Background Standard venous thromboembolism (VTE) prophylaxis with enoxaparin results in inadequate protection in certain patients, with sub-therapeutic plasma anti-Xa levels associated with elevated VTE rates. We hypothesized that many trauma patients would be sub-therapeutic on the standard prophylactic dose of enoxaparin. Our goal was to adjust the enoxaparin dose to achieve target anti-Xa levels to take advantage of the drug based on its pharmacologic properties. Methods Patients admitted to the trauma service were included if they received at least 3 doses of prophylactic enoxaparin and underwent at least 2 screening venous duplex. Peak plasma anti-Xa levels ≤ 0.2 IU/ml were considered low and the dose was increased by 10mg bid until adequate anti-Xa levels were obtained. A strict screening venous duplex protocol was followed. Patients were excluded if they were diagnosed with a DVT prior to beginning enoxaparin or did not have correctly timed anti-Xa levels. Results Sixty-one trauma patients met inclusion criteria. There were 3 patients diagnosed with VTE (4.9%). Patients had a mean age of 45.9 years and were predominantly male (70.5%). Of the 61 patients, 18 (29.5%) had therapeutic anti-Xa levels on standard enoxaparin 30mg bid. Compared to patients who had therapeutic anti-Xa levels on enoxaparin 30mg bid, the 43 patients (70.5%) who were sub-therapeutic were more likely to be male, have larger body weight, and larger body surface area. There were no significant bleeding events in the group that received an enoxaparin dose adjustment. Conclusions A majority of patients had sub-therapeutic anti-Xa levels while on enoxaparin 30mg bid suggesting inadequate VTE prophylaxis. The need for routine use of a higher dose of prophylactic enoxaparin in trauma patients and the effects of routinely dose adjusting enoxaparin on VTE rates should be the study of future prospective, randomized trials.

IntroductionSince their release in 2017, standing electric motorized scooters (eScooters) have risen in popularity as an alternative mode of transportation. We sought to examine the incidence of injury, injury patterns, prevalence of helmet and drug and alcohol use in eScooter trauma.MethodsThis was a multi-institutional retrospective case series of patients admitted for injuries related to operation of an eScooter following the widespread release of these devices in September 2017 (September 1, 2017 to October 31, 2018). Demographics, drug and alcohol use, helmet use, admission vitals, injuries, procedures, hospital and intensive care unit length of stay (LOS), death, and disposition were analyzed.Results103 patients were admitted during the study period, and monthly admissions increased significantly over time. Patients were young men (mean age 37.1 years; 65% male), 98% were not wearing a helmet. Median LOS was 1 day (IQR 1–3). 79% of patients were tested for alcohol and 48% had a blood alcohol level >80 mg/dL. 60% of patients had a urine toxicology screen, of which 52% were positive. Extremity fractures were the most frequent injury (42%), followed by facial fractures (26%) and intracranial hemorrhage (18%). Median Injury Severity Score was 5.5 (IQR 5–9). One-third of patients (n=34) required an operative intervention, the majority of which were open fixations of extremity and facial fractures. No patients died during the study. The majority of patients were discharged home (86%).ConclusioneScooter-related trauma has significantly increased over time. Alcohol and illicit substance use among these patients was common, and helmet use was extremely rare. Significant injuries including intracranial hemorrhage and fractures requiring operative intervention were present in over half (51%) of patients. Interventions aimed at increasing helmet use and discouraging eScooter operation while intoxicated are necessary to reduce the burden of eScooter-related trauma.Level of evidenceLevel IV.