Prophylaxis of Deep Venous Thrombosis in Trauma Patients: A Review

Abstract

Current RecommendationsThe most recent guidelines to address prophylaxis of VTE in the trauma patient were published in 2012 from the American College of Chest Physicians. They suggest that for "major trauma patients... the use of LDUH or LMWH, or mechanical prophylaxis, preferably over IPC, over no prophylaxis" [19]. The use of the Caprini risk assessment model is encouraged to stratify the level of risk [20]. The Eastern Association for the Surgery of Trauma (EAST) has practice management guidelines regarding DVT prophylaxis which were published in 2002 [11]. Using the Caprini risk assessment model, developed at the University of Michigan health system, assessing patients for risk of VTE is essential for initiating appropriate prophylaxis [20]. Patients are given a base risk assessment which results in a cumulative risk score, which is then correlated with the incidence of DVT. Based on this stratified risk assessment for each patient, appropriate prophylaxis is recommended, based on the current ACCP Guidelines (9 th Edition) [21]. There are several challenging trauma patient subtypes that will be detailed below and their VTE prophylaxis issues. AbstractTrauma patients are at high risk for venous thromboembolism. While a variety of risk factors predispose them to deep venous thrombosis and pulmonary embolism, the goal of aggressive chemical prophylaxis needs to be balanced against the risk of hemorrhage, making this a most challenging population to adequately prophylax. The use of titration of the prophylaxis to ant factor Xa levels is discussed. Special consideration needs to be taken in some particularly challenging trauma subpopulations, including those with renal failure, nonoperatively managed solid organ injury, traumatic brain injury with intracranial hemorrhage, spinal cord injury and the bariatric trauma patient, which are reviewed.

Very early initiation of chemical venous thromboembolism prophylaxis after blunt solid organ injury is safe

“…[10][11][12] Current guidelines highlight a lack of evidence for or against early initiation of chemical VTE prophylaxis in patients undergoing NOM of blunt SOIs and have in par ticular stressed the unique challenge of managing these patients. 8 A lack of evidence precluded recommendations on this specific patient population particularly regarding the timing of chemical VTE prophylaxis by the Eastern Association for the Surgery of Trauma. 13,14 Four recent retrospective studies have attempted to address this prob lem.…”

“…Nonoperative management (NOM) of blunt SOIs is becoming more common, and the safety of early initiation of chemical VTE prophylaxis in this unique population remains unclear. 8 The goal of our study was to determine the rate of fail ure of NOM with early initiation of chemical VTE pro phylaxis in patients with isolated blunt SOIs who undergo an initial trial of NOM.…”

Review article: Do inferior vena cava filters prevent pulmonary embolism in critically ill trauma patients and does the benefit outweigh the risk of insertion? A narrative review article

“…Also, during the post-resuscitation phase of trauma, tissue factor (TF), C-reactive proteins and thrombin are upregulated as part of the systemic inflammatory response syndrome (SIRS). [7][8][9] This is a physiological response to promote clotting and hasten tissue repair. Proteins C and S and antithrombin 3 are natural anticoagulants that decrease in proportion to the increase in TF.…”

“…In the review by DeMuro and Hanna, up to 58% of trauma patients who were not given prophylaxis developed a deep vein thrombosis (DVT) and 1.68% of these had a fatal PE. 9 DVTs were diagnosed by serial impedance plethysmography and lower-extremity contrast venography.…”

Novel screening criteria for post‐traumatic venous thromboembolism by using D‐dimer

“…The injury mechanisms included traffic accidents (n = 43), falling off (n = 24), falling down (n = 1), burns (n = 2), and compression (n = 1). An ISS of 29 (19-38), RAP score of 12 (9)(10)(11)(12)(13)(14)(15)(16)(17), and Wells score of 2 (2-2) were obtained. The screening criteria were satisfied on day 7 (6-10), and CE-CT was carried out on day 10 (7-14) ( Table 2).…”