TRAUMA UPDATE
Educational Objectives
| The goal of this program is to improve the management of deep venous thrombosis (DVT) in trauma patients, severely injured
kidneys, and solid organ injuries. After hearing and assimilating this program, the clinician will be better able to:
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 | 1. Recognize the risk factors for DVT.
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| 2. Prescribe the appropriate agent for prophylaxis of DVT.
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| 3. Utilize nonoperative management of penetrating trauma to kidneys.
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| 4. Review the indications for surgery of renal and renovascular injuries.
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| 5. Apply the new advances in nonoperative care of solid organ injuries.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning
committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest.
Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a
proprietary business or commercial interest. For this program, the faculty and planning committee reported nothing to disclose.
Acknowledgements
Drs. Karmy-Jones and Santucci were recorded at the Detroit Trauma Symposium, held November 8-9, 2007, in Detroit,
MI, and sponsored by the DMC Detroit Receiving Hospital and Wayne State University School of Medicine. Dr.
McGonigal was recorded at Emergency Medicine and Trauma Update, held November 8, 2007, in Bloomington, MN,
and sponsored by the Minnesota Chapter, American College of Physicians, and HealthPartners Institute for Medical
Education. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production
of this program.
| DEEP VENOUS THROMBOSIS IN THE TRAUMA PATIENT —Riyad Karmy-Jones, MD, Medical Director, Thoracic
and Vascular Surgery, Southwest Washington Medical Center, Vancouver, WA
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| Deep venous thrombosis (DVT): incidence high in trauma patients (two-thirds), especially without prophylaxis; even
with prophylaxis, seen in one-third of patients, of which ≈25% proximal (popliteal vein or higher); whether popliteal vein
involved critical; common cause of death in trauma patients who have survived first 24 hr; trauma ideal model for DVT;
local manifestation of systemic disease; procoagulant factors in trauma patients elevated early and remain elevated long
after traumatic event; study followed patients with daily ultrasonography (US) and found that by day 30, cumulative incidence
of DVT ≈60%; high-risk factors—age; venous lines; venous injury; head injury; immobilization; obesity; hypercoagulable
states; pregnancy; guidelines state that anyone at risk should receive thromboprophylaxis and low-molecular-
weight heparin (LMWH) as soon as possible (if no contraindications)
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| DVT prophylaxis: study—looked at thromboprophylaxis with LMWH; 311 patients with close to 10% incidence of
DVT or PE or both; found pharmacologic prophylaxis started within 48 hr in only 25% of patients (>1 wk in 25%); 3-
fold increased risk for DVT in patients started on prophylaxis ≥4 days; agents used—unfractionated heparin; LMWH
(eg, enoxaparin [Lovenox]); factor IIa inhibitors; factor Xa inhibitors; fondaparinux
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| Unfractionated heparin: given subcutaneously (SC) or intravenously (IV); has mixed effect on factor Xa and factor IIa activity;
partial thromboplastin time (PTT) reflects its factor IIa action, not its factor Xa action; side effects include heparin-induced
thrombocytopenia (HIT) and effect on bone suppression; PTT inaccurate way of measuring
anticoagulation, especially for heparin; bioavailability of heparin and amount absorbed unpredictable, if given SC
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| HIT: in type 1, slight drop in platelet count; in type 2, low platelet count with venous and arterial thrombosis; occurs in
0.75% of patients on therapeutic doses of heparin and in <0.10% of those on prophylactic doses; those with cardiovascular
problems at risk; drop in platelet count (<50% of controls) and bleeding at lesion sites present; platelet antibody test; serotonin
platelet release assay (takes few days, but more accurate); ≈50% of patients already have thrombogenic complication
by time HIT recognized; treatment to discontinue heparin and give anticoagulant to avoid complications; should not
use warfarin (Coumadin) as monotherapy (may result in complications due to hypercoagulability)
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| LMWH: enoxaparin—more uniform agent; good bioavailability; more specific anti-Factor Xa; markedly reduced risk for
HIT; unable to assay with PTT; for prophylaxis, dose 30 mg bid; absorbed if given SC in absence of local problems (eg,
edema); study comparing enoxaparin with heparin found markedly reduced incidence of DVT and proximal DVT with
enoxaparin (has slightly increased risk for bleeding); contraindications to LMWH—intracranial hemorrhage; ongoing
uncontrolled bleeding; incomplete spinal cord injury (SCI)
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| Fondaparinux: binds to heparin-binding site; has safer profile and not associated with HIT; excreted renally; 4 studies found
significant decrease in incidence of DVT or venothrombolic complications, but increased risk for bleeding; once-daily
