Creatinine clearance predicts the goal enoxaparin dose in traumatic brain injury.

BACKGROUND: Patients with traumatic brain injury (TBI) are at high risk of venous thromboembolism (VTE). Recent guidelines recommend starting TBI patients on enoxaparin 30 mg twice daily and then considering weight-based dosing. Creatinine clearance may be better than weight for patients when considering high and low enoxaparin dose requirements. We hypothesize that creatinine clearance (CrCl) predicts goal enoxaparin dose better than weight-based dosing. METHODS: A retrospective review was conducted on patients admitted to an urban, academic Level I trauma center from August 2017 to February 2020. Patients were included if greater than 18 years, admitted longer than 48 hours, and head and neck AIS ≥ 3. Patients were excluded if they did not have TBI, if they received deep vein thrombosis prophylaxis other than enoxaparin 12-hour dosing, if no anti-Xa levels were drawn, or if the goal anti-Xa level was not reached. Patients were grouped into dosing cohorts based on dose of enoxaparin required to reach goal. Pearson's correlation was used to compare mean CrCl and mean weight across dosing cohorts. RESULTS: A total of 120 patients met inclusion and exclusion criteria, mean age was 47 years and 68% of patients were male. The mean hospital length of stay was 24 days. There were 5 (4.2%) deep vein thrombosis, no pulmonary embolism, and 5 (4.2%) patients died. Mean CrCl increased significantly with increased dosing of enoxaparin, Pearson's correlation coefficient of 0.484 ( p < 0.001). Weight on admission also increased with increasing enoxaparin dose requirements, with Pearson's correlation coefficient of 0.411 ( p < 0.001). CONCLUSION: Creatine clearance predicts goal enoxaparin dose in TBI better than a weight-based dosing strategy. Further research with a larger patient population is required to validate CrCl values to guide enoxaparin dosing. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

The futility of closed chest compressions after trauma: A multi-institutional study.

BACKGROUND: The desire to deliver appropriate care after trauma creates challenges when deciding to proceed if care appears futile. This study aimed to analyze survival rates for trauma patients who undergo closed chest compressions by decade of life. METHODS: A multicenter retrospective review of trauma patients with an Injury Severity Score ≥16 who underwent closed chest compressions from 2015 to 2020 at four large, urban, academic Level I trauma centers was conducted. Those with intraoperative arrest were excluded. The primary endpoint was survival to discharge. RESULTS: Of the 247 patients meeting inclusion criteria, 18% were 70 years or older, 78% were male, and 24% presented due to a penetrating mechanism of injury. Compressions occurred in the prehospital setting (56%), emergency department (21%), intensive care unit (19%), and on the floor (3%). On average, patients arrested on hospital day 2, and survived 1 day after arrest if return of spontaneous circulation was achieved. Overall mortality was 92%. Average hospital length of stay was lower in patients 70 years or older (3 days vs. 6 days, p < 0.01). Survival was highest in patients 60 years to 69 years (24%), and although patients 70 years or older presented with lower Injury Severity Scores (28 vs. 32, p = 0.04), no patient 70 years or older survived to hospital discharge (0% v 9%, p = 0.03). CONCLUSION: Closed chest compressions are associated with a high mortality rate after moderate to severe trauma with 100% mortality in patients older than 70 years. This information may assist with the decision to withhold chest compression, especially in older adults. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Creatinine Clearance May Predict Goal Enoxaparin Dose in Trauma.

BACKGROUND: Guidelines for enoxaparin dosing after trauma recommend an initial dose of 40 mg twice daily for most patients and then adjusting by anti-Xa levels. Previous studies indicated higher enoxaparin doses are necessary with higher levels of creatinine clearance (CrCl). We sought to determine if the goal enoxaparin dose correlates with the admission CrCl to reduce the reliance on measuring anti-Xa levels. STUDY DESIGN: A retrospective review was conducted of patients admitted to an urban, academic Level 1 trauma center from April 2017 to February 2020. Patients started on enoxaparin who reached goal anti-Xa trough levels were included, and patients were excluded if they did not reach goal anti-Xa levels. Data collection included patient demographics, injury characteristics, admission CrCl, and final enoxaparin dose. CrCl was then correlated with the final enoxaparin dose. RESULTS: Of 421 patients included, the mean age was 46.6 years and 73% were male. The median goal enoxaparin dose was 40 mg twice daily. The mean CrCl significantly increased with increasing twice-daily doses of enoxaparin (20 mg: 69.2 mL/min; 30 mg: 89 mL/min; 40 mg: 112.8 mL/min; 50 mg: 140.5mL/min; 60 mg: 147.4 mL/min; and 70 mg: 140 mL/min; p < 0.01). CONCLUSIONS: Admission CrCl may predict the enoxaparin dose required to achieve adequate anti-Xa levels. Our data indicate that CrCls of approximately 70, 90, 110, 140, and 150 mL/min may predict the twice-daily enoxaparin doses of 20, 30, 40, 50, and 60 mg, respectively. CrCl dosing guidance may reduce the time to goal anti-Xa levels and the frequency of anti-Xa measurements. Further research is necessary, and enoxaparin dosing should continue to be monitored by anti-Xa levels.

Pleural Endometriosis: An Atypical Cause of Hemoptysis.

