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Study Objective: Enoxaparin is standard of care for venous thromboembolism (VTE) prophylaxis in adult trauma patients, but fixed‐dose protocols are suboptimal. Dosing based on body mass index (BMI) or total body weight (TBW) improves target prophylactic anti‐Xa level attainment and reduces VTE rates. A novel strategy using estimated blood volume (EBV) may be more effective based on results of a single‐center study. This study compared BMI‐, TBW‐, EBV‐based, and hybrid enoxaparin dosing strategies at achieving target prophylactic anti‐Factor Xa (anti‐Xa) levels in trauma patients. Design: Multicenter, retrospective review. Data Source: Electronic health records from participating institutions. Patients: Adult trauma patients who received enoxaparin twice daily for VTE prophylaxis and had at least one appropriately timed anti‐Xa level (collected 3 to 6 hours after the previous dose after three consecutive doses) from January 2017 through December 2020. Patients were excluded if the hospital‐specific dosing protocol was not followed or if they had thermal burns with > 20% body surface area involvement. Intervention: Dosing strategy used to determine initial prophylactic dose of enoxaparin. Measurements: The primary end point was percentage of patients with peak anti‐Xa levels within the target prophylactic range (0.2‐0.4 units/mL). Main Results: Nine hospitals enrolled 742 unique patients. The most common dosing strategy was based on BMI (43.0%), followed by EBV (29.0%). Patients dosed using EBV had the highest percentage of target anti‐Xa levels (72.1%). Multiple logistic regression demonstrated EBV‐based dosing was significantly more likely to yield anti‐Xa levels at or above target compared to BMI‐based dosing (adjusted odds ratio (aOR) 3.59, 95% confidence interval (CI) 2.29‐5.62, p < 0.001). EBV‐based dosing was also more likely than hybrid dosing to yield an anti‐Xa level at or above target (aOR 2.30, 95% CI 1.33‐3.98, p = 0.003). Other pairwise comparisons between dosing strategy groups were nonsignificant. Conclusions: An EBV‐based dosing strategy was associated with higher odds of achieving anti‐Xa level within target range for enoxaparin VTE prophylaxis compared to BMI‐based dosing and may be a preferred method for VTE prophylaxis in adult trauma patients. [ABSTRACT FROM AUTHOR]

Background: The optimal dosing for enoxaparin venous thromboembolism (VTE) prophylaxis in low-weight trauma patients is unknown. Estimated blood volume (EBV) has shown promise as a dose modifier. Objective: To characterize the association of enoxaparin dose per EBV with the prevalence of VTE and bleeding in low-weight trauma patients. Methods: This was a retrospective study of trauma patients admitted over a 4-year period. Included patients were adults weighing <60 kg who received a minimum of 3 consecutive doses of enoxaparin. The primary endpoint was a comparison of enoxaparin dose per EBV in patients experiencing bleeding and VTE. Secondary endpoints included comparisons of dose per body mass index (BMI) and total body weight (TBW) and the ability of dose per EBV to predict clinical endpoints. Subgroup analyses for patients weighing <50 kg were performed for all endpoints. Results: A total of 189 patients were included. Statistical comparisons for VTE were not performed because of low prevalence. The dose of enoxaparin per EBV was not statistically different between patients who did and did not bleed in all analyses. Doses per BMI and TBW were also not statistically different between the groups. In patients weighing <50 kg, numerically higher doses per EBV, BMI, and TBW were noted in patients that bled versus those that did not. Enoxaparin dose per EBV was not a statistically significant predictor of bleeding in logistic regression models. Conclusion and Relevance: No significant associations between enoxaparin dose per EBV, BMI, or TBW and bleeding were noted in the study. Future analyses of EBV and other dose modifiers should consider inclusion of patients weighing <50 kg. [ABSTRACT FROM AUTHOR]

Purpose Fixed-dose and body mass index (BMI)–based enoxaparin regimens provide inadequate venous thromboembolism (VTE) prophylaxis for many trauma patients. The purpose of this study was to evaluate the effectiveness of a novel blood volume (BV)–based enoxaparin guideline vs a historical BMI-based guideline for VTE prophylaxis in trauma patients. Methods This was a retrospective pre/post study completed at a large academic level 1 trauma center. All adult trauma patients admitted from October through December 2019 and August through October 2020 who received prophylactic enoxaparin per guideline were included. The BV dosing was as follows: patients with a BV of 3 to 4.9 L received enoxaparin 30 mg every 12 hours, those with a BV of 5 to 6.9 L received 40 mg every 12 hours, and those with a BV of ≥7 L received 60 mg every 12 hours. The primary outcome was the percentage of patients who attained a target anti–factor Xa (anti-Xa) postdosing level at the first steady-state assessment (0.2 to 0.5 IU/mL). Results A total of 241 patients (99 for the BMI group and 142 for the BV group) were included. The study groups had a median age of 38 vs 42 years, a mean BMI of 27.4 vs 27.7 kg/m2, and a mean BV of 5.1 vs 5.1 L, respectively. A total of 63 patients (62.6%) in the BMI group attained target anti-Xa levels compared to 115 patients (81%) in the BV group (P = 0.008). In multivariate regression, the BV-based guideline was the only variable associated with attainment of target anti-Xa levels (adjusted odds ratio, 2.02; P = 0.01). Clinically relevant bleeding and VTE rates were similar between the groups. Conclusion Dosing prophylactic enoxaparin using a BV-based dosing guideline significantly increased attainment of target anti-Xa levels. [ABSTRACT FROM AUTHOR]

