Low-risk Trauma Patients Research Articles

Implementation of the Modified Canadian C-Spine Rule by Paramedics.

The Canadian C-spine rule was modified and validated for use by the paramedics in a multicenter study where patients were assessed with the Canadian C-spine rule yetall transported with immobilization. This study evaluated the clinical impact of the modified Canadian C-spine rule when implemented by paramedics. This single-center prospective cohort implementation study took place in Ottawa, Canada (from 2011 to 2015). Advanced and primary care paramedics were trained to use the modified Canadian C-spine rule, collect data on a standardized study form, and selectively transport eligible patients without immobilization. We evaluated all consecutive low-risk adult patients (Glasgow Coma Scale [GCS] 15, stable vital signs) at risk for a neck injury. We followed all patients without initial radiologic evaluation for 30 days. Analyses included descriptive statistics with 95% confidence intervals (CI), sensitivity, specificity, and kappa coefficients. The 4,034 enrolled patients had a mean age of 43 (range 16 to 99), and 53.4% were female. Motor vehicle collisions were the most common mechanism of injury (55.1%), followed by falls (23.9%). There were 11 clinically important injuries. The paramedics classified these injuries with a sensitivity of 90.9% (95% CI, 58.7 to 99.8) and specificity of 66.5% (95% CI, 65.1 to 68.0). There was no adverse event or resulting spinal cord injury. The kappa agreement between paramedics and investigators was 0.94. A total of 2,583 (64.0%) immobilizations were avoided using the modified Canadian C-spine rule. Paramedics could accurately apply the modified Canadian C-spine rule to low-risk trauma patients and significantly reduce the need for spinal immobilization during transport. This resulted in no adverse event or any spinal cord injury.

Predicting risk for trauma patients using static and dynamic information from the MIMIC III database.

Risk quantification algorithms in the ICU can provide (1) an early alert to the clinician that a patient is at extreme risk and (2) help manage limited resources efficiently or remotely. With electronic health records, large data sets allow the training of predictive models to quantify patient risk. A gradient boosting classifier was trained to predict high-risk and low-risk trauma patients, where patients were labeled high-risk if they expired within the next 10 hours or within the last 10% of their ICU stay duration. The MIMIC-III database was filtered to extract 5,400 trauma patient records (526 non-survivors) each of which contained 5 static variables (age, gender, etc.) and 28 dynamic variables (e.g., vital signs and metabolic panel). Training data was also extracted from the dynamic variables using a 3-hour moving time window whereby each window was treated as a unique patient-time fragment. We extracted the mean, standard deviation, and skew from each of these 3-hour fragments and included them as inputs for training. Additionally, a survival metric upon admission was calculated for each patient using a previously developed National Trauma Data Bank (NTDB)-trained gradient booster model. The final model was able to distinguish between high-risk and low-risk patients to an AUROC of 92.9%, defined as the area under the receiver operator characteristic curve. Importantly, the dynamic survival probability plots for patients who die appear considerably different from those who survive, an example of reducing the high dimensionality of the patient record to a single trauma trajectory.

Tranexamic Acid Treatment for Trauma Victims.

Worldwide, traumatic injury is responsible for over 5 million deaths per year, the majority due to exsanguination and head injury. The antifibrinolytic drug tranexamic acid is the only drug proven to reduce deaths after traumatic injury. Several large randomized controlled trials have provided high-quality evidence of its effectiveness and safety in trauma patients. Early tranexamic acid reduces deaths on the day of the injury in polytrauma patients and patients with isolated traumatic brain injury by around 20%. Treatment is time critical; for patients to benefit, tranexamic acid must be given as soon as possible after injury. Intramuscular administration is well tolerated and rapidly absorbed, with the potential to reduce time to treatment. Because the proportional reduction in bleeding death with tranexamic acid does not vary by baseline risk, a wide range of trauma patients stands to benefit. There are far more low-risk trauma patients than high-risk patients, with a substantial proportion of bleeding deaths in the low-risk group. As such, treatment should not be limited to patients with severe traumatic hemorrhage. We must give paramedics and physicians the confidence to treat a far wider range of trauma patients while emphasizing the importance of early treatment.

