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Erkens PMG, Prins MH. Fixed dose subcutaneous low molecular weight heparins versus adjusted dose unfractionated heparin for venous thromboembolism. Cochrane Database Syst Rev 2010(9): CD001100.

Attina D, Valentino M, Galie N, Modolon C, Buia F, de Luca F, et al. Application of a new pulmonary artery obstruction score in the prognostic evaluation of acute pulmonary embolism: comparison with clinical and haemodynamic parameters. Radiol Med 2011;116:230-45.

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Kyrle PA, Rosendaal FR, Eichinger S. Risk assessment for recurrent venous thrombosis. Lancet 2010;376(9757):2032-9.

Kaczynska A, Kostrubiec M, Pacho R, et al. Elevated D-dimer concentration identifies patients with incomplete recanalization of pulmonary artery thromboemboli despite 6 months anticoagulation after the first episode of acute pulmonary embolism. Thromb Res 2008;122:21-5.

Romera A, Cairols MA, Vila-Coll R, et al. A randomised open-label trial comparing long-term sub-cutaneous low-molecular-weight hep- arin compared with oral-anticoagulant therapy in the treatment of deep venous thrombosis. Eur J Vasc Endovasc Surg 2009;37:349-56.

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Hyperalgesic acetabular fracture treated by transversus abdominis plane block in the ED^B

To the Editor,

We considered the critical situations using transversus abdominis plane block (TAP) for analgesia described by Herring et al [1]. We used TAP in an original indication: hyperalgesic, opiate-resistant acetabular fracture analgesia.

In the emergency department, a 21-year-old woman with major trauma was admitted after a car crash. She had no significant medical history. She had stable pelvic fracture with left acetabular, right iliac wing and right ischium

fractures, and stable spleen hematoma. Simple immobiliza- tion was indicated. She had severe left hip pain. It was 90/100 on the numerical rating scale (NRS). A Multimodal analgesia was started with paracetamol, nefopam, and morphine association. A sentinel CPA (morphine sulfate) was also installed. After morphine (12 mg), the patient presented adverse effects: drowsiness and bradypnea without effective analgesia (NRS, 70/100). On day 2, a left ultrasound-guided subcostal TAP block was performed. We injected 15 mL of lidocaine 2% and introduced a catheter in the injection space (Figure). It allowed sufficient analgesia (NRS, 10/100) after 30 minutes. We maintainED analgesia by continuous 0.2% ropivacaine infusion. Morphine consumption was 8 mg (CPA) on day 1 (before TAP catheter insertion) and only 2 mg on day 2, used for posterior pelvic pain preceding nursing mobilizations. The patient was discharged on day 4 in the orthopedic ward. Transversus abdominis plane block catheter was removed on day 5. After catheter removal, hip pain scored NRS 30/100 was controlled by multimodal analgesia. Epidural anesthesia could be adapted for pain control, but strict decline induced lateralization difficult to realize epidural procedure. That is why we proposed TAP. This technique induces thoracolumbar nerve blockade (T7 to L1), which supply anterolateral abdominal wall innervation [2]. Very few complications are described for this technique [3].

The Analgesic efficacy of the TAP has been demonstrated in prospective randomized trials compared with placebo, in different surgical procedures such as abdominal surgery, hysterectomy, retropubic prostatectomy, cesarean delivery, and laparoscopic cholecystectomy [2]. It showed as well good results in acute pancreatitis [4]. Catheter insertion is possible to provide bolus as an effective alternative to epidural infusion to provide postoperative analgesia after upper abdominal surgery [5]. Transversus abdominis plane block is efficient for parietal and intraabdominal pain [6], but only few reports are presented on pelvic pain. Chiono et al

[7] presented a study on analgesia with TAP in Iliac crest bone graft: 20 minutes after injection, 62.5% of the patients reported complete anesthesia, and 34% hypoesthesia. At 18 months, 80% of patients did not complain about pain at

^B Conflict of interest: none. Figure TAP catheter and posttrauma skin pelvic lesion.

the iliac crest site. Zetlaoui et al [6] reported 2 patients with TAP use for iliac bone surgery (a pubic symphysis fixation and an iliac wing fracture fixation). Iliopubic branch is only innerved by the L3, and ilium wing, by L4. These nerves are not reached by TAP. The block of thoracolumbar nerves from T7 to L1 was effective on ilium pain (T12 and L1), on the skin pain due to surgical incision, and probably induced in part by muscular relaxation of the abdominal wall. It avoids permanent traction on ischium and pubis [8]. In our case, there was only bone pain, without abdominopelvic incision. Acetabulum is a fusion of 3 bones with abdominal muscles insertions certainly responsible of pain by traction on the acetabular fracture home: ilium (external and internal obliques, and iliaca muscles), pubis (rectus, pectineus and pyramidal abdominal muscles), and ischium (obturator internus and externus muscles).

