Finally, a consensus report has been finalized by the Institute for Clinical Systems Improvement (ICSI) regarding bleeding in patients taking dabigatran (Pradaxa). I’ve written about the special problems posed by patients who are injured while taking this drug and related ones. I’ve also provided some management algorithms for consideration while complete ones were crafted. Well, here they are.
A workgroup of experts from hospitals here in Minnesota were convened to consider and provide a framework for managing these patients. A document was released recently to help guide their care.
To summarize, patients who experience a severe bleed, say from trauma, should be managed with:
Holding the medication
Evaluating bleeding. In trauma, this will generally involve CT scan.
Consider the need for surgery
Give activated charcoal if the drug was taken within 2 hours
Transfuse blood if hemoglobin / hematocrit needs to be improved
Infuse plasma after 4 units of red cells, and cryoprecipitate after 8 units packed cells / 4 units plasma if needed
Consider prothrombin complex concentrate or activated Factor VII in extreme cases
Blunt injury to the thoracic aorta is one of those potentially devastating ones that you (and your patient) can’t afford to miss. Quite a bit has been written about the findings and mechanisms. But how do you put it all together and decide when to order a screening CT?
There are a number of high risk findings associated with blunt aortic injury. Recognize that they are associated with the injury, but are still not very common. They are:
Here’s a sensible method for screening for blunt aortic injury, using CT scan:
Reasonable mechanism (fall from greater than 20 feet, pedestrian struck, motorcycle crash, car crash at “highway speed”) PLUS any one of the high risk findings above.
Extreme mechanism alone (e.g. car crash with closing velocity at greater than highway speed, torso crush)
Note on torso crush: I have seen three aortic injuries from torso crush in my career, one from a load of plywood falling onto the patient’s chest, one from dirt crushing someone when the trench they were digging collapsed, and one whose chest was run over by a car.
Trauma surgeons often rely on consultants to assist in the care of their patients. Orthopedic surgeons and neurosurgeons are some of the more frequent consultants, but a variety of other surgical and medical specialists may be needed. I have found that providing a set of guidelines to consultants helps to ensure quality care and provide good communication between caregivers and patients / families.
We have disseminated a set of guidelines to our colleagues, and I wanted to touch on some of the main points. You can download the full document using the link at the bottom of this post.
In order to deliver the highest quality and most cost-effective care, we request that services we consult do the following:
Please introduce yourself to our patient and their family, and explain why you are seeing them.
Although you may discuss your findingswith the patient, please discuss all recommendationswith a member of the trauma service first. This avoids patient confusion if the trauma team chooses not to implement any recommendations due to other patient factors you may not be aware of.
Document your consultation results in writing (paper or EMR) in a timely manner.
If additional tests, imaging or medications are recommended, discuss with the trauma service first. We will write the orders or clear you to do so if appropriate, and will discuss the plan with the patient.
We round at specific times every day and welcome your attendance and input.
Please communicate any post-discharge instructions to us or enter in the medical record so we can expedite the discharge process and ensure all followup visits are scheduled.
Bottom line: A uniform “code of behavior” is important! Ensuring good patient communication is paramount. They need to hear the same plans from all of their caregivers or else they will lose faith in us. One of the most important lessons I have learned over the years is that you do not need to implement every recommendation that a consultant makes. They may not be aware of the most current trauma literature, and they will not be familiar with how their recommendations may impact other injuries.