Deep Venous Thrombosis and Pulmonary Embolism in Trauma Patients

Abstract

Trauma patients are at exceedingly high risk for the development of deep venous thrombosis and pulmonary embolism. The incidence, pathophysiology, diagnosis, prophylaxis, and therapy of deep venous thrombosis and pulmonary embolism in the trauma patient are reviewed. The type of injury, systemic pertubations, and enforced immobility are important factors in pathogenesis. Patients with lower extremity injuries and spine fractures with paraplegia appear to be at highest risk. Orthopedic devices used to treat these injuries often preclude the conventional noninvasive diagnostic modalities. Further, hemorrhagic risk often impacts the judgment regarding the use of prophylactic measures as well as the therapy once deep venous thrombosis is diagnosed. Better data regarding the incidence of venous thromboembolism and the applicability of existing diagnostic, prophylactic, and treatment approaches in this population are needed. Accidents are responsible for over 140,000 deaths and approximately 70 million nonfatal injuries annually in the United States [1]. Most of the fatalities occur within hours of injury as a result of exsanguination or a lethal head injury, but approximately 20% survive for days or weeks [2], usually in the intensive care unit. The primary causes of late death are sepsis and multiple-organ failure [2]. Increasing evidence, however, suggests that pulmonary embolism (PE) is now becoming a leading cause of late death, especially in some high-risk groups [3][4][5].The increase in the incidence of PE is due in part to improvements in trauma care, which have lowered the early mortality rate [6-8], leaving more patients at risk for late death. In addition, autopsy examinations, used more frequently to audit trauma care systems [6,9], have documented an increase in clinically unsuspected deep venous thrombosis (DVT) and PE.This review was prompted because of the apparent increase in DVT and PE in the trauma population, and because the trauma patient presents very difficult and unique problems compared with the nontrauma patient with regard to the diagnosis, prophylaxis, and treatment of these disorders. In this review, we address the incidence, pathophysiology, diagnosis, treatment, and prophylaxis of DVT and PE in the trauma patient. We do not consider the entities of fat embolism or pulmonary microemboli as a cause of late pulmonary failure.

Venous Thromboembolism in Trauma: A Local Manifestation of Systemic Hypercoagulability?

“…Although spine and lower extremity fractures were associated with VTE in the bivariate analysis, they were not independent predictors of VTE when included with duration of immobilization in the multivariate analysis. These findings differ from those suggesting that either the specific type [2][3][4]6,7 or overall severity of injury 4,6,32 are important factors in determining the risk of VTE. Using precise definitions, the current study suggests that duration of immobilization and obesity are the only significant predictors of thromboembolism in injured patients.…”

“…The reported incidence of DVT among series of trauma patients has varied from 18% to 90%, with an average incidence of 42%. 2,22 In the largest reported venographic study, Geerts et al 3 identified DVT in 57.6% of 349 trauma patients undergoing contrast venography 1 to 3 weeks after admission.…”

“…1 Many reports of venous thromboembolism in trauma have focused on the identification of high-risk injury patterns. A higher incidence of DVT has been associated with head injury, 2 fractures of the lower extremity or pelvis, [2][3][4][5] and spinal cord injury. 3,6,7 Although useful in identifying patients in whom particular attention to prophylaxis may be warranted, such studies do not address the underlying pathophysiology of VTE in trauma.…”

The effect of vein repair on the risk of venous thromboembolic events: A review of more than 100 traumatic military venous injuries

“…[36][37][38] Several studies suggested that major venous injury or venous repair results in an increased risk of DVT. 39,40 More important, there is risk of PE as a complication of DVT.…”

Thromboprophylaxis following major skeletal trauma: a systematic review

“…Venous thromboemobolism is also a life-threatening complication following major trauma [4][5][6][7]. The incidence of pulmonary embolism (PE) is estimated to be between 2 and 22% of all trauma patients, whilst deep venous thrombosis (DVT) is seen in up to 60% of this population [8][9][10][11][12][13]. Pulmonary embolism has been cited as the third most common cause of death in trauma patients who survive the first 24 h postinjury [9,13].…”