The efficiency of TAP in acetabular fracture could be explained by abdominal muscular relaxation, avoiding traction on fracture home. Ultrasound-guided TAP is a safe and easy technique. Others studies are necessary to evaluate the interest of the TAP in this indication.

Ingrid Millot MD David Plancade MD Julien Nadaud MD Sophie Cottez MD Elodie Schaeffer MD Nicolas Gagnon MD

Jean-Christophe Favier MD Christian Landy MD Department of Emergency

Anesthesiology and Critical Care Legouest Military Teaching Hospital

57000 Metz, France E-mail address: [email protected]

doi:10.1016/j.ajem.2012.03.019

References

1. Herring AA, Stone MB, Nagdev AD, et al. Ultrasound-guided Abdominal wall nerve blocks in the ED. Am J Emerg Med 2011 doi: 10.1016/j.ajem.2011.03.008.
2. Bonnet F, Berger J, Aveline C, et al. Transversus abdominis plane block: what is its role in postoperative analgesia? Br J Anaesth 2009;103:468-70.
3. Jankovic Z, Ahmad N, Ravishankar N, Archer F. Transversus abdominis plane block: how safe is it? Anesth Analg 2008;107:1758-9.
4. Landy C, Plancade D, Millot I, Gagnon N, Nadaud J, Favier JC. Another use of ultrasound-guided transversus abdominis plane block in the ED. Am J Emerg Med 2012 doi:10.1016/j.ajem.2011.12.012.
5. Niraj G, Kelkar A, Jeyapalan I, et al. Comparison of analgesic efficacy of subcostal transversus abdominis plane blocks with epidural analgesia following upper abdominal surgery. Anaesthesia 2011;66:465-71.
6. Beloeil H, Zetlaoui PJ. TAP block and blocks of the abdominal wall. Ann Fr Anesth Reanim 2011;30:141-6.
7. Chiono J, Bernard N, Bringuier S, et al. The ultrasound-guided transversus abdominis plane block for anterior iliac crest bone graft postoperative pain relief: a prospective descriptive study. Reg Anesth Pain Med 2010;35:520-4.
8. Zetlaoui PJ. Bloc dans le plan du muscle transverse de l’abdomen pour l’analgesie de la chirurgie du bassin anterieur. Ann Fr Anesth Reanim 2011 doi:10.1016/j.annfar.2011.10.022.

   Nine modalities to report D-dimer concentration: how many is too many?

   To the Editor,

   pulmonary thromboembolism (PTE) is commonly unsus- pected in the emergency department (N50% of PTE patients go unrecognized) [1] because symptoms are often not specific enough (they are “typically atypical”), because many diagnostic methods do not have the specificity we want, and because death may come very quickly, before the results of Diagnostic procedures. For example, sudden death is the initial clinical presentation of 25% of PTE patients [2]. Moreover, in PTE, up to 80% of deaths occur within

   2.5 hours into the admission [3].

   D-dimer(DD) is thebestrecognizedbiomarkerfortheinitial

   assessment of suspected venous thromboembolism [4]. D-dimer is a small peptide fragment, an end product of fibrinogen and cross-linked fibrin degradation, and the name DD is adequate because DD consists of 2 cross-linked D fragments of fibrinogen [5]. D-dimer points to activated coagulation and fibrinolysis. Although it signifies activated coagulation, itshouldpreferablybeusedtoexcludethrombosis (VTE) because its negative predictive value is high [4,6].

   Negative DD combined with low clinical probability enables us to avoid both radiation and contrast exposure as well as anticoagulant therapy in more than 25% of patients presenting with symptoms suggestive of VTE [4]. Interpre- tation of high DD concentration is also a demanding task: many physiologic and pathologic states may raise DD concentration [7,8].

   The situation is even more complicated in the field of DD -unreasonably, by difficulties in reading and learning about DD-because of different measures used. At least 9 different DD units have been used:

   mg/L [9,10]

9. mg/dL [11]
10. ng/dL [12,13]
11. ng/mL [14,15]
12. ug/L [9,11] and [16]
13. ug/mL [17,18]
14. ug/dL [19]
15. mg/mL [20,21].
16. ng/L [22].

    Insomearticles, even 2 different DDunitswereused [1,9,11]. Searching backwards, we identified an article from the year 2007 about using 6 different DD unit values [23]. The same problem was noticed with troponin [24]. Moreover, already in 2005, the College of American Pathologists found