Correspondence

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American Journal of Emergency Medicine

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Aggressive imaging in young children on antithrombotic therapy with minor traumatic head injury

Clinical decision rules have been developed to guide clinicians to perform or to omit a CT scan in children with minor traumatic head in- jury (MTHI) [1-3]. These guidelines do not define the use of antithrom- botic therapy as a major risk factor for intracranial pathology in young children, in contrast to children of six years and older and adults, where this is an indication to perform a CT scan.

A two-year-old boy on Antithrombotic treatment fell on the back of his head from a one-meter high slide. There was no loss of conscious- ness, he cried immediately, and after 30 min he vomited once. At the emergency department, 60 min after the incident, his Glasgow Coma Scale was fifteen. At physical and Neurological examination, no abnor- malities were observed, except an occipital bump. He used low dose an- tiplatelet therapy (Carbasalate Calcium, 19 mg once daily) as thrombosis prophylaxis after a liver transplantation. According to Dutch guidelines, vomiting is a criterion to perform a head CT-scan in children two years and older. The CT scan revealed a right frontoparietal subdural hematoma with mild mass effect and Midline shift without concomitant Skull fractures. The patient did not undergo neurosurgery and was discharged after 48 h. At follow up neurological examination was normal.

This case shows that antithrombotic therapy should be regarded as a major risk factor for intracranial pathology also in children after MTHI and there should be a low threshold to perform a CT scan. All three clinical decision rules (PECARN, CATCH, CHALICE) do not mention anything about the use of antithrombotic therapy in children [1-3]. One reason could be lack of awareness. Only one pro- spective multicenter study compared CT use and intracranial hemor- rhage after MTHI in children with and without congenital and acquired Bleeding disorders, including the use of antithrombotic therapy [4]. Only 16 of all 43,904 (0.04%) included children received antithrombotic therapy. Of these 16 patients, one six-year old child with a congenital heart disorder receiving warfarin showed trau- matic intracranial hemorrhage on the CT scan.

Antithrombotic therapy is given for the prevention or treatment of venous and/or arterial thrombosis. The use of antithrombotic drugs in pediatric patients has increased over last decades because of an increased incidence of venous thromboembolism [5,6]. The placement of central venous devices is an important contributor in the development of VTE in pediatric patients [7-9]. Other medical conditions associated with VTE in children include malignancies, in- flammatory bowel disease, neuromuscular disease, trauma, surgery and/or vascular malformations [5,6,10,11]. Therefore, with a grow- ing number of children surviving with chronic medical conditions re- quiring antithrombotic therapy, we expect more children on antithrombotic therapy that may present at the emergency depart- ments with MTHIs.

Low Molecular Weight Heparin is the most commonly used drug for Acute VTE in pediatric patients [12,13]. A review reported of 308 children receiving Therapeutic doses LMWH for the treated of VTE, nine (2.9%) had a major bleeding, and 72 (23.4%) a minor bleeding [14]. In 133 children receiving prophylactic doses of LMWH, one (0.8%) had a major bleeding, and four (3.0%) a minor bleeding. These bleedings occurred all spontaneously without a Traumatic cause. vitamin K antag- onists (VKA) include warfarin, acenocoumarol and phenprocoumon. The most common VKA used in the pediatric setting is warfarin [13]. Risk of major bleeding varies including 0.5% per patient year reported in a large cohort study versus 12.2% in a randomized controlled trial of 41 children [15]. Aspirin is the most commonly used antiplatelet agent for the prevention of arterial thrombotic events in children [16]. It is commonly used for the prevention of stroke recurrence and prophylac- tically after interventional cardiac catheterization (ICC) and cardiac sur- gery. In older children, aspirin rarely causes important hemorrhage, except in the presence of an underlying hemostatic defect or in children also treated with anticoagulants or thrombolytic therapy [13].

