pulmonary embolism following fixation in a lower extremity fracture: a clinical presentation by:...
DESCRIPTION
Purpose Discuss potential impact of a pulmonary embolism (PE)/deep vein thrombosis (DVT) on recovery from a traumatic injury.TRANSCRIPT
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Pulmonary embolism following fixation in a
lower extremity fracture: a clinical
presentation By: AJ Cushman
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PurposeDiscuss potential impact of a pulmonary embolism
(PE)/deep vein thrombosis (DVT) on recovery from a traumatic injury.
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My Patient-Mr. Salesman27 y/o African-American maleCar salesmanRuns 3 miles dailyNo family hx, prior sx, comorbiditiesLives with fatherAdmitted May 26, 2014 for gun shot wound (GSW)
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History of present illnessORIF of L distal femur fx s/p GSW
TTWB LLEHgb dropped: 125.0 mmHgTachycardic/orthostatic: 130180bpm on standing
Transferred to STICUC/o pain RLE
Possible DVT/PE Chest CT found small/moderate PE L lower lobe.
Heparin bolus
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PT EvaluationSubjective
8/10 pain R (uninjured) > L at
beginning of session L > R at end
Odd sensations in L foot Activity Level Living Situation/equipment
With father, stairs, crutches
Goals
Objective Observe: lethargic Vitals: Tachycardic throughout Integument: clammy,
temperature R>L, Swelling L>R
Sensation: L=paresthesias, R=pain
ROM: R-WFLs, L-0-35˚ knee flexion
Mobility: supineEOB, sitstand, ambulation
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Relevant FindingsPain (BLE) Decreased strength Decreased ROM (L knee flexion) Ability to maintain WB statusActivity tolerance/enduranceIndependence with ambulation and ADLs…
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Prognosis and GOALSPt is good candidate for PTLikely return to previous level of function and d/c
home (+)- age, prior activity level, no comorbidities, pt
motivation, cognition, family assistance at home (-)- severity of pain and injuries, level of dysfunction,
and…complications aka DVT/PE???
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Goals and PlanAt time of discharge (1 week), patient will be able
to:1) Actively achieve 90 degrees of knee flexion2) Ambulate 150 feet independently using LRAD3) Up/down one flight of stairs using LRAD
Plan: 5x/wk. Expected d/c = home
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InterventionsFunctional mobility(Gait training)Therapeutic exerciseActivity Tolerance
Increase endurance
Patient education WB status DVT/PE
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Outcomes/Re-eval Assessment of re-eval…Goals Met (1/3): Pt able to achieve 90˚ L knee
flexionRationale for other goals NOT met:
Delays in PT visitsUnable to ambulate/maintain WB status
Information I am missing…
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Does the incidence of a pulmonary embolism negatively impact the prognosis in a healthy, young adult recovering from a lower extremity fracture?
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A meta-analysis of best rest versus early ambulation in the
management of pulmonary embolism, deep vein thombosis, or both.
International Journal of Cardiology; Volume 137, Issue 1, Pages 37-41
Nadia Aissaoui, Edith Martins, Stéphane Mouly, Simon Weber and Christophe Meune
Copyright 2008 Elsevier Ireland Ltd
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PurposeDetermine the best recommendation for PE/DVT
managementAmbulation versus bed restAlong with anticoagulants
Previous arguments in literature versus recent articlesEnd to confusion?
