BET 2: Is early chemical thromboprophylaxis safe in patients with blunt trauma solid organ injury (SOI) undergoing non-operative management (NOM)?

Therapeutic Dilemma: Acute Myocardial Infarction in a Patient with Traumatic Hepatic and Mesenteric Injuries: A Case Report

ST-elevation myocardial infarction (STEMI) in a trauma patient with solid abdominal organ or vascular injuries can present complex diagnostic and therapeutic challenges. Evidence for managing such demanding cases is scarce, and isolated case reports remain the source of information in treating these patients. We present a patient with traumatic mesenteric and hepatic injuries who developed acute STEMI in the immediate postoperative period.

Liver Trauma: Management in the Emergency Setting and Medico-Legal Implications

Traumatic abdominal injuries are life-threatening emergencies frequently seen in the Emergency Department (ED). The most common is liver trauma, which accounts for approximately 5% of all ED admissions for trauma. The management of blunt liver trauma has evolved significantly over the past few decades and, according to the injury’s severity, it may require massive resuscitation, radiological procedures, endoscopy, or surgery. Patients admitted to the ED with blunt abdominal trauma require a multidisciplinary evaluation, including emergency physicians, surgeons, radiologists, and anesthetists, who must promptly identify the extent of the injury to prevent serious complications. In case of a patient’s death, the execution of a forensic examination carried out with a multidisciplinary approach (radiological, macroscopic, and histological) is essential to understand the cause of death and to correlate the extent of the injuries to the possibility of survival to be able to manage any medico-legal disputes. This manuscript aims to collect the most up-to-date evidence regarding the management of hepatic trauma in the emergency room and to explore radiological findings and medico-legal implications.

Relationship Between Anti-Xa Level Achieved with Prophylactic Low-Molecular Weight Heparin and Venous Thromboembolism in Trauma Patients: A Systematic Review and Meta-Analysis

BACKGROUND

Trauma patients have simultaneously high venous thromboembolism (VTE) and bleeding risk. Optimal chemoprophylaxis regimens remain unclear. This study aims to answer three questions for trauma patients. Is there any association between anti-Xa and VTE? Does dose adjustment improve prophylactic anti-Xa rates? Does dose adjustment improve anti-Xa adequacy and VTE compared to standard dosing?

METHODS

Systematic search of MEDLINE, Embase, Scopus, and Web of Science occurred in May 2021.Two author review included trauma studies that: evaluated low molecular weight heparin chemoprophylaxis, reported anti-Xa level, and evaluated ≥1 outcome. Data was dually extracted and estimated effects were calculated using RevMan 5.4 applying the Mantel-Haenszel method. Analysis #1 compared patients with peak anti-Xa ≥ 0.2 IU/ml or trough ≥0.1 IU/ml to those with lower anti-Xa using VTE as the primary outcome. Analysis #2 reported the effect of dose adjustment on anti-Xa. Analysis #3 compared standard dosing to dose adjustment with the primary outcome being anti-Xa adequacy; secondary outcomes were VTE, pulmonary embolism, and bleeding complications.

RESULTS

3401 studies were evaluated with 24 being included (19 retrospective studies, 5 prospective studies). In analysis #1, achieving adequate anti-Xa was associated with reduced odds of VTE (4.0% to 3.1%, OR 0.52, p = 0.03). Analysis #2 demonstrated that 768 (75.3%) patients achieved prophylactic anti-Xa with adjustment protocols.Analysis three suggested that dose adjusted chemoprophylaxis achieves prophylactic anti-Xa more frequently (OR 4.05, p = 0.007) but without VTE (OR 0.72, p = 0.15) or PE (OR 0.48, p = 0.10) differences. In subgroup analysis, anti-Xa dose adjustment also suggested no VTE reduction (OR 0.68, p = 0.08).

CONCLUSIONS

Patients with higher anti-Xa levels are less likely to experience VTE, and anti-Xa guided chemoprophylaxis increases anti-Xa adequacy. However, dose adjustment, including anti-Xa guided dosing, may not reduce VTE.