In the pediatric population, little is known on the risk of intracranial hemorrhage after a MTHI when using a form of antithrombotic therapy. Intracranial pathology after a MTHI in patients on antithrombotic ther- apy has mostly been described in adults, with inconsistent conclusions about the associated risk of intracranial pathology. Direct oral anticoag- ulants (DOACs) are considered lower-risk medication compared to war- farin for intracranial pathology after MTHI in the adult population [17]. However, currently there is a lack of information about their efficacy and safety in children, and therefore they are seldom used in children. In adults and the elderly, no consensus exists on which antithrombotic has the highest risk on intracranial pathology after MTHI. A recent meta-analysis showed that Antiplatelet therapy is associated with an in- creased risk of intracranial pathology after MTHI [18]. Generally, aspirin as monotherapy is considered a safe option in regard to intracranial pa- thology after MTHI.

In conclusion, children using antithrombotic therapy constitute a high-risk patient group for Intracranial bleeding after MTHI. Current guidelines need to be adapted.

Conflicts of interest and sources of funding

None to declare.

Kelly Brouwer, MD

Department of Pediatrics, Tergooi Hospital, Rijksstraatweg 1, 1261 AN

Blaricum, the Netherlands Department of Pediatrics, Spaarne Gasthuis Hospital, Spaarnepoort 1, 2134

TM Hoofddorp, the Netherlands Corresponding author at: Department of Pediatrics, Tergooi Hospitals, Rijksstraatweg 1, 1261 AN Blaricum, the Netherlands.

E-mail address: [email protected].

0735-6757/(C) 2018

Nicky Niele, MD

Department of Pediatrics, Tergooi Hospital, Rijksstraatweg 1, 1261 AN

Blaricum, the Netherlands

Marlies A. van Houten, MD, PhD

Department of Pediatrics, Spaarne Gasthuis Hospital, Spaarnepoort 1, 2134

TM Hoofddorp, the Netherlands

Frans B. Plotz, MD PhD

Department of Pediatrics, Tergooi Hospital, Rijksstraatweg 1, 1261 AN

Blaricum, the Netherlands

22 May 2018

https://doi.org/10.1016/j.ajem.2018.09.005

References

1. Kuppermann N, Holmes JF, Dayan PS, Hoyle JD, Atabaki SM, Holubkov R, et al. Identification of children at Very low risk of clinically-important brain inju- ries after head trauma: a prospective cohort study. Lancet 2009;374: 1160-70.
2. Dunning J, Patrick Daly J, Lomas J-P, Lecky F, Batchelor J, Machway-Jones K, et al. Derivation of the children’s head injury algorithm for the prediction of important clinical events decision rule for head injury in children. Arch Dis Child 2006;91:885-91.
3. Osmond MH, Klassen TP, Wells GA, Correll R, Jarvis A, Joubert G, et al. CATCH: a clin- ical decision rule for the use of computed tomography in children with minor head injury. CMAJ 2010;182:341-8.
4. Lee LK, Dayan PS, Gerardi MJ, Borgialli DA, Badawy MK, Callahan JM, et al. Intracra- nial hemorrhage after Blunt head trauma in children with bleeding disorders. J Pediatr 2011;158:1003-8.
5. Raffini L, Huang Y, Witmer C, Feudtner D. Dramatic increase in venous thromboem- bolism in children’s hospitals in the United States from 2001-2007. Pediatrics 2009; 124:1001-8.
6. Setty BA, O’Brien SH, Kerlin BA. Pediatric venous thromboembolism in the United States: a tertiary care complication of chronic diseases. Pediatric Blood Cancer 2012;59:258-64.
7. Van Ommen CH, Heijboer H, Buller HR, Hirasing RA, Heijmans HSA, et al. Venous thromboembolism in childhood: a prospective two-year registry in The Netherlands. J Pediatr 2001;139:676-81.
8. Schmidt B, Andrew M. Neonatal thrombosis: report of a prospective Canadian and international registry. Pediatrics 1995;96:939-43.
9. Betensky M, Bittles MA, Colombani P, Goldenberg NA. How we manage pediatric deep venous thrombosis. Semin Intervent Radiol 2017;34:35-49.
10. Andrew M, David M, Adams M, Ali K, Anderson R, et al. Venous thromboembolic complications (VTE) in children: first analyses of the Canadian Registry of VTE. Blood 1994;83:1251-7.
11. Vu LT, Nobuhara KK, Lee H, Farmer DL. Determination of risk factors for deep venous thrombosis in hospitalized children. J Pediatr Surg 2008;43:1095-9.
12. Young G, Male C, Van Ommen CH. Anticoagulation in children: making the most of little patients and little evidence. Blood Cells Mol Dis 2017;67: 48-53.
13. Monagle PM, Chan AKC, Goldenberg NA, Ichord RN, Journeycake JM, et al. Antithrombotic therapy in neonates and children: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physi- cians Evidence-based Clinical Practice Guidelines. Chest 2012;141: e737S-801S.
14. Nowak-Gottl U, Bidlingmaier C, Krumpel A, Gottl L, Kenet G. Pharmacokinetics, effi- cacy, and safety of LMWHs in venous thrombosis and stroke in neonates, infants and children. Br J Pharmacol 2008;153:1120-7.
15. Massicotte P, Julian JA, Gent M, Shields K, Marzinotto V, et al. An open-label randomized controlled trial of low molecular weight hepa- rin compared to heparin and Coumadin for the treatment of venous Thromboembolic events in children: the REVIVE trial. Thromb Res 2003;109:85-92.
16. Israels SJ, Michelson AD. Antiplatelet therapy in children. Thromb Res 2006;