Pragmatic Strategy Empowering Paramedics to Assess Low-Risk Trauma Patients With the Canadian C-Spine Rule and Selectively Transport Them Without Immobilization: Protocol for a Stepped-Wedge Cluster Randomized Trial.

BackgroundEach year, half a million patients with a potential neck (c-spine) injury are transported to Ontario emergency departments (EDs). Less than 1.0% (1/100) of these patients have a neck bone fracture. Even less (1/200, 0.5%) have a spinal cord injury or nerve damage. Currently, paramedics transport all trauma victims (with or without an injury) by ambulance using a backboard, cervical collar, and head immobilizers. Importantly, prolonged immobilization is often unnecessary; it causes patient discomfort and pain, decreases community access to paramedics, contributes to ED crowding, and is very costly. We therefore developed the Canadian C-Spine Rule (CCR) for alert and stable trauma patients. This decision rule helps ED physicians and triage nurses to safely and selectively remove immobilization, without x-rays and missed injury. We successfully taught Ottawa paramedics to use the CCR in the field in a single-center study.ObjectiveThis study aimed to improve patient care and health system efficiency and outcomes by allowing paramedics to assess eligible low-risk trauma patients with the CCR and selectively transport them without immobilization to the ED.MethodsWe propose a pragmatic stepped-wedge cluster randomized design with health economic evaluation, designed collaboratively with knowledge users. Our 36-month study will consist of a 12-month setup and training period (year 1), followed by the stepped-wedge trial (year 2) and a 12-month period for study completion, analyses, and knowledge translation. A total of 12 Ontario paramedic services of various sizes distributed across the province will be randomly allocated to one of three sequences. Paramedic services in each sequence will cross from the control condition (usual care) to the intervention condition (CCR implementation) at intervals of 3 months until all communities have crossed to the intervention. Data will be collected on all eligible patients in each paramedic service for a total duration of 12 months. A major strength of our design is that each community will have implemented the CCR by the end of the study.ResultsInterim results are expected in December 2019 and final results in 2020. If this multicenter trial is successful, we expect the Ontario Ministry of Health will recommend that paramedics evaluate all eligible patients with the CCR in the Province of Ontario.ConclusionsWe conservatively estimate that in Ontario, more than 60% of all eligible trauma patients (300,000 annually) could be transported safely and comfortably, without c-spine immobilization devices. This will significantly reduce patient pain and discomfort, paramedic intervention times, and ED length of stay, thereby improving access to paramedics and ED care. This could be achieved rapidly and with lower health care costs compared with current practices (possible cost saving of Can $36 [US $25] per immobilization or Can $10,656,000 [US $7,335,231] per year).Trial RegistrationClinicalTrials.gov NCT02786966; https://clinicaltrials.gov/ct2/show/NCT02786966.International Registered Report Identifier (IRRID)DERR1-10.2196/16966

MP14: Quantification of head-neck motion in trauma patients in the emergency department under spinal motion restriction: a prospective observational study