LEVEL OF EVIDENCE

Level IV; Systematic Review Meta-Analysis.

Venous thromboembolism prophylaxis in the trauma intensive care unit: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document

Venous thromboembolism (VTE) is a potential sequela of injury, surgery, and critical illness. Patients in the Trauma Intensive Care Unit are at risk for this condition, prompting daily discussions during patient care rounds and routine use of mechanical and/or pharmacologic prophylaxis measures. While VTE rightfully garners much attention in clinical patient care and in the medical literature, optimal strategies for VTE prevention are still evolving. Furthermore, trauma and surgical patients often have real or perceived contraindications to prophylaxis that affect the timing of preventive measures and the consistency with which they can be applied. In this Clinical Consensus Document, the American Association for the Surgery of Trauma Critical Care Committee addresses several practical clinical questions pertaining to specific or unique aspects of VTE prophylaxis in critically ill and injured patients.

Is early chemical thromboprophylaxis in patients with solid organ injury a solid decision?

BACKGROUND

The optimal time to initiate chemical thromboprophylaxis (CTP) in patients who have undergone nonoperative management (NOM) of blunt solid organ injuries (SOI) remains controversial. The aim of our study was to assess the impact of early initiation of CTP in patients with blunt abdominal SOIs.

METHODS

We performed a 2-year (2013-2014) retrospective analysis of American College of Surgeons Trauma Quality Improvement Program. We included all adult trauma patients (age, ≥ 18 years) with blunt SOI who underwent NOM. Patients were stratified into three groups based on timing of CTP (early, ≤48 hours of injury; late, >48 hours of injury,; and no prophylaxis group). Our primary outcomes were rates of failure of NOM, pRBC transfusion, and mortality. Our secondary outcomes were the rate of venous thromboembolic (VTE) events (i.e., deep venous thrombosis [DVT] and/or pulmonary embolism [PE]) and length of stay.

RESULTS

A total of 36,187 patients met the inclusion criteria. Mean age was 49.5 ± 19 years and 36% of patients received CTP (early, 37% (n = 4,819) versus late, 63% (n = 8,208)). After controlling for confounders, patients receiving early CTP had lower rates of DVT (p = 0.01) and PE (p = 0.01) compared with the no prophylaxis and late CTP groups. There was no difference between the three groups regarding the postprophylaxis pRBC transfusions, failure of NOM, and mortality.

CONCLUSION

Our results suggest that in patients undergoing NOM of blunt abdominal SOI, early initiation of CTP should be considered. It is associated with decreased rates of DVT and PE, with no significant difference in post prophylaxis pRBC transfusion, failure of nonoperative management, and mortality.

LEVEL OF EVIDENCE

Therapeutic, level V.

It's sooner than you think: Blunt solid organ injury patients are already hypercoagulable upon hospital admission - Results of a bi-institutional, prospective study

INTRODUCTION

The optimal time to initiate venous thromboembolism (VTE) chemoprophylaxis in blunt solid organ injury (BSOI) patients is debated. We hypothesize that 1) BSOI patients are hypercoagulable within 12 h of injury and 2) hypercoagulability dominates in patients who develop clot complications (CC).

MATERIAL AND METHODS

This is a prospective study of BSOI patients admitted to two Level-1 Trauma Centers' trauma intensive care units (ICU). Serial kaolin thrombelastography (TEG) and tissue plasminogen activator (tPA)-challenge TEGs were performed. CC included VTE and cerebrovascular accidents.

RESULTS

On ICU admission, all patients (n = 95) were hypercoagulable, 58% were in fibrinolysis shutdown, and 50% of patients were tPA-resistant. Twelve patients (13%) developed CC. Compared to those without CC, they demonstrated decreased fibrinolysis at 12 h and higher clot strength at 48 h CONCLUSIONS: BSOI patients are universally hypercoagulable upon ICU admission. VTE chemoprophylaxis should be started immediately in BSOI patients with hypercoagulability on TEG.