1 00:00:00,000 --> 00:00:07,000 Global Cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child 2 00:00:07,000 --> 00:00:08,600 health around the globe. 3 00:00:08,600 --> 00:00:10,280 Hello, Pediatric Surgery family. 4 00:00:10,280 --> 00:00:13,880 I'm Lizzie Lee from Cincinnati Children's Hospital Medical Center. 5 00:00:13,880 --> 00:00:18,400 Our 12th annual update course in pediatric surgery was held this past August. 6 00:00:18,400 --> 00:00:23,480 In this video series, we will recap the sessions and share the main highlights with you. 7 00:00:23,480 --> 00:00:27,640 This year, we introduced a new approach to classify practice-changing ideas at our update 8 00:00:27,640 --> 00:00:29,520 course. 9 00:00:29,520 --> 00:00:34,520 Diamonds now fall into three categories, green circles for established practices, blue squares 10 00:00:34,520 --> 00:00:39,480 for promising newer practices, and black diamonds for early adopter practices only. 11 00:00:39,480 --> 00:00:45,040 Today, we will talk about deep vein thrombosis or DVT porphylaxis in pediatric trauma with 12 00:00:45,040 --> 00:00:47,760 doctors Regan Williams and Katie Russell. 13 00:00:47,760 --> 00:00:51,640 They brought us a case about a 15-year-old in a high-speed motor vehicle crash. 14 00:00:51,640 --> 00:00:55,720 This topic falls into the blue category of newer approaches. 15 00:00:55,720 --> 00:01:02,440 A 15-year-old who is in a high-speed motor vehicle crash is hemodynamically normal with 16 00:01:02,440 --> 00:01:05,080 a hematocrit of 28 in the trauma bay. 17 00:01:05,080 --> 00:01:11,560 He's got a three-millimeter subdural hemorrhage that is stable on a CT scan six hours after 18 00:01:11,560 --> 00:01:12,560 injury. 19 00:01:12,560 --> 00:01:17,520 He had an operative pelvis fracture and he's going to be non-weight-bearing for six weeks. 20 00:01:17,520 --> 00:01:20,600 When should we start chemical DVT porphylaxis in this patient? 21 00:01:20,600 --> 00:01:22,720 24 hours. 22 00:01:22,720 --> 00:01:29,160 The big challenge is that the neurosurgical community is in large denial of the data that 23 00:01:29,160 --> 00:01:33,480 says that it's safe to do and that if you don't do it, you have big complications. 24 00:01:33,480 --> 00:01:34,840 The literature is clear. 25 00:01:34,840 --> 00:01:38,720 Some hospitals have rewritten their protocol that the decision for DVT porphylaxis should 26 00:01:38,720 --> 00:01:40,360 be up to the trauma surgeon. 27 00:01:40,360 --> 00:01:44,560 The trauma surgeon decides if the patient is going to get DVT porphylaxis. 28 00:01:44,560 --> 00:01:48,280 You just ask the trauma surgeon and what the trauma surgeon says is what we do. 29 00:01:48,280 --> 00:01:52,680 A recent cohort study showed that chemical VTE porphylaxis was safe. 30 00:01:52,680 --> 00:01:56,960 It did not cause bleeding complications and should be done within 24 hours of admission 31 00:01:56,960 --> 00:01:59,120 to prevent development of VTE. 32 00:01:59,120 --> 00:02:05,240 They looked at it and found that in trauma patients, if you gave DVT porphylaxis within 33 00:02:05,240 --> 00:02:09,960 24 hours of injury, they are much less likely to get a DVT. 34 00:02:09,960 --> 00:02:13,400 So I think our goal should be really to start within 24 hours. 35 00:02:13,400 --> 00:02:16,360 When should we avoid giving chemical DVT porphylaxis? 36 00:02:16,360 --> 00:02:22,520 You can absolutely give DVT porphylaxis in solid organ injuries. 37 00:02:22,520 --> 00:02:28,480 In general, pediatric trauma patients with a low risk of bleeding with stable head, pelvic 38 00:02:28,480 --> 00:02:33,000 or solid organ injuries should receive chemical VTE porphylaxis. 39 00:02:33,000 --> 00:02:37,840 On the other hand, those with continued evidence of bleeding and unstable injuries should not 40 00:02:37,840 --> 00:02:40,400 receive chemical VTE porphylaxis. 41 00:02:40,400 --> 00:02:46,680 The EAST guidelines, which are the best data we have, would suggest that for adolescent 42 00:02:46,680 --> 00:02:50,640 patients with an ISS greater than 25, they need to get porphylaxis. 