New Scoring System Could Revolutionize Blood Clot Prevention After casts
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A groundbreaking new risk assessment model is poised to change how doctors approach blood clot prevention in patients with lower limb casts. The TRiP(cast) score, developed by researchers in the Netherlands, France, and belgium, offers a more precise way to identify individuals at high risk of venous thromboembolism (VTE), reducing the need for possibly unneeded preventative treatments. [[3]]
VTE, encompassing deep vein thrombosis (DVT) and pulmonary embolism (PE), is a serious complication that can arise from prolonged immobilization, such as that following a lower limb fracture and subsequent casting. Traditionally, many patients in such situations receive prophylactic anticoagulation, a preventative blood-thinning medication. however, the TRiP(cast) score allows for a more targeted approach.
The TRiP(cast) score considers various factors related to the patient’s condition, the nature of the injury, and the immobilization itself. “This score was published in the literature 2 or 3 years ago and it includes criteria concerning trauma, concerning immobilization and concerning patients,” explains a leading researcher. A score of 7 or higher indicates a higher risk of VTE,prompting the use of preventative anticoagulation. [[1]]
A recent study, CASTING, further validated the effectiveness and safety of the TRiP(cast) score. The study,involving over 2,100 patients,demonstrated that using the score to guide anticoagulation decisions led to a significant reduction in preventative medication prescriptions—a 26% decrease.”The application of the TRiP(cast) score allows a reduction in preventive anticoagulation prescriptions of 26%, which is considerable and which is also associated with a safety threshold which is indeed much less than 1%; so it is safe not to do it when the score is low,” the researcher noted. The study also confirmed a low incidence of VTE in low-risk patients who did not receive prophylactic treatment.[[2]]
This progress has significant implications for U.S. healthcare. By reducing unnecessary anticoagulation, the TRiP(cast) score could minimize the risk of bleeding complications associated with these medications, leading to improved patient safety and potentially lower healthcare costs. The more targeted approach also promises to improve patient experience by reducing the need for unnecessary medication and potential side effects.
The TRiP(cast) score represents a significant advancement in the management of VTE in patients with lower limb casts. Its adoption promises to optimize treatment strategies, enhancing patient safety and improving healthcare efficiency.
Groundbreaking Medical Studies Challenge Established Practices
Recent medical research is forcing a re-evaluation of established practices in emergency medicine and trauma care. Three significant studies, published in leading medical journals, present compelling evidence that challenges long-held assumptions about patient management in critical situations.
Intubation in Comatose Patients with Toxic Ingestion
A pragmatic,high-quality study published in JAMA examined the necessity of systematic intubation in comatose patients who have ingested toxic substances. The study, which included 237 patients randomized into intervention and no-intervention groups, excluded those with intoxication from cardiotropic drugs, benzodiazepines, or opioids. “The main toxicant that was found was of course alcohol (around 70%),” the study notes. The results revealed no significant difference between the two groups, suggesting that systematic intubation may not be necessary in all cases, regardless of Glasgow Coma Scale score. This finding has the potential to significantly alter emergency room procedures. you can read the full study here.
Restrictive vs. Liberal oxygenation in COPD Patients
An international study published in BJA Open investigated the optimal oxygenation strategy for patients with chronic obstructive pulmonary disease (COPD) and acute hypoxemic respiratory failure in the ICU. This randomized controlled trial, conducted across multiple centers in Denmark, the Netherlands, and Switzerland, enrolled 1979 adult trauma patients. The study compared a restrictive oxygenation strategy (targeting oxygen saturation of 94%) to a liberal strategy (12-15 liters of oxygen per minute). “This did not significantly reduce deaths and major respiratory complications within 30 days,” the study concluded, challenging the prevailing preference for liberal oxygenation in severe trauma cases.
The full study is available here.
Prehospital Resuscitation with Aortic Occlusion Balloon
Researchers from London’s Air ambulance conducted a prospective observational cohort study published in JAMA Surgery, exploring the use of a resuscitative endovascular balloon occlusion of the aorta (REBOA) for subdiaphragmatic hemorrhage in prehospital care. the study, conducted between June 2020 and March 2022, included over 2,960 trauma patients over the age of 16. Focusing on bloodless patients with subdiaphragmatic injuries, the study found that “femoral arterial access was attempted with balloon mounting above the trunk celiac” in 16 patients. “The first thing that can be said is that cannulation was possible for 13,” the study reports, providing valuable data on the feasibility and potential of this prehospital intervention. Read the complete study here.
