Rosen & Barkin's 5-Minute Emergency Medicine Consult (162 page)

FOLLOW-UP

• Open fracture
  
• Associated injuries that are potentially life threatening
  

• Isolated closed clavicle fracture without other injuries
  
• Appropriate support services at home (especially for elderly patients)
  
• Orthopedic follow-up
  
• Adequate pain management
  

Open fracture, complex injury, signs of neurovascular injury require immediate orthopedic referral.

Follow-up with an orthopedic surgeon:

• Seek medical care immediately with any changes in neurologic function, sensation, or motor strength.
  

• Always be wary of associated injuries that can be life threatening including cervical spine injury, aortic injury, and other cardiopulmonary injuries:
  
• Always assess for any neurologic deficits associated with the fracture.
  

• Banerjee R, Waterman B, Padalecki J, et al. Management of distal clavicle fractures.
  J Am Acad Orthop Surg.
  2011;19:392–401.
  
• Heckman J, Bucholz R.
  Rockwood and Green’s Fractures in Adults.
  5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2001.
  
• Judd DB, Pallis MP, Smith E, et al. Acute operative stabilization versus nonoperative management of clavicle fractures.
  Am J Orthop
  . 2009;38(7):341–345.
  
• Malik S, Chiampas G, Leonard H. Emergent evaluation of injuries to the shoulder, clavicle, and humerus.
  Emerg Med Clin North Am.
  2010;28:739–763.
  
• Toogood P, Horst P, Samagh S, et al. Clavicle fractures: A review of the literature and update on treatment.
  Phys Sportsmed.
  2011;39:142–150.
  
• van der Meijden OA, Gaskill TR, Millett PJ. Treatment of clavicle fractures: Current concepts review.
  J Shoulder Elbow Surg.
  2012;21:423–429.
  

CODES

• 810.00 Closed fracture of clavicle, unspecified part
  
• 810.02 Closed fracture of shaft of clavicle
  
• 810.10 Open fracture of clavicle, unspecified part
  

BASICS

• Patient on anticoagulant medications with minor, major, or clinically significant bleeding needing close monitoring +/− anticoagulant reversal
  
• Anticoagulant medication
  
  • Indirect inhibitors of thrombin
    
    • Unfractionated heparin (UFH)
      
    • Low–molecular-weight heparin (LMWH)
      
      • Enoxaparin
        
      • Dalteparin
        
      • Tinzaparin
        
  • Anti-platelet agents
    
    • Aspirin
      
    • Clopidogrel hydrogen sulfate (Plavix)
      
  • Factor Xa inhibitors (FXa inhibitors)
    
    • Fondaparinux (Arixtra)
      
    • Rivaroxaban (Xarelto)
      
  • Direct thrombin inhibitors (DTIs)
    
    • Argatroban
      
    • Bivalirudin (Angiomax)
      
    • Dabigatran (Pradaxa)
      
    • Hirudin derivatives
      
      • Desirudin
        
      • Lepiruden (Refludan)
        

• Heparin and LMWH are the most commonly utilized anticoagulants beyond warfarin
  
• Routine use of DTIs is being studied
  

Excretion primarily renal with FXa inhibitors, Dabigatran, and Hirudin derivatives necessitating caution with impaired renal function

• Indirect inhibitors of thrombin
  
  • Up to 1/3 patients develop bleeding complication
    
  • 2–6% of bleeding is major
    
• Anti-platelet agents
  
  • >300 over-the-counter medications contain aspirin
    
  • Conflicting studies regarding increased hematoma expansion and mortality
    
• FXa Inhibitors
  
  • Unknown
    
• DTIs
  
  • Unknown
    

• Indirect inhibitors of thrombin
  
  • Combines with antithrombin III to inactivate activated FXa and also inhibits thrombin
    
  • LMWH has a reduced ability to inactivate thrombin
    
  • Half-life is dose dependent (30–150 min), can be up to 8 hr with LMWH
    
• Anti-platelet agents
  
  • Inactivates cyclooxygenase-1 (COX-1) preventing formation of thromboxane A2, which inactivates platelets
    
  • Single dose suppresses for 1 wk
    
  • New platelet production recovers 10%/day
    
  • Patients may manifest normal hemostasis with as few as 20% platelets with normal COX1 activity
    
  • Aspirin half-life 15–30 min
    
  • Clopidogrel half-life 8 hr
    
• FXa inhibitors
  
  • Binds to antithrombin III, catalyzing FXa inhibition
    
  • No direct inhibitory effect on thrombin
    
  • Half-life 12–21 hr in normal renal function
    
• DTIs
  
  • Competitively targets active site of thrombin +/− exosite (substrate binding site)
    
  • Half-life long with dabigatran (14–17 hr) and short with others (20–45 min)
    

DIAGNOSIS

• Patient on anticoagulants with active bleeding
  
• Indications for reversal
  
  • Serious or life-threatening bleeding
    
    • Trauma
      
    • GI bleeding
      
    • Intracerebral hemorrhage (ICH)
      
  • Procedural
    

• Type of anticoagulant
  
• Last anticoagulant use
  
• Length of anticoagulant
  
• Recent injury or trauma
  
• Bleeding location
  
• Symptoms (fatigue, lightheadedness, headache, abdominal pain)
  