Introduction: This was a prospective observational study involving a convenience sample of low-risk trauma patients presenting to a Level 1 Trauma Centre under spinal motion restriction (SMR). To our knowledge no prior studies have objectively measured head-neck (H-N) motion in trauma patients with suspected spine injuries during emergency department (ED) care. The goal was to establish the feasibility of deploying non-invasive motion sensors on trauma patients in the ED and to provide initial estimates for H-N kinematics under SMR during different phases of treatment. Methods: Low-risk adult patients treated by Winnipeg Fire Paramedic Service who sustained non-life threatening trauma with the potential for spine injury were eligible for inclusion. Participants received usual pre-hospital care; application of spine board and/or cervical collar, as determined by local practice protocol. Inertial measurement units (IMUs) were placed on participant's forehead, sternum and stretcher upon arrival to the ED. Data was collected during three phases of care: patient handling (log rolls, transfers, clothing removal); stretcher movement (to imaging, etc); stretcher stationary. IMUs were removed upon disposition decision by the attending physician. IMUs yielded data on H-N motion in terms of linear acceleration (resultant) and angular displacement (rotation + flexion-extension + side-flexion = total). Peak (M +/- SE) displacements and accelerations are reported, with comparisons across treatment phases using repeated measures ANOVA. Results: Eleven patients were enrolled in the study (age: 49 +/- 16 years; Injury Severity Score 13.4 +/- 9.9; female = 2). Substantial H-N motion was observed during ED care. Total H-N displacement (28.6 +/- 3.6 deg) and acceleration (7.8 +/- 1.0 m/s2) were higher during patient handling compared to stretcher moving (13.0 +/- 2.5 deg; 4.6 +/- 0.9 m/s2; p < .05) but not while the stretcher was stationary (18.9 +/- 3.4 deg; 5.4 +/- 1.2 m/s2; p > .06). Similar differences were detected for side-flexion and flexion-extension (p < .05), with peak displacements of 11.4+/-1.5 deg and 14.6 +/- 2.2 deg during patient handling, respectively. Conclusion: IMU use on trauma patients safely described H-N motion kinematics in a small sample of patients with different spectrums of illness during their care in the ED. Future studies utilizing IMUs could inform ED spine motion restriction protocols and compare movement of patients in specific subsets (intoxicated, spinal tenderness, injury severity etc.).

Prevalence of Serious Injuries in Low Risk Trauma Patients

Prevalence of Serious Injuries in Low Risk Trauma Patients

Prevalence of serious injuries in low risk trauma patients

ObjectivesComputed tomography (CT) utilization is widespread in contemporary Emergency Departments (EDs). CT overuse leads to radiation exposure, contrast toxicity, overdiagnosis, and incidental findings. This study explores the prevalence of clinically significant injuries in patients identified as low-risk trauma patients (LRTPs) using newly created criteria that account for the patient's age, trauma mechanism, assessability (which relies on level of consciousness, intoxication, and neurologic deficits), vital signs and other evidence of hypoperfusion, bleeding risk, and past medical history. MethodsThis was a 6-month retrospective chart review of all LRTPs presenting to a level 1 trauma center in Queens, New York. Data abstraction was performed independently by two abstractors and discrepancies adjudicated by the senior author. Patients were identified using the hospital trauma registry and two reports, created by the researchers, identifying selected chief complaints and discharge diagnoses. Results750 patients were identified of which 352 (46.93%) received one or more CT scans. There were a total of 790 CT scans ordered, of which 731 (92.53%) were negative for acute injury. There were 13 clinically significant injuries of which only one (0.13%) required immediate intervention. There were no mortalities in this LRTP group. ConclusionThe prevalence of clinically significant injuries in this population is very low and injuries requiring immediate intervention are even lower. CT utilization in LRTPs should be guided by an explicit consideration of benefit and harm for each patient.

A prospective evaluation of cervical spine immobilisation in low-risk trauma patients at a tertiary Emergency Department

