing by smoking is unclear. It may be due to physiologic effects of inhaled tobacco components on blood flow, blood vessels, transforming growth factor levels or collagen formation. It could also be a secondary effect of socioeconomic variables, patient compliance, or a host of other factors. Regardless, it’s bad. Smoking should be forbidden while in hospital, and should be strongly discouraged after discharge.

Reference: Cigarette smoking influences the clinical and occupational outcome of patients with tibial shaft fractures. Injury 42:1435-1442, 2011.

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