dosing; given for simple orthopedic injuries
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| Devices: 2 studies suggest benefit with sequential compression devices (SCDs) in closed head injuries; unfractionated heparin,
compression stockings, and SCDs, by themselves, not adequate prophylaxis in SCIs (enoxaparin recommended);
recommend against inferior vena cava (IVC) filters as primary prophylaxis; during rehabilitation, convert (in anyone
with limited mobility) to outpatient enoxaparin or low-dose warfarin for ≤1 yr
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| Screening: US operator-dependent and not preventive; screen patient with inadequate or no prophylaxis
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| Summary: in high-risk trauma patient with severe head injury, SCDs and surveillance indicated; in high-risk patients with
no contraindication to prophylaxis, enoxaparin, SCDs, and surveillance; in simple orthopedic injuries, enoxaparin and
SCDs; everyone else, unfractionated heparin and/or SCDs; prophylactic filters never indicated; in some institutions,
scoring system for prophylaxis on every chart and must be filled in daily
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| Prophylactic filters: accepted or potential indications (outside of guidelines) include, eg, SCI with quadriplegia, closed
head injury with Glasgow Coma Scale score <8, pelvic fracture; insufficient evidence to recommend prophylactic insertion
of IVC filters in trauma patients, even those at high risk; data at 2-yr follow-up—incidence of recurrent PE with prophylactic
filter 1.5% (2% with therapeutic filter); incidence of significant and crippling symptoms 25% with prophylactic
filter (43% with therapeutic filter); speaker believes that filter, in and of itself, does not cause thrombosis; not proven that
filters reduce PE; study—multicenter (21 centers); looking at retrievable filters; of ≈600 filters placed, 92% prophylactic;
bulk of permanent filters placed at 8 centers; showed that permanent filters more likely placed by surgeons for therapeutic
indications in older patients; no complications reported with permanent filters at 4- to 5-mo follow-up; of 446 retrievable
filters, 75% prophylactic (most placed by interventional radiologists through femoral approach); retrieval achieved in
only 20% of cases; reasons for failure to retrieve include loss to follow-up and patient still at risk with poor ambulation;
5% incidence of recurrent PE after filters removed (none had duplex scan before removal of filter); service that places filter
should follow patient; 3 filter types; OptEase filter—uncommonly used; only filter that enters and exits via groin; has
significant inflammatory component and cable thrombosis rate; also markedly elevated symptomatic cable occlusion rate
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| Retrievable vs permanent filters: not clear that retrievable filters better than permanent filters; place permanent filter if
anticipating leaving filter in; associated with most complication rates; cannot be proven that prophylactic filters reduce fatal
PE; permanent filters probably associated with major complications in younger patients; filters do not cause thrombosis;
speaker believes best indication for retrievable filter high-risk patient going in and out of operating room (OR) and unable to
be anticoagulated; when placing filter, if patient not intubated and able to perform Valsalva maneuver, can determine
whether IVC patulous and patient at risk for complications
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| Summary of DVT management: in patient with DVT, give heparin for 5 days; need international normalized ratio
(INR) of 2 to discontinue heparin early to reduce bleeding complications; bleeding risk present when INR approaching
2.5; if patient hypoxic or unstable and PE suspected, send patient to angiography suite for diagnosis and treatment; if PE
and other conditions need to be ruled out, computed tomography (CT) angiography excellent screening test; if initially
suspect PE, do not perform CT angiography; instead, send patient to angiography suite for mechanical clot retrieval and
placement of filter (at same time); if filter not placed at same time, 20% of patients have repeat PE in next 24 hr; protocol
most important management tool; service that places filter with intention of retrieving has responsibility for following patient
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| OPERATIVE, ANGIOGRAPHIC, AND NONOPERATIVE TREATMENT OF THE SEVERELY INJURED KIDNEY —
Richard A. Santucci, MD, Specialist in Chief, Urology, Detroit Medical Center, and Chief of Urology, Detroit Receiving
Hospital, Detroit, MI
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| Grades of renal injury: grade I—renal contusion; grade II—shallow laceration; grade III—deep laceration; grade
IV—deep laceration into collecting system, but also contained hemorrhage at hilum or renal artery thrombosis; grade
V—“shattered” kidney or complete avulsion of hilum
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| Expectant approach: 100 papers support more conservative approach to renal trauma; not universally embraced; in
large trauma study of ≈1300 patients with renal injury, 23% had surgery, with 64% nephrectomy rate; data from other