BackgroundIn the Emergency Department cervical spine immobilisation precautions are frequently used. There is controversy in regard to the balance of risks and benefits of routine immobilisation in conscious patients. MethodsA prospective multi-methods evaluation in a tertiary trauma referral centre. The objectives were to investigate current practices and rate of concordance with established international guidelines. A provider survey focused on current knowledge, skills and attitudes and was disseminated to nurses, doctors and paramedics treating trauma patients. Additionally, clinical data were collected on a cohort of immobilised trauma patients. Demographic data were analysed using SPSS and content analysis was completed by manifest coding. ResultsThe response rate to the survey was 85.2%. Interdisciplinary providers included nurses (n=46), doctors (n=68) and paramedics (n=41).Content analysis revealed a range of themes for improving care. Themes identified included improved application of guidelines, tailored use of equipment in low-risk patients, improved access to radiology results, and staff education. The series of five case vignettes provided to participants revealed a high level of variance in intended approaches to immobilisation. In the cohort of trauma patients (n=54), the median age was 54 years and the most common mechanism of injury was falls (40.7%). Median time spent with immobilisation was 325min. Adherence to a recognised decision tool was 35/54 (64.8%). Precautions were initiated by paramedics in 42/54 (77.8%). ConclusionsDespite widespread dissemination of guidelines, observed approaches to patient immobilisation appear to be highly variable in this trauma centre. Reducing variation for low-risk patients is likely to improve the patient journey and minimise the risk of prolonged immobilisation. Further assessment of the causes of variation could define goals for targeted translational change.

Yield of serious axial injury from pan scans after blunt trauma in haemodynamically stable low-risk trauma patients.

Whole body computed tomography (WBCT) scanning for trauma has gained popularity but its role in low-risk patients is controversial. We aimed to determine the rate of serious axial/truncal injury and emergency intervention in conscious, stable patients undergoing WBCT for blunt trauma in two non-trauma centre EDs in the Victorian trauma system. Retrospective cohort study by medical record and radiology report review. Patients were included if they were conscious, haemodynamically stable adults presenting by ambulance and having WBCT scan. Exclusion criteria were age <16 years, no history of trauma, Glasgow Coma Scale <14, systolic blood pressure <90 mmHg and intoxication with alcohol or drugs. Data collected included demographics, clinical findings, results of CT scans and emergency interventions (emergency truncal surgery, transfer to a trauma centre and/or transfusion within 24 h). The outcomes of interest were the rate of defined serious axial/truncal injury and emergency interventions. One hundred and four patients were studied. Median age was 45 years; 67% were men. Median injury severity score (ISS) was 1.5 (interquartile range 0-5); only one patient had an ISS ≥15. Ninety (87%, 78-92%) patients had no defined serious injury. Five (5%) patients had a defined emergency intervention - four trauma centre transfers and one transfusion. Two of these were not trauma-related. The rate of serious axial/truncal injury was low. The high rate of normal scans makes it likely that the risk:benefit ratio between injury identification and radiation related cancer risk is unacceptably high. This data supports a selective CT strategy in low-risk trauma patients.

PL03: Implementation of the Canadian C-Spine Rule by paramedics: a safety evaluation

Introduction: The Canadian C-Spine Rule (CCR) was validated by emergency physicians and triage nurses to determine the need for radiography in alert and stable Emergency Department trauma patients. It was modified and validated for use by paramedics in 1,949 patients. The prehospital CCR calls for evaluation of active neck rotation if patients have none of 3 high-risk criteria and at least 1 of 4 low-risk criteria. This study evaluated the impact and safety of the implementation of the CCR by paramedics. Methods: This single-centre prospective cohort implementation study took place in Ottawa, Canada. Advanced and primary care paramedics received on-line and in-person training on the CCR, allowing them to use the CCR to evaluate eligible patients and selectively transport them without immobilization. We evaluated all consecutive eligible adult patients (GCS 15, stable vital signs) at risk for neck injury. Paramedics were required to complete a standardized study data form for each eligible patient evaluated. Study staff reviewed paramedic documentation and corresponding hospital records and diagnostic imaging reports. We followed all patients without initial radiologic evaluation for 30 days for referral to our spine service, or subsequent visit with radiologic evaluation. Analyses included sensitivity, specificity, kappa coefficient, t-test, and descriptive statistics with 95% CIs. Results: The 4,034 patients enrolled between Jan. 2011 and Aug. 2015 were: mean age 43 (range 16-99), female 53.3%, motor vehicle collision 51.9%, fall 23.8%, admitted to hospital 7.0%, acute c-spine injury 0.8%, and clinically important c-spine injury (0.3%). The CCR classified patients for 11 important injuries with sensitivity 91% (95% CI 58-100%), and specificity 67% (95% CI 65-68%). Kappa agreement for interpretation of the CCR between paramedics and study investigators was 0.94 (95% CI 0.92-0.95). Paramedics were comfortable or very comfortable using the CCR in 89.8% of cases. Mean scene time was 3 min (15.6%) shorter for those not immobilized (17 min vs. 20 min; p=0.0001). A total of 2,569 (63.7%) immobilizations were safely avoided using the CCR. Conclusion: Paramedics could safely and accurately apply the CCR to low-risk trauma patients. This had a significant impact on scene times and the number of prehospital immobilizations.

