85 years old male is BIBA after mechanical fall onto his left side in drive way about 45 min ago. He has obvious swelling and bruise of left shoulder, left leg externally rotated on initial review. No history of head trauma. His vitals on arrival are HR 76, BP 102 systolic. Temp 35.6. RR 18, sats 98 RA. His GCS is 15 but complaining of lot of pain in shoulder and hip. ECG sinus rhythm. His Past medical history includes atrial fibrillation, He is on apixaban and spiranolactone and compliant with his medications. His primary survey on arrival is okay. Log roll has not been done yet.
His Hb on arrival is 115. 30 min later his BP drops to 77/54, and HB has dropped to 91 on repeat VBG. His xrays so far have confirmed left proximal humerus fracture and left proximal femoral shaft fracture. He is given 500 ml fluid bolus awaiting response.
Answers: 1
A ) Main clinical concern in this patient is developing haemorrhagic shock from long bone fractures ( so far investigated).
B) Presence of apixaban makes it more challenging for clinicians and also more detrimental for patient especially if hemodynamically unstable.
C) Probable other injuries that have not been found as yet on initial scans so needs a detailed secondary survey to find any other potential source of bleeding.
2. Further investigations depend upon detailed secondary survey , does the patient have associated abdominal injuries. ? Log roll of the patient for potential spine or back injuries / haematomas. Needs urgent Group and Hold and cross matching, coagulation profile .
further exam revealed that he had significant swelling to left thigh, and complained lower back pain on Log roll.
3. Management : Although initial primary survey was okay, Circulation seemed to be the problem about 30 min later. Unstable trauma management should follow ” FIND THE BLEEDING, STOP THE BLEEDING ” theme. Special attention to apixaban reversal in this case is utmost. So the main management steps of circulation would be:
a) Ensure wide bore iv access X 2. Think about wide bore catheters i.e RICC lines , swan sheath in unstable trauma. Patient is in resus and fully monitored.
b) Application of pelvic binder if unstable pelvic fracture in addition to NOFF fracture.
c) FAST as part of “C” to look for free fluid.
d) Activation of MTP and urgent advice from haematology regarding apixaban effect reversal.
APIXABAN: It is a NOAC , is factor Xa inhibitor just like rivoraxaban. Starts working within 3 hours and half life is around 12 hours. Mainly excreted in faeces so can not be dialysed. It can affect INR/ PT/ APT T but normal values do not rule out significant effects when overdosed. Anti Xa levels can be done to monitor and plan ( less than 30-50 ng/ml ) likely no significant anticoagulant effect.
e) While awaiting for blood, 1 gram IV tranexamic acid should be given. The urgent advice from haematologist was to give 1 X PRBC, 4 units FFPS and prothrombinex. Prothrombinex has got factor 2, 7, and 10 . .
Patient was admitted to HDU, blood products given, Observed and stabilized over 24 hours, and then eventually had surgery on hip. He also had an acute L1 fracture with surrounding haematoma but with no neurology ( conservatively managed.