centers had lower operative rate of 16% (counter to McAninch data) with few complications; European data showed that
with lower operative rates, overall blood loss less, with no development of renovascular hypertension; another study also
had lower operative rate of 21% (45% in McAninch data) and showed shorter hospital stay, but 7% had delayed surgery;
meta-analysis—16 studies; grade IV renal injuries; 10% had surgery; 90% managed nonoperatively; of 90%, ≈12% required
delayed surgery (of which 5% nephrectomies); study—6 patients with grade V blunt renal injuries treated conservatively
(no surgery); did not consider other 12 patients whose lives saved with nephrectomy; study of 6 patients who had
nephrectomies compared to 6 treated conservatively found none required delayed surgeries, fewer transfusions, and lower
mortality rate
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| Indications for surgery: grade V pedicle avulsion; exsanguinating injury; persistent renal bleeding (≥2 U/day); associated
enteric and pancreatic injury requires more attention; extracapsular urine extravasation with devascularized parenchymal
segment—small study of patients with grade V injuries had high complication rate when observed; another study
found that presence of devitalized segment resulted in increased negative outcomes for hospital stay, transfusions, and need
for delayed procedures; small study found high morbidity rate if associated enteric and pancreatic injury present;
conclusions—patients with grade I and II renal injuries treated nonoperatively; most or even all grade III and IV injuries
can be treated nonoperatively (90% of grade IV injuries); not enough data for grade V injuries; think twice about nonoperative
management for colon and pancreatic injuries or devitalized segments
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| Penetrating trauma: conservative management well established in South Africa; study using conservative management
found 80% success rate and 20% complication rate (embolization, nephrectomy, heminephrectomy, and treatment for arteriovenous
malformation); similar study in United States had identical complication rate (20%); in stab wounds to kidney,
assuming patient not bleeding to death, try nonoperative management, but be prepared for complications; University
of Southern California study—≈1800 patients with abdominal gunshot wounds; as long as hemodynamically stable with
no peritonitis, patient placed in intensive care unit and given serial abdominal examinations; 96% of patients never had
surgery; ≈4% developed peritoneal signs for which surgery performed; conservative management of gunshot wounds—
little data; “no touch” approach at Detroit Receiving Hospital if patient not exsanguinating; only those exsanguinating
from kidney operated on (all grade V); nephrectomy rate of 75% for grade V injuries, 0% for all others; few studies also
prove conservative management for low-velocity renal gunshot wounds; Greek study had ≈50% of patients doing well
with nonoperative management, with few complications; in children—1% to 19% incidence of renal abnormalities, eg,
congenital hydronephrosis, Wilms’ tumor; beware of potential “major injury from minor trauma”; majority of those with
hydronephrosis managed with percutaneous drainage of kidney, followed by delayed repair of congenital problem
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| Renovascular injuries: in patient with single kidney, should be repaired; also with significant bilateral injuries; conservative
management often involves nephrectomy; renal artery repair often fails; success rate 0% to 14%; one study reported
5 L of blood loss; nephrectomy widely recommended; one study had 40% success rate with repair, but study never
replicated; relative indications for surgery include contained hemorrhage and patient not bleeding to death; if bleeding
starts, may perform repair, but if unable to perform good repair, perform nephrectomy; should not operate on segmental
injuries (almost always not significant)
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| Angiography: primary and salvage use; primary use common for renal injuries, but published reports scarce; in one
study of 16 stab wounds, 11 had angiography (9 successful); 2 failed and taken to OR; many studies show that if delayed
bleeding present, angiography should be performed
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| Benefits of renal salvage: no unnecessary surgery; no iatrogenic nephrectomy; probably true that saving nephrons
saves patients; removing 50% of nephrons leaves 50% glomerular filtration rate; higher need for dialysis when kidney
removed; final word—cannot treat ureteric or renal pelvic injuries nonoperatively
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| NONOPERATIVE CARE OF SOLID ORGAN INJURIES —Michael D. McGonigal, MD, Assistant Professor of
Surgery, University of Minnesota School of Medicine, and Director of Trauma Services, Regions Hospital, Minneapolis,
MN
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| State of art: by rigorously applying protocol for nonoperative management of solid organ injuries in hospital, expect 93%
of patients to successfully avoid operation; operative management usually consists of splenectomy; excludes individuals
with instability and hemodynamic issues at presentation; most institutions coupling angiography with nonoperative management