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Method5 studies selected (out of original 363 found)
comprising a total of 3048 patientsInclusion criteria:Relative risk (RR), 95% confidence intervals (CI)
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ResultsEarly ambulation:
1. Not associated with higher risk of new PE
(RR 1.03, 95% CI 0.65-1.63)
2. Associated with a lower trend of new/progression of DVT
(RR 0.79; 95% CI 0.55–1.14)
3. Not associated with higher rate of mortality
(RR 0.79, 95% CI 0.40-1.56)
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Discussion and ConclusionMust achieve effective level of anticoagulation
first!Confirmed efficacy as first line
EARLY AMBULATION DOES NOT INCREASE RISK OF ADVERSE OUTCOMES Trend toward lower risk in previously stated areas
Other positive benefits…
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Study LimitationsTiming of early ambulation range = 0-2 daysAddition of compression devices not assessedMassive PE excludedNo distinction between:
PE and DVT symptomatic and asymptomatic PE
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The effect of anticoagulant
pharmacotherapy on fracture healing
Tobias Lindner, Andrew J Cockbain, Mohamed A El Masry, Paul Katonis, Evgenios Tsiridis, Constantin Schizas &
Eleftherios Tsiridis
Expert Opin. Pharmacother. (2008) 9(7):1169-1187
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PurposeConsider potential recommendations between
specific agents and dosage in trauma patients (ie fracture)Current guidelines distinguish between low versus
high risk (provoked and idiopathic)
Presents evidence concerning the effect of common anticoagulants on:1) Fracture healing (in vivo) - 7 studies2) Bone metabolism (in vivo) – 6 studies3) Bone cells (in vitro) – 8 studies
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Anticoagulants in clinical use
HeparinLow molecular weight heparins (LMWHs) (Enoxaparin)Synthetic pentasaccharides (Fondaparinux)Vitamin K antagonists (Warfarin/coumarins)Acetylsalicylic acid (aspirin, Bayer Leverkusen)Direct thrombin inhibitors (DTIs) (argatroban,
lepirudin and hirudin)HIT alternative
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Biology of fracture healing
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Anticoagulants on fracture healing (in vivo)
Warfarin Heparin LMWH AspirinStudy #1 *Worst
union delay with earlier Rx
*Worst union delay with earlier Rx
Study #2 NO LONGER CLINICAL
Study #3 Hard callus formation (>soft)
Study #4 Bone formation & strength
Study #5 Bone formation
No impair
Study #6 No impair No impairStudy #7 No impair
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Anticoagulants on bone biology (in vivo)
Warfarin Heparin LMWHStudy #1 Bone
form/resorb (osteocalcin)
Study #2 Cancellous bone (inc resorb, dec form)
Cancellous bone (dec form only)
Study #3 Same as #3 Same as #3Study #4 *Prolonged
effects ≥56days
Study #5 Bone volume and strength (both ends)
Study #6 Bone mineral content
Not significant
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Anticoagulants on bone cells (in vitro)
Heparin LMWH FondaparinuxStudy #1
Bone nodule formation (greater osteoporosis risk than LMWH)
Bone nodule formation
Study #2
Cell concentration (osteoblast growth)
Cell concentration (osteoblast growth)
Study #3
Gene expression Gene expression *Inc matrix calcium/type 1 collagen)
Study #4
*Biphasic effect (low vs high dose)
Study #5
Osteoblast/gene expression (4x)
Osteoblast/gene expression
Study #6
Blast prolif, protein synthesis, osteocalcin
No inhib
Study #7
Osteoblast/osteocalcin
Study #8
Osteoclast formation
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Discussion
Anticoagulants impair fracture healing and bone health
All different stages in healing
Considerations Type
Heparin, Warfarin, and aspirin are worst
LMWHs are better Fondaparinux is best per this review
(further study required)
Dosage Less is more
Onset Immediate = worst Early mechanical thromboprophylaxis
Duration Early termination in patients with
provoked PE
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Study LimitationsLack of clinical studies
Must assume adequate comparison between animal and human
Unknown degree/significance of effectsVariable mechanisms expressed
Method for study selectionNot systematic
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According to the research…
DOES MR. SALESMAN’S PE NEGATIVELY AFFECT HIS
PROGNOSIS?
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Short termNOAmbulation recommended. Begin addressing his
problem list without restriction (once properly anticoagulated) Length of stay not increased
Patient will have altered WB status with or without anticoagulants
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Long Term(+) Provoked = lower risk of reoccurrence
No issue resuming independence with work and ADLs (-) Provoked = prescribed anticoagulants for 3-6
months…Delay fx healing delay normal WB progression?Residual effects?
NO CONCLUSION on severity and duration of Heparin effectsPatient education of potential riskSlower progression of WB and return to running Imaging?
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Heparin LMWH Warfarin Aspirin Fondaparinux
Union delaysBone strengthOsteoblastOsteoclast
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Heparin LMWH Warfarin Fondaparinux
-Delayed unions-Bone formation
-Delayed unions-Soft callus > hard callus