You are sending home a patient from the ED with a broken ankle after you carefully crafted a new plaster. Hmmmm… do you need to worry about DVT prophylaxis?
Guidelines
and local practice vary. When you see this variation, it invariably means there
is not conclusive evidence to inform practice.
Perhaps
this RCT from the New England Journal of Medicine might help?
These
researchers from the USA conducted a pragmatic, multicentre, randomized
non-inferiority trial. They included patients who had a fracture of an
extremity (hip to midfoot or shoulder to wrist) that were treated
operatively or who had pelvic or acetabular fracture.
Patients
were randomized to aspirin 81mg BD vs. enoxaparin 30mg BD while
in hospital but could get whatever after discharge “according to the
clinical protocols of each hospital.” (For what it’s worth, BD aspirin is
not a typo…)
Primary
outcome was death
from any cause and secondary outcomes looked at PE’s, DVT’s and bleeding
complications.
Results?
12,211
patients were
included! Mean age 44 years old and 87% had lower extremity fractures.
Median BMI was 27. On average, patients received about 9 in-hospital
doses of thromboprophylaxis and were prescribed a 21-day supply of whatever
upon discharge.
Primary
outcome… no
difference at 0.7% mortality in both groups. There was statistically
more DVT’s in the aspirin group by a whopping 0.8% margin (NNT 125). PE’s were no
different and nor were complications.
What should
we conclude in the ED?
Yes, this
is the tricky. The patients included in this study were not patients discharged from the ED.
Extrapolating the findings from this RCT to our population is problematic. Bummer…
In
addition, I’m disappointed they did not standardize the take home
thromboprophylaxis. This likely made it much more difficult to find
differences between the groups as patients were likely to cross-over.
Further,
this trial did not restrict enrollment to high-risk patients. These are
precisely the patients I want to target… another bummer. It is very possible
that enrolling all-comers diluted down the benefits & differences of
therapy. Who knows… but it’s common sense.
In the end,
I don’t think this should substantially change how we think about ED patients
that we send home with fractures. Nevertheless, I anticipate this study will influence
the guidelines… we might see some more aspirin being recommended. But I'm not sure if this is for the better or worse.
Covering:
METRC
Consortium, Aspirin or Low-Molecular-Weight Heparin for Thromboprophylaxis
after a Fracture. N Engl J Med 2023;338:203-13. [Link to article]
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