Evaluation and management of blunt traumatic aortic injury: a practice management guideline from the Eastern Association for the Surgery of Trauma.

Blunt traumatic aortic injury (BTAI) is the second most common cause of death in trauma patients. Eighty percent of patients with BTAI will die before reaching a trauma center. The issues of how to diagnose, treat, and manage BTAI were first addressed by the Eastern Association for the Surgery of Trauma (EAST) in the practice management guidelines on this topic published in 2000. Since that time, there have been advances in the management of BTAI. As a result, the EAST guidelines committee decided to develop updated guidelines for this topic using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework recently adopted by EAST. A systematic review of the MEDLINE database using PubMed was performed. The search retrieved English language articles regarding BTAI from 1998 to 2013. Letters to the editor, case reports, book chapters, and review articles were excluded. Topics of investigation included imaging to diagnose BTAI, type of operative repair, and timing of operative repair. Sixty articles were identified. Of these, 51 articles were selected to construct the guidelines. There have been changes in practice since the publication of the previous guidelines in 2000. Computed tomography of the chest with intravenous contrast is strongly recommended to diagnose clinically significant BTAI. Endovascular repair is strongly recommended for patients without contraindications. Delayed repair of BTAI is suggested, with the stipulation that effective blood pressure control must be used in these patients.

Spinal clearance guideline for out-of hospital providers

Introduction Unnecessary spinal cord immobilisation is a common problem in South Africa, even though out-of hospital spinal clearance is becoming standard of care in international emergency medical care (EMC) communities. Large numbers of unnecessary spinal immobilisations, in low risk trauma patients, result in an increased health and economic burden in both the in-hospital and out-of hospital settings. Currently, informal spinal clearance is being practiced in South Africa creating large practice variation, potential patient safety compromise and probable economic burden. An evidence-based out-of hospital spinal clearance algorithm would minimise the unnecessary hospitalisation of low risk spinal patients. Our objectives included: (i) To provide an accurate and reproducible algorithm to identify and correctly refer clinically relevant spinal injury in the out-of hospital setting and (ii) To inform policy makers of best practice for spinal cord clearance through evidence informed decision making and provide implementation and evaluation recommendations. This document provides recommendations for a spinal clearance guideline for South Africa and includes implementation strategies and evaluation criteria. Methods A Population, Intervention, Professionals, Outcomes and Health Context (PIPOH) research question was designed to answer the guideline topic. The literature was systematically searched for spinal clearance guidelines or recommendations. These were screened, appraised and adapted by a specialist emergency care review group using the Appraisal of Guidelines Research and Evaluation (AGREE II) and ADAPTE tools recommended for guideline adaptation and development. The results were filtered by the primary author using pre-defined selection criteria. Results A total of 8 guidelines met the inclusion criteria. Each guideline was independently assessed by two emergency care specialists using the AGREE II tool. A forum discussion was held to adapt the included guidelines to the local out-of hospital needs. Emergency care policy stakeholders and operational and student paramedics were asked to review and comment on the adapted algorithm. Conclusion An out-of hospital spinal clearance guideline was developed with evaluation and implementation strategies for the out-of hospital context. The author would like to acknowledge the South African Cochrane Centre and Dr Tamara Kredo for their support.