(not in all patients); liver injuries have higher morbidity than splenic injuries; patients with liver injuries may develop
complications (usually occur in following months; include fluid collections and infections and occasionally require
delayed surgery for removal of devitalized tissue)
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| Contrast-enhanced US: IV contrast (Levovist) solution made of galactose granules; diluted with saline, shaken well,
creating microbubbles with galactose granules, then injected; as contrast injected, immediately begin imaging; as it circulates,
US able to detect contrast differences between blood and microbubbles of air attached to granules; contrast dissolves
in few minutes and microbubbles reabsorbed; enhances images of heart and solid organs; disadvantage inability to
grade injury; main advantage decreased radiation exposure; disadvantages include less detail, less information, and requires
specially trained radiologist
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| New advances: previously, patients with solid organ injuries treated nonoperatively typically in hospital for 7 to 10 days,
with substantial time on bed rest; present average length of stay 2 days (occasionally 1.5 days); move toward earlier discharge,
but concern about rebleeding after discharge; early discharge—study found early failure rate of 5% and late failure
rate of 2%; 3-day cutoff; no significant difference; unable to find predictors of failure; splenic pseudoaneurysm—
thought major cause of early failure; forms within first 4 days; repeat CT after 48 hr and send for embolization if blush
seen; selective embolization—practice patterns vary; issue of deciding when to perform angiography; moving toward
performing angiography based on hemodynamics; suspect if patient stable but somewhat tachycardic or requires >2 L of
fluid; blush seen on early CT compelling evidence; complications include infarction, air bubbles, infection (abscess), and
coil migration; type of complication depends on location of emboli (proximally near end of main splenic artery or distally
in subsegmental vessels of spleen); in proximal embolization, two-thirds of patients have infarction (most fairly small); in
distal embolization, 100% of patients have infarcts, but most small; in combined embolization, results similar to proximal
alone; majority of patients have no problems, other than abnormal findings on repeat CT; minority develop gas bubbles
(problematic when associated with fever and night sweats); small bubbles harmless and reabsorbed in ≈1 wk; bubbles associated
with fever, leukocytosis, or air-fluid levels indicate abscess requiring drainage and/or splenectomy
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| Summary: management of solid organ injuries continues to improve; use of embolization evolving; new complications
arising but most harmless
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Suggested Reading
Allen TL et al: Retrievable vena cava filters in trauma patients for high-risk prophylaxis and prevention of pulmonary
embolism. Am J Surg 189:656, 2005; Anderson FA Jr et al: Risk factors for venous thromboembolism. Circulation
107:I9, 2003; Avorn J et al: Comparing the costs, risks, and benefits of competing strategies for the primary prevention
of venous thromboembolism. Circulation 110:IV25, 2004; Barsness KA et al: Renovascular injury: an argument for renal
preservation. J Trauma 57:310, 2004; Davis KA et al: Predictors of the need for nephrectomy after renal trauma. J
Trauma 60:164, 2006; Demetriades D et al: Selective nonoperative management of penetrating abdominal solid organ
injuries. Ann Surg 244:620, 2006; Malhotra AK et al: Multiplicity of solid organ injury: influence on management and
outcomes after blunt abdominal trauma. J Trauma 54:925, 2003; McGahan JP et al: Appearance of solid organ injury
with contrast-enhanced sonography in blunt abdominal trauma: preliminary experience. AJR Am J Roentgenol 187:658,
2006; Pryor JP et al: Nonoperative management of abdominal gunshot wounds. Ann Emerg Med 43:344, 2004; Rozycki
GS et al: Surgeon-performed bedside organ assessment with sonography after trauma (BOAST): a pilot study from
the WTA Multicenter Group. J Trauma 59:1356, 2005; Rutherford EJ et al: Optimal dose of enoxaparin in critically ill
trauma and surgical patients. J Trauma 58:1167, 2005; Schiff RL et al: Identifying orthopedic patients at high risk for
venous thromboembolism despite thromboprophylaxis. Chest 128:3364, 2005; Schuerer DJ et al: Evaluation of the applicability,
efficacy, and safety of a thromboembolic event prophylaxis guideline designed for quality improvement of the
traumatically injured patient. J Trauma 58:731, 2005; Stefanidis D et al: Extended interval for retrieval of vena cava filters
is safe and may maximize protection against pulmonary embolism. Am J Surg 192:789, 2006; Stuhlfaut JW et al:
Blunt abdominal trauma: performance of CT without oral contrast material. Radiology 233:689, 2004; Valentino M et
al: Blunt abdominal trauma: emergency contrast-enhanced sonography for detection of solid organ injuries. AJR Am J
Roentgenol 186:1361, 2006; Velmahos GC et al: Nonoperative treatment of blunt injury to solid abdominal organs: a
prospective study. Arch Surg 138:844, 2003.
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