Endometriosis is a benign, inflammatory disease characterized by the presence of dysfunctional endometrial tissue outside the uterus. Typically confined to the pelvis, endometriosis is frequently associated with pain, dysmenorrhea, and infertility. Rarely, endometrial tissue has been documented to implant within the lung parenchyma and involve both parietal and visceral pleura of the thorax. Manifestations of thoracic endometriosis include catamenial pneumothorax, hemothorax, and hemoptysis. We present a case of thoracic endometriosis in a 43-year-old female who was found to have a loculated pleural effusion with an associated pleural nodule after gynecologic surgery. The patient underwent thoracotomy, decortication, and nodule excision. Pathology of the pleural nodule showed evidence of endometrial tissue within the parietal pleural. Thoracic endometriosis is a medical problem that is frequently undiagnosed and encountered by the practicing surgeon. Early diagnosis reduces both disease progression and late complications, allowing for early initiation of appropriate medical and surgical therapy.

Paradoxical Emboli as a Cause of Stroke.

Cerebrovascular embolic strokes are responsible for significant morbidity. 40% of strokes have no inciting cause and are thought to be the result of paradoxical emboli (PDE) passing into the arterial system by way of intra-cardiac or pulmonary vascular defects. We present two cases of PDE resulting in acute ischemic events. A 63-year-old female presented for evaluation of left upper extremity numbness. Imaging was significant for an acute right middle cerebral artery infarct and evidence of a large saddle pulmonary embolism. The patient's stroke was postulated to have been secondary to a patent foramen ovale (PFO). An 87-year-old male presented for evaluation of chest pain. The patient underwent three-vessel CABG and experienced an acute left hemispheric stroke post-operatively. Transthoracic echocardiogram demonstrated a biatrial thrombus transversing a PFO and was postulated to have been the cause. The prompt diagnosis of PDE is paramount to preventing the morbidity associated with repeat ischemic events.

Successful Cesarean Section in a COVID-19 Patient on Extracorporeal Membrane Oxygenation (ECMO).

The pandemic of COVID-19-related respiratory failure has increased utilization of ECMO in diverse patient populations. There are limited published reports of ECMO use in pregnancy, and reports of successful delivery of the fetus with survival of the mother on ECMO are exceptionally rare. We present a case of Cesarean section while on ECMO for COVID-19-related respiratory failure with survival of both mother and infant.A 37-year-old pregnant female presented with dyspnea following a positive COVID-19 test. D-Dimer and CRP were elevated and chest radiography was consistent with COVID-19 pneumonia. Her respiratory status rapidly decompensated-requiring endotracheal intubation within 6 hours of presentation, and ultimately veno-venous ECMO cannulation. Three days later, fetal heart rate decelerations prompted emergent caesarean delivery. The infant was transferred to the NICU and progressed well. The patient improved and she was decannulated on hospital day 22 (ECMO day 15) before discharge to rehab on hospital day 49.In this case, ECMO allowed survival of both mother and infant in an otherwise non-survivable respiratory failure. Consistent with existing reports, we believe ECMO is a viable strategy for refractory respiratory failure in the pregnant patient.

Acute Basilar Artery Occlusion and Death Secondary to Bilateral Vertebral Artery Dissection.

Vertebral artery dissection as a cause of basilar artery thrombosis is an exceedingly rare event that is associated with significant morbidity and poor outcomes. We present an unusual case of bilateral vertebral artery dissection and spinal cord compression in a 21-year-old male involved in a diving accident. The patient received limited antithrombotic therapy in pursuit of surgical spinal decompression, ultimately contributing to thrombosis of the basilar artery in the post-operative period and death following anterior cervical discectomy and fusion. Our goal is to highlight the severity of vertebral artery injury and the critical importance of treatment in the prevention of associated sequelae.

Protective Arteriovenous Fistula in Traumatic Common Carotid Transection.

Penetrating injuries of the neck involving major vessels are associated with high morbidity and mortality. A traumatic arteriovenous (AV) fistula can provide a protective effect by decompressing the injured arterial structure and prevent massive blood loss and airway compression. We present a novel description of CCA (common carotid artery) transection with associated protective AV fistula. Protective AV fistulae have been uncommonly described, and to our knowledge, this is the first case involving carotid transection with associated protective AV fistula ultimately allowing lifesaving operative repair.

Early Operation for Complications Arising From Bariatric Surgical Tourism.

The patient is a 48-year-old female, who underwent LAGB in Tijuana, Mexico, via bariatric medical tourism in 2008. She had no follow up after surgery. Subsequently had a port infection, for which the port was removed, but the band was left in place. Suffered with chronic abdominal pain for many years before the retained band was recognized. During band removal, it was discovered that she had complete band erosion. After removal, her symptoms resolved. This case demonstrates the issues with bariatric medical tourism. Specifically, because of the lack of appropriate follow up. Follow up and monitoring after surgery is important for preventing bariatric surgery complications and assisting with adequate weight loss. The other aspect of the case is the importance to recognize bariatric surgery complications. Port infection should warrant an investigation for potential intra-abdominal sources. Band erosion is uncommon but known complication of LAGB and requires band removal.

Etiology and Management of Peristomal Pseudoepitheliomatous Hyperplasia.

This is a report of a 48-year-old male patient who presented with worsening peristomal dermatitis. He proceeded to form a nodular hyperplastic overgrowth that was proven to be pseudoepitheliomatous hyperplasia on histological examination. On surgical exploration, he was found to have an apparent peristomal enterocutaneous fistula propagating this hyperplastic growth. This report reviews the etiology and management of peristomal complications with special attention to pseudoepitheliomatous hyperplasia.