Tracheostomy is commonly used for managing the airway of trauma patients. Complications are common and result in increased length of stays and treatment cost. The aim of this study is to evaluate whether the utilization of skin sutures or foam barrier dressings affect tracheostomy complication rates. This is a single-center retrospective review of patients who underwent a tracheostomy by the trauma service between January 2014 and December 2017. Collected variables included demographics, patient history, treatment variables, complications, and outcomes. Univariate and multivariate analyses were constructed to identify significant predictors for the development of complications. A total of 268 patients were included. The median age was 43.5 y, 221 (82.5%) patients were men, and the median BMI was 28 (IQR 24.6, 32.2). Most (87.3%) of the procedures were performed in the operating room and 82.5% were open. Skin sutures were used in 46.3% and 53.4% had a foam barrier dressing placed. Current smoking [OR 8.1 (95% CI 1.5, 43.6)] and BMI [OR 1.1 (95% CI 1.03, 1.2)] significantly increased the risk of developing pressure necrosis. Use of sutures or foam dressings was not associated with pressure necrosis, bleeding, or surgical site infection. There were no unexpected tracheostomy decannulations regardless of the use of skin sutures. Suturing the tracheostomy or applying a foam barrier dressing was not associated with overall complications or decannulation rates. Based on our data, we suggest that skin sutures may be safely abandoned. [ABSTRACT FROM AUTHOR]

The objective of this study was to assess the current practice pattern regarding posthospitalization follow-up of trauma patients among the members of the Eastern Association for the Surgery of Trauma (EAST). An anonymous online multiple-choice survey of EAST members in 2016 was conducted. Ten questions relating to the follow-up care of injured patients were presented to the Active, Senior, and Associate members of EAST. Data were screened for quantitative concerns prior to analysis. Of the 1,610 members surveyed, 289 responded (18%). Approximately 52% of respondents stated that their institution has a dedicated trauma follow-up clinic where most injured patients are seen after discharge. Less than 20% reported that nontrauma multidisciplinary providers are present in clinics. Most (89.5%) reported that follow-up is a single visit, unless a patient has long-standing issues. Only 3 respondents stated that patients are regularly seen 3+ months out from injury, and a significant minority (17.7%) acknowledged no set follow-up timeline. Only 3.6% of participants indicated that they have a psychologist embedded in the trauma team, and 11.5% reported that no system is currently in place to manage mental health. Despite more than 20 years of literature highlighting the long-term physical and mental health sequelae after trauma, these survey results demonstrate that there is a lack of standardized and multidisciplinary follow-up. Given the improvement in outcomes with the identification and treatment of these sequelae, greater attention should be paid to functional recovery, social and psychological well-being, and chronic pain. [ABSTRACT FROM AUTHOR]

Background Hemothorax and/or pneumothorax can be managed successfully managed with tube thoracostomy (TT) in the majority of cases. Improperly placed tubes are common with rates near 30%. This study aimed to determine whether TT trajectory affects the rate of secondary intervention. Methods A retrospective review of all adult trauma patients undergoing TT placement over a 4-y period was performed. TT trajectory was classified as ideal, nonideal, or kinked-based on anterior–posterior chest x-ray. TTs with sentinel port outside the thoracic cavity were excluded. The primary outcome was any secondary intervention. Results Four-hundred eighty-six patients and a total of 547 hemithoraces underwent placement and met inclusion criteria. The majority of patients were male (76%), with a median age of 41 y, and majority suffered blunt trauma ideal trajectory was identified in 429 (78.4%). Kinked TTs were noted in 33 (6%) hemothoraces with a 45.5% replacement rate. Review with staff demonstrates inherent bias to replace kinked TTs. The overall secondary intervention rate was 27.8%. Kinked TTs were removed from final analysis due to treatment bias. Subsequent analysis demonstrated no significant difference between ideal and nonideal trajectories (25.1% versus 34.1%, P = 0.09). Conclusions Intrathoracic trajectory of nonkinked TTs with the sentinel port within the thoracic cavity does not affect secondary intervention rates, including the rate of surgical intervention. [ABSTRACT FROM AUTHOR]