Prospective evaluation of the safety of enoxaparin prophylaxis for venous thromboembolism in patients with intracranial hemorrhagic injuries.

BACKGROUND: Patients with traumatic intracranial hemorrhagic injuries (IHIs) are at high risk for venous thromboembolism (VTE). The safety of early anticoagulation for IHI has not been established. HYPOTHESIS: Enoxaparin can be safely administered to most patients with IHI for VTE prophylaxis. SETTING: Level I trauma center. DESIGN: Prospective, single-cohort, observational study. PATIENTS AND METHODS: One hundred fifty (85%) of 177 patients with blunt IHI received enoxaparin beginning approximately 24 hours after hospital admission until discharge. Brain computed tomographic (CT) scans were performed at admission, 24 hours after admission, and at variable intervals thereafter based on clinical course. Patients were excluded for coagulopathy, heparin allergy, expected brain death or discharge within 48 hours, and age younger than 14 years. Complications of enoxaparin prophylaxis were defined as Marshall CT grade progression of IHI, expansion of an existing IHI, or development of a new hemorrhagic lesion on follow-up CT after beginning enoxaparin use. RESULTS: Thirty-four patients (23%) had CT progression of IHI. Twenty-eight CT scans (19%) worsened before enoxaparin therapy and 6 (4%) worsened after beginning enoxaparin use. No differences between operative patient (2/24, 8%) and nonoperative patient (4/126, 3%) complications were identified (P =.23). Study group mortality was 7% (10/150). All 6 patients who developed progression of IHI after initiation of enoxaparin therapy survived hospitalization. A deep vein thrombosis was identified in 2 (2%) of 106 patients. CONCLUSION: Enoxaparin can be safely used for VTE prophylaxis in trauma patients with IHI when started 24 hours after hospital admission or after craniotomy.

Erythromycin reduces delayed gastric emptying in critically ill trauma patients: a randomized, controlled trial.

BACKGROUND: Early enteral feeding has been shown to be beneficial in improving outcome in critically injured trauma patients. Delayed gastric emptying occurs frequently in trauma patients, increasing the time to achieve nutritional goals, and limiting the benefit of early enteral feedings. Intravenous erythromycin is an effective agent for improving gastric motility in diabetics and postgastrectomy patients. The purpose of this study is to determine the effectiveness of erythromycin for improving gastric motility in critically injured trauma patients. METHODS: All critically injured patients who received gastric feedings within 72 hours of admission were candidates for the study. Those patients who failed to tolerate feedings at 48 hours (gastric residual > 150 mL) were eligible for enrollment. Patients were prospectively assigned to two treatment groups by randomization to receive either erythromycin (ERY) or placebo (PLA). Treatment was continued in patients who tolerated gastric feedings until the feedings were no longer required. Patients with continued intolerance for 48 hours after randomization were considered failures of therapy and given metoclopramide. RESULTS: Sixty-eight patients were enrolled and were well matched for age, sex, and Injury Severity Score. Mortality, intensive care unit length of stay, hospital length of stay, number of ventilator days, and rate of nosocomial infections were similar in each group. There was a significant difference between the ERY group and the PLA group in the amount of feedings tolerated at 48 hours (58% vs. 44%, p = 0.001). There was no difference in the amount of feedings tolerated (as a percentage of target goal volume) throughout the entire duration of the study (ERY [65% of target] vs. PLA [59%], p = 0.061). Overall success of therapy at 48 hours was 56% in the ERY group versus 39% in the PLA group, but this also did not reach statistical significance (p = 0.22). CONCLUSION: Intravenous erythromycin improves gastric motility and enhances early nutritional intake in critically injured patients.

A prehospital glasgow coma scale score < or = 14 accurately predicts the need for full trauma team activation and patient hospitalization after motor vehicle collisions.

BACKGROUND: Trauma team activation protocols should ideally minimize the undertriage of seriously injured patients and eliminate unnecessary activations for those patients that do not require hospitalization. This study examined which physiologic parameter(s) most reliably predicted the need for hospitalization after motor vehicle collisions (MVCs). METHODS: A prehospital triage tool using standard physiologic parameters was developed and prospectively analyzed for reliability in predicting subsequent patient admission at a Level II trauma center after MVCs. Data were collected on 4,014 consecutive patients, 2,880 (72%) of whom had all of the physiologic parameters reported and recorded. Patients who arrived in extremis, who were dead on arrival, or who died shortly after arrival despite appropriate trauma team activation were ineligible for the study. Multivariate stepwise logistic regression analysis was used to determine which parameters were associated with hospital admission. RESULTS: The Glasgow Coma Scale (GCS) score was the only prehospital physiologic parameter providing a clinically identifiable difference between those patients admitted (13 +/- 4) and those discharged to home (15 +/- 0.5) (mean + SD) (relative risk for hospitalization, 2.24; 95% confidence interval, 1.86-2.70 for GCS score < 14). CONCLUSION: The prehospital GCS score is a reliable physiologic parameter for predicting hospital admission after MVC. When obvious indicators (hypoxemia, multiple long bone fractures, focal neurologic deficits) for trauma team activation are lacking, the prehospital GCS score may be used to reduce overtriage and undertriage rates.