The use of temporary abdominal closure in low-risk trauma patients

Temporary abdominal closure (TAC) has become a widely used technique in severely injured patients. However, there is growing concern that TAC is being overutilized. We sought to identify less severely injured patients who underwent TAC and to compare their outcomes with patients managed with a single-stage laparotomy (SSL). This is a analysis of all trauma patients who underwent immediate laparotomy from 2005 to 2009. Risk modeling identified TAC patients who met all low-risk criteria: systolic blood pressure >90, no severe head injury, no combined solid + hollow viscus injury, or vascular injury. The low-risk cohort (LR-TAC) was compared with a matched similarly injured cohort managed with SSL using univariate and multivariate regression analysis. Among the 282 patients undergoing TAC, 62 (22%) met low-risk criteria and were included in the LR-TAC group. There were 566 patients identified in the SSL group. There was no significant difference between groups for age, mechanism, Injury Severity Scores, associated injuries, base deficit, temperature, blood transfusion, solid organ injury, or bowel resection. The LR-TAC group had more hospital and ventilator days and increased complications rates (all p < 0.05). This included a higher rate of bowel ischemia/perforation with LR-TAC (7% vs. 0.7%). The use of TAC in the low-risk group was independently associated with increased complications (odds ratio 3.0, p = 0.01) and prolonged hospital stays (odds ratio 9.6, p < 0.01). TAC was associated with increased morbidity and resource utilization when applied to less severely injured patients. Further study is indicated to clarify populations that may be harmed or benefitted by TAC. : III, therapeutic study.

267: Using Body Mass Index to Predict the Adequacy of Cervical Spine Radiography in Trauma Patients

Plain radiography is the first line study for low-risk trauma patients undergoing ED evaluation of possible cervical spine injury because of its lower cost and radiation exposure relative to CT. We sought to determine if body mass index (BMI), as a measurable indicator of body habitus, is a useful tool to predict who should go directly to CT because plain radiographic views would be inadequate to rule out injury, thereby reducing the time, expense, and radiation associated with two radiographic studies.

The safety of nurse clearance of the cervical spine using the National Emergency X‐radiography Utilization Study low‐risk criteria

To determine the level of agreement between trained ED nursing staff and senior ED medical staff in the application and interpretation of the National Emergency X-radiography Utilization Study (NEXUS) low-risk criteria (NLC). A NEXUS training and accreditation package was developed. It was successfully undertaken by 22 senior ED nursing staff and 26 senior ED medical staff. A study nurse and doctor independently applied the NLC to a convenience sample of patients who had been placed in a hard cervical collar prior to arrival in the ED. The findings for each of the NLC and the overall decision regarding collar removal were recorded on specific case report forms. The primary endpoint was the level of agreement for the overall decision to leave the collar in place. Levels of agreement for the individual NLC were also examined. In total, 183 patients were recruited. The level of 'safe agreement' where nursing and medical staff agreed that the collar should be left in place was 94.3% (95% CI: 89.5-97.2%). Agreement with regard to individual NLC varied from good to fair. The median times from patient arrival to completion of study nurse and doctor assessments were 14 min (interquartile ranges [IQR] 5-30) and 29 min (IQR 15-47), respectively. The study demonstrated a high level of agreement between nursing and medical staff for stable low-risk trauma patients.

