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How To Manage TBI In Patients On Warfarin

We all know that the combination of traumatic brain injury (TBI) and warfarin can be dangerous. Here at Regions, we developed a reversal protocol a few years ago. However, we found that just having a list of preferred “antidotes” to give was not enough. The time factor is very important, and we found that we needed to ensure prompt use of these medications when indicated.

So we added features that ensured timely response and reversal. You can download the protocol by clicking the image above or the link at the bottom of this post.

First, we recognized that any patient with a known or suspected TBI who was taking warfarin was at risk. If the initial GCS was <14, then a full trauma team activation is called. This gives the patient priority lab processing and immediate access to the CT scan. In addition, 2 units of thawed plasma are administered while in the resuscitation room. If the head CT is negative, plasma is stopped.

For patients with a GCS of 14 or 15, a “Code RED” is called, ensuring that an ED physician sees the patient immediately. A point of care INR is drawn and the patient is sent for stat head CT. If the head CT is negative with INR>2.5, the patient is admitted for observation and a repeat head CT is obtained 12 hours later. We have seen patients develop delayed hemorrhage when they have high INR.

We apply a restrictive set of criteria to determine if a patient may go home from the ED, which causes us to admit most for observation. And if they do have a positive CT, we use the algoritm listed below for comprehensive management and reversal.

Bottom line: Patients with any head trauma and an elevated INR are a walking time bomb. They need prompt assessment and reversal of their anticoagulation if indicated. Feel free to share your protocols here as well by posting a comment.

Download the full protocol; click here.

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protocols

CIWA Protocol Precautions

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The post entitled “CIWA Demystified” is one of the most popular on this blog. This type of symptom triggered therapy for alcohol withdrawal applies some degree of objectivity to a somewhat subjective problem. However, it is possible to take it too far.

A retrospective review of registry patients who received CIWA guided therapy was performed. A total of 124 records were reviewed for appropriateness of CIWA useand adverse events. They found that only about half of patients (48%) met both usage criteria (able to communicate verbally, recent alcohol use). And 31% did not meet either criterion! There were 55 nondrinkers in this study, and even though 64% of them could communicate that fact, they were placed on the protocol anyway! Eleven patients suffered adverse events (delirium tremens, seizures, death). Four of them did not meet criteria for use of the protocol.

Bottom line: In order to be placed on the CIWA protocol, a patient must have a recent history of alcohol use, and must be able to communicate verbally. Some physicians assume that patients with autonomic hyperactivity or psychological distress are withdrawing and order the CIWA protocol. This can  cover up other causes of delirium, or may make it worse by administering benzodiazepines. This represents inappropriate use of the protocol!

Reference: Inappropriate use of symptom-triggered therapy for alcohol withdrawal in the general hospital. Mayo Clin Proc 83(3):274-279, 2008.

protocols

The Value of Protocols in Trauma

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Earlier this week, I wrote about several protocols that can be used in patients with rib fractures. Most trauma centers have a massive trauma protocol. Many have pain management or alcohol withdrawal or a number of other protocols. The question arose: why do we need another protocol? Can we show some benefit to using a protocol?

I’ve looked at the literature, and unfortunately there’s not a lot to go on. Here are my thoughts on the value of protocols.

In my view, there are a number of reasons why protocols need to be developed for commonly encountered issues.

  • They allow us to build in adherence to any known practice guidelines or literature.
  • They help conserve resources by standardizing care orders and resource use.
  • They reduce confusion. Nurses do not have to guess what cares are necessary based on the specific admitting surgeon.
  • They reduce errors for the same reason. All patients receive a similar regimen, so potential errors are more easily recognized.
  • They promote team building, particularly when the protocol components involve several different services within the hospital.
  • They teach a consistent, workable approach to our trainees. When they graduate, they are familiar with a single, evidence based approach that will work for them in their practice.

A number of years ago, we implemented a solid organ injury protocol here at Regions Hospital. I noted that there were large variations in simple things like time at bedrest, frequency of blood draws, how long the patient was kept without food and whether angiography should be considered. Once we implemented the protocol, patients were treated much more consistently and we found that costs were reduced by over $1000 per patient. Since we treat about 200 of these patients per year, the hospital saved quite a bit of money! And our blunt trauma radiographic imaging protocol has significantly reduced patient exposure to radiation.