    118:75-83.

    Feeney JM, Santone E, Difiori M, Kis L, Jayaraman V, et al. Compared to warfarin, di- rect oral anticoagulants are associated with lower mortality in patients with blunt traumatic intracranial hemorrhage: a TQIP study. J Trauma Acute Care Surg 2016; 81:843-8.

17. Van den Brand CL, Tolido T, Rambach AH, Hunink MG, Patka P, et al. Sys- tematic review and meta-analysis: is pre-injury antiplatelet therapy asso- ciated with traumatic intracranial hemorrhage? J Neurotrauma 2017;34: 1-7.

    A novel chain-based sponge dressing for management of junctional hemorrhage

    Dear Editor

    Bleeding is the leading cause of death on the battlefield. With the widespread use of extremity tourniquet, junctional hemor- rhage becomes the most common cause to lead death [1]. Currently, there is no perfect hemostatic product available for junctional hemorrhage [2]. We have made a new type of hemo- static device based on chain structure that can be used in the junctional hemorrhage.

    The Chain Sponge Dressing (CSD) is made of polyvinyl alcohol expansion sponge (Network Medical Products Ltd.). Each one con- tains 20 triangles which are strung together with surgical suture

    (VICRYL, Johnson& Johnson). Every triangle is 1 * 1.5 * 0.45 cm and packed in a 20 ml syringe. Each device can expand 10-12

    times in 20s.

    Using 5 female Bama miniature pigs, accepted the femoral artery injury model (6-mm arteriotomy) [3]. Exposure and isolation of at least 6 cm of the femoral artery was performed. A 0.6 cm wound on the femoral artery with a drill. After 30 s of free bleeding, blood loss was collected by gauze, the device was applied into the wound. Hemostasis was judged by if there was no oozing with vi- sual observation. Pressure was not allowed after packing. After ob- servation for 180 min, the dressings were removed. Resuscitation was continued for the entire observation period. In the end, all 5 completed hemostasis within 45 s and the survival rate reached 100%. The average time to remove the device was 38.8 s (Table 1) (Fig. 1).

    This study was demonstrated that the device has the potential to stop bleeding without additional compression. It could permit quick ap- plication with syringe applicator. The chain structure reduced the time of removing dressings. The hemostasis unit adopted triangular structure which increases the contact area with the blood and increases the ex- pansion speed.

    This study was a first step to introduce and demonstrate this de- vice was effective in junctional hemorrhage. In the follow-up study, we will continue to improve this device such as adding radiopaque. To compare the effect of the device with standard gauze would be important.

    Acknowledgements

    The authors would like to thank all participants who contributed to the study.

    Competing interests

    There are no conflicts of interest.

    Disclosure

    The product is still investigational.

    Funding information

    This study was supported by the National Science and Technology Major Projects for “Major New Drugs Innovation and Development” (2018ZX09J18), the Medical Science and Technology Major Projects of PLA (CNJ15J004), and the Fuzhou General Hospital Fund Project (2015J01).