Asymptomatic Trauma Patients Screened for Venous Thromboembolism Have a Higher Risk Profile with Lower Rate of Pulmonary Embolism: A Five-Year Single-Institution Experience

Abstract

Deep vein thrombosis (DVT) is linked to reimbursements and publicly reported metrics. Some hospitals discourage venous duplex ultrasound (VDUS) screening in asymptomatic trauma patients because they often find higher rates of DVT. We aim to evaluate the association between lower extremity (LE) VDUS screening and pulmonary embolism (PE) in trauma patients. Trauma patients admitted to an urban Level-1 trauma center between 2010 and 2015 were retrospectively analyzed. We characterized the association of asymptomatic LE VDUSs with PE, upper extremity DVT, proximal LE DVT, and distal LE DVT by univariate and multivariable logistic regression controlling for confounders. Of the 3959 trauma patients included in our study—after adjusting for covariates related to patient demographics, injury, and procedures—there was a significantly lower likelihood of PE in screened patients (odds ratio (OR) = 0.02, P < 0.001) and a higher rate of distal LE DVT (OR 11.1, P = 0.004). Screening was not associated with higher rates of proximal LE DVTafter adjustment for covariates (OR = 1.8, P = 0.193). PE was associated with patient transfer status, pelvis fracture, and spinal procedures in unscreened patients. After adjusting for covariates, we have shown that LE VDUS asymptomatic screening is associated with lower rates of PE in trauma patients and not associated with higher rates of proximal LE DVT. Our detailed institutional review of a large cohort of trauma patients over five years provides support for ongoing asymptomatic screening and better characterizes venous thromboembolism outcomes than similarly sized purely administrative data reviews. As a retrospective cohort study with a large sample size, no loss to follow-up, and a population with low heterogeneity, this study should be considered as level III evidence for care management.

The risk of thromboembolic events with early intravenous 2‐ and 4‐g bolus dosing of tranexamic acid compared to placebo in patients with severe traumatic bleeding: A secondary analysis of a randomized, double‐blind, placebo‐controlled, single‐center trial

“…27 The theoretical value of active screening is that it allows for earlier detection of thrombosis and the initiation of anticoagulation if appropriate. 28 For example, an RCT of approximately 2000 trauma patients at moderate to high risk of F I G U R E 3 Cumulative probability of thromboembolic event for each intervention group. There were 149 patients were included in the analysis, with 50 patients in the placebo group, 49 patients in the 2-g TXA group, and 50 patients in the 4-g TXA group.…”

“…A recent survey of 317 individual surgeons reported a wide variation in opinions regarding deep vein thromboembolism screening in asymptomatic trauma patients (53% agree, 36% disagree, and 11% neither agree nor disagree) 27 . The theoretical value of active screening is that it allows for earlier detection of thrombosis and the initiation of anticoagulation if appropriate 28 . For example, an RCT of approximately 2000 trauma patients at moderate to high risk of thromboembolism reported a significant reduction in pulmonary embolism incidence using screening duplex ultrasound of the lower extremities 29 .…”

Trauma patients at risk for venous thromboembolism who undergo routine duplex ultrasound screening experience fewer pulmonary emboli: A prospective randomized trial

“…4,41 The increased DVT rate observed in the US group was primarily due to the diagnosis of distal DVT and, to a much lesser degree, proximal DVT (11.7% more vs. 1.1% more, respectively), similar to other findings. 26,27 It could therefore be argued that the diagnosis of proximal DVT is less susceptible to surveillance bias and remains an important target for the implementation of routine DUS. While this study was not designed to evaluate the management of the distal DVT, it is essential to acknowledge the lack of agreement surrounding its clinical impact and management.…”

Characteristics of Deep Venous Thrombosis in Isolated Lower Extremity Fractures and Unsolved Problems in Guidelines: A Review of Recent Literature

“…Meanwhile, it was also possible that the author found more upper limb DVT by using more frequent ultrasound examinations than before, which was the so‐called “more examination, more discovery” 75 . Johnson et al 76 . studied 1021 patients who had received intravenous ultrasound screening more than once during hospitalization.…”

“…Meanwhile, it was also possible that the author found more upper limb DVT by using more frequent ultrasound examinations than before, which was the so-called "more examination, more discovery" 75 . Johnson et al 76 studied 1021 patients who had received intravenous ultrasound screening more than once during hospitalization. The results showed that the more examinations, the higher the incidence of distal DVT and the lower the incidence of PE, which had nothing to do with the incidence of proximal DVT, indicating that the more ultrasound examinations that occurred, the more the total incidence of DVT.…”