These three studies highlight the ongoing evolution of emergency medicine and trauma care,emphasizing the importance of rigorous research to refine and improve patient outcomes. The findings presented challenge existing practices and offer valuable insights for clinicians and researchers alike.
Emergency Procedure Shows Promise, But Challenges Remain
A recent study evaluating the use of REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) in trauma patients has yielded mixed results, highlighting both its potential and significant limitations. The research, while showing feasibility in certain cases, also underscores the need for further refinement before widespread adoption.
The study involved 16 trauma patients, eight of whom experienced traumatic cardiac arrest. In the cardiac arrest cases, the procedure resulted in a resumption of circulatory activity for most patients, and all showed a marked improvement in systolic blood pressure upon arrival at the hospital. “In the latter, the authors noted a resumption of circulatory activity for the majority of them, and for all patients, a significant improvement in systolic blood pressure on arrival at the receiving department,” a summary of the findings stated.
Despite these positive outcomes, the overall 30-day mortality rate remained high, at approximately 82%. “The mortality data in this paper are essentially the same as those we know,with 30-day mortality which was around 82% (therefore high mortality),” the study concluded.
While two patients did survive the early stages of treatment, the study also revealed significant technical hurdles. “But as far as it is feasible, this does not necessarily mean that REBOAs shoudl be fitted to these patients in these situations, because in fact, the study clearly states that ther are technical constraints for placement,” a leading expert noted. These constraints include difficulties with vascular access, identifying the precise level of occlusion, and the need for rapid, ideally within 20 minutes, follow-up surgery.
Although several medical teams are exploring the potential of REBOA,the current findings suggest that widespread implementation is premature. “So even if several french teams are interested in this subject, I think that in the current state of things, it seems that this technique cannot be recommended, or at least not generalized,” the expert concluded.
Further research is crucial to address the technical challenges and improve the overall success rate of REBOA before it can be considered a standard treatment option for trauma patients.
A New Era in VTE Prevention
Dr. Emily Carter, a leading hematologist specializing in venous thromboembolism (VTE) prevention, sheds light on a groundbreaking risk assessment tool revolutionizing patient care.
Could you explain what VTE is and why it’s a concern for patients with lower limb casts?
VTE, or venous thromboembolism, is a condition that includes both deep vein thrombosis (DVT) and pulmonary embolism (PE). DVT occurs when a blood clot forms in a deep vein, typically in the legs, while PE happens when a clot travels from the leg to the lungs, blocking blood flow.
Immobilization, especially following lower limb fractures and casting, significantly elevates the risk of VTE. When a limb is immobilized, blood flow slows down, increasing the chance of clot formation.
Traditionally, many patients with lower limb casts received preventive blood-thinning medication. What’s changing this practice?
A new risk assessment model called the TRiP(cast) score is changing how we approach VTE prevention. This score considers various factors related to the patient’s condition, the nature of the injury, and the immobilization itself.
How does the trip(cast) score work, and how does it guide treatment decisions?
The TRiP(cast) score assigns points based on specific criteria related to trauma, immobilization, and patient characteristics. A score of 7 or higher indicates a higher risk of VTE, prompting the use of preventive anticoagulation.For patients with scores lower than 7, the risk of VTE is considered low, and they may not require preventative medication.
What are the benefits of using the TRiP(cast) score?
The TRiP(cast) score allows for a more precise and personalized approach to VTE prevention. By accurately identifying high-risk patients, we can ensure they receive appropriate preventative treatment, minimizing the risk of serious complications.
Conversely, the score helps us avoid unnecessary anticoagulation for low-risk patients, reducing the risk of bleeding and other side effects associated with these medications. This targeted approach ultimately improves patient safety and perhaps lowers healthcare costs.
Has the TRiP(cast) score been extensively studied?
Yes. A recent large-scale study called CASTING, involving over 2,100 patients, validated the effectiveness and safety of the TRiP(cast) score. The study demonstrated a notable reduction in preventative medication prescriptions – a 26% decrease – without an increase in VTE incidents in low-risk patients who didn’t receive prophylactic treatment.
What are the implications of the TRiP(cast) score for US healthcare?
The TRiP(cast) score represents a significant advancement in VTE management. By enabling more targeted prevention strategies, it has the potential to minimize unnecessary medication use, reduce bleeding complications, and ultimately improve patient outcomes and healthcare efficiency.
This score is likely to become a standard tool for physicians managing patients with lower limb casts, marking a crucial step towards more personalized and effective VTE prevention.