Bottom line: Although the proof is not necessarily apparent in the literature, protocol development is important for trauma programs for the reasons outlined above. But don’t develop them for their own sake. Identify common problems that can benefit from consistency. It will turn out to be a very positive exercise and reap the benefits listed above.

General

Rib Fracture Management

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A reader sent a query yesterday regarding treatment of rib fractures, and specifically asking about epidural analgesia. Today, I’ll try to answer those questions.

Rib fractures, with or without other injuries, are a big killer in trauma patients. This is particularly true in the elderly. Overall mortality rates range from 3% to 13%, with the most import factor being pain. So what is the best way to manage patients with rib fractures to speed their safe recovery?

It’s best to attack this problem from three different directions simultaneously: pain control, respiratory hygiene (or pulmonary toilet if you’re a pessimist), and activity management.

There are many approaches to pain management, which include:

  • Oral or IV analgesics
  • Various types of blocks (intrapleural, intercostal, paravertebral, epidural)
  • Topical agents (xylocaine patch)
  • Stabilization (surgical only; belts and straps are bad for breathing)

Epidural analgesia is usually seen as the ultimate form of pain control, and is usually recommended for patients with multiple fractures or severe pain with inadequate response to medications and blocks. Much of the literature on its use is based on ICU patients who were not injured. A meta-analysis was conducted that specifically looked at epidural analgesia results in trauma patients, and found that it did improve pain management and some pulmonary function tests. However, there did not appear to be any change in mortality, ICU or hospital length of stay, or time on a ventilator.

Respiratory hygiene may involve simple measures such as coughing and deep breathing, incentive spirometry, and even mechanical ventilation in severe cases. Activity management consists of turning, sitting in a chair, walking, and forms of mechanical chest wall oscillation.

Bottom Line: The key to rib fracture management is a systematic approach that address all three dimensions of care based on objective patient measures. One size does not fit all, so more aggressive measures are warranted for more severe injury. I’ve attached an interesting patented scoring system and management algorithm, as well as two protocols from US trauma centers that range from simple (Vanderbilt) to more complex (West Virginia University).

Please feel free to comment, and I’d be happy to look at your protocol. Please email it to me!

Related post: History of epidural analgesia

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References

  • Effect of epidural analgesia in patients with traumatic rib fractures: a systematic review and meta-analysis of randomized controlled trials. Can J Anaesth 56(3):230-42, Epub 2009 Feb 11.
  • Rib Fracture Score and Protocol, US Patent #7,225,813 B2 – June 5, 2007
General

Results – Blunt Trauma Radiographic Imaging Protocol

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In my previous post (click here to view) I discussed an imaging protocol that we developed and implemented last year. Today, I’ll detail what it has accomplished in our patients.

We looked at 229 patients who had their imaging performed according to the new protocol during a 3 month period and compared them to 215 patients who were imaged the previous year. Each scan administered to each body area (head, chest, abdomen/pelvis, c-spine, t-spine, l-spine, face, neck angio) were tabulated separately.

We found that the overall number of scans performed decreased significantly. We looked at our data and generated numbers per 100 patients. During the control period, we did 298 CT scans per 100 patients. This decreased to 271 during the study period. The number of head scans remained the same (82 per 100 patients during control, 85 per 100 during the study), as did the cervical spine scans (84 vs 86).

The biggest declines were seen in chest CT (53 per 100 control vs 33 per 100 study) and abdominal CT (57 vs 43).

We did see an increase in conventional xrays of the thoracic and lumbar spines to offset the absence of reformatted spine images that would have been generated from the chest and abdominal CT scans. We also noted small increases in CT of the head, cervical spine, and neck angio. This was likely due to better adherence to specific guidelines.

Bottom line: we believe that our work shows that careful adoption of well thought out guidelines can make a difference in practice and significantly decreases radiation exposure in our blunt trauma patients.

To read the post on this protocol, or to download it, click here.

Click here to download the Blunt Trauma Radiographic Imaging Protocol Worksheet