Venous thromboembolic disease in admitted blunt trauma patients: what matters?

BACKGROUND: Venous thromboembolic events (VTE) are a significant cause of morbidity and mortality following traumatic injury. We examined demographic characteristics, chemoprophylaxis, and outcomes of VTE patients with blunt trauma requiring hospitalization. METHODS: A retrospective review of adult blunt trauma hospitalizations with and without VTE between 2012 and 2019 was conducted. Deaths in the emergency department were excluded. Univariate and multivariable analyses, including machine learning classification algorithms for VTE, were performed. RESULTS: Of 10,926 admitted adult blunt trauma patients, 177 had VTE events. VTE events occurred at a median of 6 [IQR 3-11] days, with 7.3% occurring within 1 day of admission. VTE patients were more often male, and more often underwent surgery. They had higher injury severity as well as longer intensive care unit and hospital lengths of stay. While VTE occurred throughout the spectrum of injury severity, 27.7% had low injury severity (ISS < = 9). In multivariable analyses, both heparin and enoxaparin had reduced adjusted odds ratios for VTE. CONCLUSION: Approximately 7.3% of VTE events occurred within one day of admission. A substantial proportion of VTE events occurred in patients with low injury severity (ISS < = 9). Subcutaneous unfractionated heparin and enoxaparin chemoprophylaxis were both inversely associated with VTE. These findings underscore the need for vigilance for VTE identification in blunt trauma patients throughout their hospitalization and VTE prevention efforts.

"Please Keep Mom Alive One More Day"-Clashing Directives of a Dying Patient and Her Surrogate.

All medical care providers are legally and ethically bound to respect their patients' wishes. However, as patients lose decision-making capacity and approach end of life, their families or surrogates, who are confronted with grief, fear, self-doubt, and/or uncertainty, may ask physicians to provide treatment that contradicts the patients' previously stated wishes. Our work discusses the legal and ethical issues surrounding such requests and provides guidance for clinicians to ethically and compassionately respond-without compromising their professional and moral obligations to their patients.

Infection, sepsis, and immune function in the older adult receiving critical care.

The elderly are vulnerable to developing sepsis due to functional and immune changes, and frequent instrumentation and contact with the health care system. Those infected often present with nonspecific complaints and are at risk for underrecognition and undertreatment, with greater likelihood of rapid progression to severe sepsis and septic shock; however, often respond well to early, organized, and aggressive interventions. Survivors may not return to baseline level of function and may require long-term care facilities after discharge from the hospital. Patient and family preferences for goals of care should be explored as early as possible and incorporated into treatment plans.