Lyceum Bullets: Trauma

Authors: Manpreet Singh, MD and Adaira Landry, MD (emDocs editorial staff) // Editor: Alex Koyfman, MD

Adapted with permission from EM Lyceum – If you would like to see more of these posts, please comment below

1. When do you use tranexamic acid in trauma?

Tranexamic acid (TXA) – Synthetic lysine analog that binds plasminogen, and prevents fibrinolysis.

• Evidence: CRASH-2 – RCT of 20K trauma pts in 40 countries with, or at risk of, bleeding, to either TXA or placebo.
  • Pros:
    • Large sample from multiple countries
    • Double blinded randomization
    • Similar baseline factors in both groups
    • Minimal loss to follow-up
  • Cons:
    • Diagnosis of traumatic hemorrhage on presentation is difficult
      • However, broad inclusion criteria (hypotension, tachycardia, physician judgment) makes study more applicable and generalizable
    • Some included pts might not have been bleeding at time of randomization (reduces power)
  • Outcomes:
    • All-cause mortality reduced by 5% (14.5% TXA vs. 16.0% placebo [RR 0.91, 95% CI 0.85-0.97; p=0.0035])
    • Risk of death reduced by 8% (RR 0.85, p=0.0077)
    • No difference in deaths from vascular occlusion (MI, CVA, PE), MOF, and head injury
    • No difference in RBC transfusion
      • Could be secondary to transfusion decisions made before administration of TXA
      • TXA group more likely to survive and thus greater opportunity to receive RBC transfusion
    • Dosing: Load 1 g over 10 minutes, then infuse 1 g over 8 hours
      • Subgroup analysis
        • The group that benefited the most was when TXA given <3 hrs from injury (RR 0.87, 99% CI 0.75-1.00).
          • Other studies, show greatest benefit if given in the first hour
        • If given >3 hrs, an increase in deaths from bleeding

BOTTOM BULLET:

Consider giving TXA to pts with traumatic hemorrhage (especially w/in three hours of injury) as it appears safe (thrombotic complications) and is beneficial (decreasing bleeding and mortality).

2. When you can’t get peripheral access in a trauma patient, do you prefer a subclavian, femoral, or intraosseous (IO)?

IV access crucial in ATLS, but can be the most difficult step in our sickest patients.

• Three Options:
  • IO, femoral, and subclavian
  • IJ not accessible due to c-collar
• IO vs. central venous catheter (CVC) – Small, retrospective, observational studies. No RCTs.
  • Higher first attempt success rate for IO (85%) landmark-based CVC (60%) (p=0.024)
  • Faster median procedure time [IO 2.0 min CVC 8.0 min (p<0.001)]
  • Relevant complications were not observed
• Catheter-related bloodstream infections (CRBI): Complication most studied
  • Class 1A Recommendation by CDC & Infectious Diseases Society of America (IDSA) to avoid femoral vein for central access
    • Based on single prospective, observational study in Critical Care Medicine, which found significant CRBI difference b/w femoral (8.34%), IJ (2.99%), and subclavian (0.97%) lines
    • Recent meta-analysis shows no significant difference in the risk of CRBI, and DVT complications between femoral and IJ routes
      • Why discrepancy?
        • Increased focus on sterile placement of lines
          • Choose site you are most comfortable with, and appropriate for pt
        • However, unclear if this is applicable to crashing trauma pts
          • Ultimate goal is to stabilize patient
          • Infection risk not primary concern
            • Lines can be changed in a more sterile environment later

BOTTOM BULLET:

Go for quickest and easiest route, which appears to be the IO, especially in single coverage EDs. However, consider CVC placement simultaneously, if additional personnel available, as it increases your chances of getting access quickly, as well as giving more access, so you can ultimately stabilize your trauma patient.

3. Which trauma patients do you give PCC to over FFP?

Lethal Triad: hypothermia, acidosis, coagulopathy

• Fresh Frozen Plasma is commonly used in traumatic hemorrhage. Prothrombin complex concentrate is a newer alternative.
  • PCC contains factors II, VII, IX and X (Trade names Kcentra, Beriplex, Profilnin, and Bebulin) at various levels depending on which product used.
    • Pros:
      • Quickly reconstituted
      • Low volume
      • Faster delivery time
    • Cons:
      • No clear target INR
      • Expensive
      • No clear dosing
    • Research by Kalina and Safaoui only show that giving PCC can correct the INR quickly. However no evidence of improved survival from this reversal. Also no clear target INR in these patients.
      • Since such heterogeneity in existing studies, will be difficult to do a meta-analysis comparing PCC to FFP.

BOTTOM BULLET:

There are no RCTs to recommend use of PCC in trauma patients with elevated INR. However, patients on Coumadin with head trauma who are at risk of mass effect and herniation should have consideration for PCC.

4. In blunt abdominal/flank trauma, do you send a urinalysis or simply look for gross hematuria?

Urinalysis can be a screening test to diagnose GU injuries. Most commonly injured structure is the kidney.

• Research by Olthof examined need for routine UA in patients with blunt trauma. They studied if UA findings led to further clinical intervention or work-up. They found little difference in outcomes in patients who had only imaging versus UA and imaging.
• Two other studies by Mee and Miller found that patients with blunt trauma, microscopic hematuria, and no evidence of shock (SBP <90) had no significant injuries.

BOTTOM BULLET:

Microscopic hematuria in setting of stable vital signs and blunt trauma offers very little value.