43 00:02:50,640 --> 00:02:55,100 The EAST or Eastern Association for the Surgery of Trauma has guidelines that recommend that 44 00:02:55,100 --> 00:03:00,700 you calculate the ISS, the Injury Severity Score, which is the traumatic injury based 45 00:03:00,700 --> 00:03:03,880 on the worst injury of six body systems. 46 00:03:03,880 --> 00:03:10,700 If the ISS is less than 25 or they have a major risk of bleeding, avoid DVT porphylaxis. 47 00:03:10,700 --> 00:03:15,120 I think if the patient has a real risk of dying from bleeding, you should not give it. 48 00:03:15,120 --> 00:03:19,800 If you have a head injury that's unstable that you're maybe going to put an ICP monitor, 49 00:03:19,800 --> 00:03:23,600 you're wondering if they need to get a cranny or not, you should probably not give it to 50 00:03:23,600 --> 00:03:24,600 them. 51 00:03:24,600 --> 00:03:26,160 Now the patient is ready to go home. 52 00:03:26,160 --> 00:03:30,640 Which DVT porphylaxis should be prescribed for this patient to continue taking at home? 53 00:03:30,640 --> 00:03:35,840 In the hospital, you started Lovenox, but he's ready to go home. 54 00:03:35,840 --> 00:03:36,840 What are you going to send him on? 55 00:03:36,840 --> 00:03:38,960 Remember, he's in a wheelchair for six weeks. 56 00:03:38,960 --> 00:03:43,960 Aspirin, Lovenox, Coumadin, some kind of a new generation DOAC. 57 00:03:43,960 --> 00:03:48,120 Let's see what the poll results showed for the different treatment options. 58 00:03:48,120 --> 00:03:51,680 About a quarter of people are going to go aspirin and about a quarter of people DOAC 59 00:03:51,680 --> 00:03:53,420 and then a lot of Lovenox. 60 00:03:53,420 --> 00:03:57,080 The downside to Lovenox is that it is an injection. 61 00:03:57,080 --> 00:04:03,920 There was a well done adult study that was published in the New England Journal of Medicine. 62 00:04:03,920 --> 00:04:09,020 A randomized controlled trial was published in 2023 by the major Extremity Trauma Research 63 00:04:09,020 --> 00:04:14,000 Consortium that included adult trauma patients with orthopedic injuries. 64 00:04:14,000 --> 00:04:19,180 They gave 6,000 of the adults aspirin and 6,000 of the adults Lovenox. 65 00:04:19,180 --> 00:04:20,520 What did they find? 66 00:04:20,520 --> 00:04:27,200 What they found is that aspirin was non-inferior to Lovenox in terms of DVT prophylaxis in 67 00:04:27,200 --> 00:04:29,000 that patient population. 68 00:04:29,000 --> 00:04:33,120 Although the study focused on adult patients, pediatric trauma surgeons are applying this 69 00:04:33,120 --> 00:04:37,880 to pediatric patients too and discharging them home on aspirin to take at home. 70 00:04:37,880 --> 00:04:41,600 That's most likely going to be followed way more than these Lovenox shots that we've 71 00:04:41,600 --> 00:04:43,080 been doing historically. 72 00:04:43,080 --> 00:04:48,520 We have started discharging kids on aspirin realizing that taking some adult data that 73 00:04:48,520 --> 00:04:54,240 is not perfect but it's effective and it's a lot better than Lovenox and a lot better 74 00:04:54,240 --> 00:04:55,240 than nothing. 75 00:04:55,240 --> 00:05:00,040 In conclusion, chemical DVT prophylaxis to start within 24 hours in pediatric trauma 76 00:05:00,040 --> 00:05:05,840 patients even with stable pelvic or solid organ injuries per the evidence and guidelines. 77 00:05:05,840 --> 00:05:10,120 Avoid chemical DVT prophylaxis if there is a high bleeding risk such as unstable head 78 00:05:10,120 --> 00:05:13,160 injuries according to the EAST guidelines. 79 00:05:13,160 --> 00:05:17,260 When patients are discharged home, aspirin is now commonly prescribed based on studies 80 00:05:17,260 --> 00:05:25,160 showing that it is as effective as Lovenox for DVT prevention but easier to administer. 81 00:05:25,160 --> 00:05:30,520 GlobalCast MD along with Cincinnati Children's Hospital sharing knowledge to improve child 82 00:05:30,520 --> 00:05:40,560 health around the globe.