• VS +/− orthostatics
  
• Search for hemorrhage locations/signs of trauma
  
• Comprehensive neurologic exam
  
• Rectal with stool guaiac test
  

• CBC
  
• PT/INR
  
• PTT
  
• Stool guaiac test
  
• +/− Fibrinogen/DIC panel
  

• Indirect inhibitors of thrombin
  
  • PTT
    
  • Anti-FXa
    
    • High is >0.8 U/mL
      
• Anti-platelet agents
  
  • Bleeding time
    
• FXa inhibitors
  
  • Anti-FXa
    
  • PT, PTT minimally helpful
    
  • Fondaparinux level (institution specific)
    
• DTIs
  
  • PTT minimally helpful
    
  • Dabigatran level aka dilute thrombin time (institution specific)
    

• Disseminated intravascular coagulopathy
  
• Inherited coagulation disorders
  
• Platelet dysfunction:
  
  • TTP/HUS
    
  • HIT
    
  • ITP
    

TREATMENT

• Pressure to hemorrhage (if possible)
  
• 2 large-bore IVs
  
• IV fluids
  

• Same as pre-hospital
  
• Hold anticoagulants
  

• Indirect inhibitors of thrombin
  
  • Level bleeding
    
    • Minor: Observe PTT, anti-FXa
      
    • Major: Protamine (Class II for UFH and Class III for LMWH)
      
  • Protamine
    
    • 1 mg IV neutralizes 100 U UFH administered in prior 3–4 hr
      
      • If <30 min since UFH, use 1 mg/100 U UFH
        
      • If 30–120 min, use 0.5 mg/100 U UFH
        
      • If >120 min, use 0.25 mg/100 U UFH
        
    • Give slowly IV over 1–3 min not to exceed 50 mg in any 10-min period
      
    • Short half-life, may need to re-dose
      
    • Protamine reversal effectiveness is compound specific for LMWH (does not reverse enoxaparin completely)
      
    • 1 mg for each 1 mg/100 IU LMWH given in last 8 hr
      
    • If 8–12 hr since LMWH, use 0.5 mg for each 1 mg/100 IU LMWH
      
    • If >12 hr since LMWH, no protamine suggested
      
    • For LMWH, if PTT remains prolonged, may repeat with half of the 1st dose
      
    • High or excessive dosing can have a paradoxical anticoagulant effect
      
    • Rapid administration can cause hypotension, bradycardia, and anaphylaxis
      
    • Anaphylaxis is more likely with a fish allergy or prior exposure to protamine and if concerned, can premedicate with corticosteroids and antihistamines
      
• Anti-platelet agents
  
  • Level bleeding
    
    • Minor: Observe bleeding
      
    • Major: DDAVP +/− platelet transfusion(s) (class III)
      
  • Desmopressin (DDAVP)
    
    • Induces the release of von Willebrand factor and factor VIII
      
    • 0.3 μg/kg IV over 15 min
      
    • Effect is immediate
      
    • Multiple doses associated with tachyphylaxis, hyponatremia, and seizures
      
  • Platelets
    
    • Transfuse to increase count by 50,000/μL (on average, 1 U increases platelet count by 10k)
      
    • May need to repeat transfusions daily
      
    • Risks include infection transmission, acute lung injury, and allergic reactions
      
• FXa inhibitors
  
  • Level bleeding
    
    • Minor: Observe bleeding
      
    • Major: PCC or rFVIIa (Class III), consider hemodialysis (HD) for fondaparinux, consider charcoal if rivaroxaban and ingested in previous 2 hr
      
  • Prothrombin complex concentrates (PCCs)
    
    • 3 factor: Contains factors II, IX, X and low concentrations of nonactivated factor VII + anticoagulant protein C, protein S, antithrombin III
      
    • 4 factor: Contains II, IX, X, activated VII
      
      • Factor 4 is now available widely in the US
        
    • FDA approved for bleeding episodes in patients with hemophilia B
      
    • Dose 25–50 U/kg not to exceed 2 mL/min
      
    • Give 1–2 U FFP for factor VIIa component
      
    • Effect in <30 min
      
    • Limited data to support use in trauma
      
    • Vary widely in composition
      
      • Several contain heparin
        
    • Long-term safety has not been assessed
      
    • Associated with risk of thrombosis
      
    • Allergic reactions may occur
      
  • Recombinant activated factor VII (rFVIIa)
    
    • FDA approved for bleeding episodes in patients with hemophilia A and B
      
    • Off-label use for life-threatening bleeding
      
    • Dose 15–90 μg/kg (suggested 40 μg/kg) IV over 3–5 min
      
    • Effect in <30 min
      
    • May repeat in 2 hr if continued bleeding
      
    • Associated with risk of thrombosis
      
  • Ultrafiltration/HD
    
    • For fondaparinux, may remove 20%
      
  • Activated charcoal
    
    • If ingestion within 1–2 hr of rivaroxaban
      
• DTIs
  
  • Level bleeding
    
    • Minor: Observe bleeding (DTIs have short half-life except dabigatran, which is 14–17 hr), IV fluids to improve renal clearance
      
    • Major: PCC or rFVIIa (no strong evidence for either), consider DDAVP, activated charcoal if within 1–2 hr ingestion, consider HD (especially if dabigatran)
      
  • PCC
    
    • Dose 25–50 U/kg not to exceed 2 mL/min
      
    • Give 1–2 U FFP if using 3 factor
      
  • rFVIIa
    
    • Dose 100 μg/kg IV over 3–5 min
      
    • May repeat in 2 hr if continued bleeding
      
  • DDAVP
    
    • Dose 0.3 μg/kg IV over 15 min
      
    • Demonstrated effectiveness with hirudin
      
  • Ultrafiltration/HD
    
    • Consider early in course for dabigatran and major bleeding
      
  • Activated charcoal
    
    • If ingestion within 1–2 hr