Current practice in clinical cervical spinal clearance: Implication for ems

Objectives. To examine the practice of clinically “clearing” the cervical spine (c-spine) of trauma patients brought to the ED by EMS with cervical immobilization in place, and to examine developing trends in prehospital c-spine clearance. Methods. A 12-question survey form was mailed to the physician medical directors of 300 randomly selected EDs. Questions examined ED clinical clearance practices, EMS clearance protocols and research, and attitudes toward prehospital clearance. Estimated clinical clearance rates were requested. Results. A total of 173 surveys were returned (58%). At 21 hospitals (12%), c-spine films are obtained for all immobilized trauma patients; clinical clearance is never attempted. Of the remaining 151 hospitals, on average, clinical clearance is attempted for 65.5% of these patients (range 3–100%, interquartile range 50–100%) and is successful (films are not obtained) for 53.7% of attempts (range 0–100%, interquartile range 35–75%). No differences exist in either attempt rate or success rate between trauma centers and non-trauma centers, or between academic/university hospitals, community teaching hospitals, and community non-teaching hospitals (t-test or ANOVA, p > 0.05). Seventy-two respondents (42%) reported significant variation in clinical clearance practice patterns among their ED physicians. Seventy-three respondents (42%) feel that EMS providers should immobilize all trauma patients, while 99 (57%) feel it is reasonable for trained EMS providers to attempt clinical clearance on low-risk trauma patients. Conclusions. There is tremendous variation in the ED practice of clinically clearing cervical spines. This, and a lack of support from many ED directors, may hinder attempts at development of research and standardized protocols for prehospital c-spine clearance.

Mild traumatic brain injuries in low-risk trauma patients.

Moderate or severe traumatic brain injury (TBI) resulting from cranial trauma is usually easily recognizable. Mild TBI (MTBI), however, may escape detection at presentation because of delayed symptoms and the absence of radiographic abnormalities. Despite its subtle or delayed presentation, the spectrum of symptoms often experienced after MTBI, collectively referred to as "postconcussive syndrome," may cause serious psychosocial dysfunction. To assess the sensitivity of emergency department screening for MTBI, a prospective follow-up study was conducted on a group of patients (N = 129) who had been evaluated at a regional trauma center after blunt trauma. None had symptoms or signs of TBI at presentation, nor any history of direct cranial trauma. All were discharged to home from the emergency department without a diagnosis of TBI. At 1 month after injury, 41 of 129 (32%) patients described an increase in symptoms consistent with MTBI. The most common symptoms were insomnia (62%), headaches (58%), irritability (56%) and fatigue (56%). At 2 months, most symptoms had decreased significantly, and none had increased in severity. Despite improvement in their symptoms over that time period, 11% of those with persistent symptoms remained unable to resume their premorbid daily activities. These data, obtained from a population of patients considered to be at extremely low risk for TBI, indicate that MTBI occurs more often among blunt trauma patients than is commonly appreciated, even in busy trauma centers. Because early recognition of MTBI may expedite referral of these patients for appropriate outpatient follow-up care, thereby avoiding potentially serious social and financial repercussions, emergency department personnel should have a high index of suspicion for MTBI in any patient sustaining blunt systemic trauma. Current measures that screen for MTBI appear to be inadequate; follow-up protocols may prove to be more sensitive screening tools.

Complications of Anticoagulation for Pulmonary Embolism in Low Risk Trauma Patients

Trauma patients are at significant risk for deep venous thrombosis (DVT) and pulmonary embolism (PE). Anticoagulation is standard therapy for DVT/PE, but may cause severe complications. We reviewed the course of 70 trauma ICU patients treated over a 28-month period. Thirty-six patients (51.4 percent) were treated by continuous IV heparin and/or oral warfarin. Of these, 13 patients (36 percent) developed complications requiring termination of anticoagulation. These included recurrent PE (four), subdural hematomas (three), hemothorax (two), heparin-induced thrombocytopenia (one), hemorrhagic pericardial effusion (one), retroperitoneal hematoma (one), and sudden unexplained drop in hemoglobin and shock (one). All patients with subdural hematomas had no prior evidence of head injury on brain computed tomography. All patients with recurrent PE received adequate anticoagulation therapy. Age > 55 was associated with increased risk of complications (8 of 13; p = .02:chi 2). Thirty-four other patients (48.6 percent) received inferior vena caval filters with no related complications or deaths. Anticoagulation for DVT/PE should be used selectively in trauma patients and avoided in elderly patients. Such patients should undergo early caval filter placement.