Prophylaxis Against Deep Venous Thrombosis in Traumatic Injury

Educational Objectives

The goal of this program is to improve outcomes of patients with traumatic injuries through management of prophylaxis against deep venous thrombosis (DVT) following traumatic injury. After hearing and assimilating this program, the clinician will be better able to:

1. Determine appropriate timing for initiation of prophylaxis against DVT following traumatic injury.
2. Prevent DVT in patients who have sustained solid organ injury.

Summary

Incidence of deep venous thrombosis (DVT) and pulmonary embolism (PE): Geerts et al (1994) measured a presurgical incidence of 58% and postsurgical incidence of ≈25% for posttraumatic DVT in patients without prophylaxis; PE is the third-leading cause of death in trauma patients who survive ≥24 hr, secondary to hypercoagulability; venous thromboembolism is the second most common postoperative complication; Hecht et al (2021) reviewed data from the Michigan Trauma Quality Improvement Program (TQIP) and showed that waiting between 24 to 48 hr to start prophylaxis increases the risk for DVT 1.26-fold; waiting >48 hr increases the risk for DVT 2.34-fold and increases the risk for mortality

Traumatic brain injury (TBI): prophylaxis against DVT should be initiated ≤48 hr following stable head computed tomography (CT); patients with TBI may have intracranial hemorrhage (ICH) and are frequently hypercoagulable, immobile, and intubated; the incidence of DVT in this population is variable and dependent on the severity of other injuries and need for intervention; Byrne et al (2016) — reviewed TQIP data from 2012 to 2014 for patients with severe, isolated TBI; results show that initiation of DVT prophylaxis ≤72 hr reduces the incidence of DVT and PE by ≈50% without increasing the risk for complications (ie, need for a procedure, mortality); Abdel-Aziz et al (2015) — stratified patients based on risk level (determined by nature and size of the ICH); author recommends initiating DVT prophylaxis ≈72 hr postinjury for patients at moderate or high risk, ≤48 hr postinjury for patients at low risk without ICH expansion, and 48 hr following stable head CT for patients at low risk with ICH expansion

DVT prophylaxis in the presence of an ICP monitor: Dengler et al (2016) — noted a high (12%) incidence of DVT but no association between initiation of prophylaxis and complications in patients with ICP monitors; DVT prophylaxis was started ≤72 hr, but ≈30% of patients never received prophylaxis and had a 25-fold greater risk of developing DVT or PE (compared with risk from, eg, subarachnoid hemorrhage, cerebral edema)

Spinal cord injury (SCI): patients with a complete SCI are permanently immobilized, may receive lifetime anticoagulation, and are at increased risk of developing epidural hematomas; a propensity-matched review of TQIP data performed by Khan et al (2018) showed a consistently low risk of developing DVT or PE with initiation of DVT prophylaxis ≤48 hr postinjury; another study found that initiation of DVT prophylaxis >48 hr after injury increases the incidence of DVT (≤12%) and PE (≈4%), compared with starting prophylaxis ≤48 hr after injury; initiation of unfractionated heparin or low-molecular-weight heparin ≤48 hr of injury is associated with statistically significant reduction in risk for DVT and PE; Arnold et al (2017) found that initiation of DVT prophylaxis ≤72 hr significantly reduces the incidences of DVT and PE

Solid organ injury (SOI): start DVT prophylaxis as soon as the patient is hemodynamically stable; immobility increases the risk for DVT and PE; Lin et al (2019) — conducted a TQIP review from 2013 to 2014 and found that initiation of DVT prophylaxis ≤48 hr after SOI does not increase the risk for failure of nonoperative management, but it reduces length of stay (LOS) in the hospital and intensive care unit (ICU), as well as the incidences of DVT and PE; Schellenberg et al (2019) — noted a statistically significant reduction in incidence of DVT and in ICU and hospital LOS with initiation of DVT prophylaxis ≤48 hr after SOI for patients >15 yr of age, with no differences in mortality rate, need for transfusion, or failure of prophylaxis, compared with later initiation of prophylaxis; Kwok et al (2016) — prophylaxis initiated <24 hr did not increase the need for angioembolization or surgery; no data was provided with regard to incidence of DVT

Readings

Abdel-Aziz H, Dunham CM, Malik RJ, et al. Timing for deep vein thrombosis chemoprophylaxis in traumatic brain injury: an evidence-based review. Crit Care. 2015;19(1):96. DOI:10.1186/s13054-015-0814-z; Arnold PM, Harrop JS, Merli G, et al. Efficacy, safety, and timing of anticoagulant thromboprophylaxis for the prevention of venous thromboembolism in patients with acute spinal cord injury: a systematic review. Global Spine J. 2017;7(3 Suppl):138S-150S. DOI:10.1177/2192568217703665; Dengler BA, Mendez-Gomez P, Chavez A, et al. Safety of chemical DVT prophylaxis in severe traumatic brain injury with invasive monitoring devices. Neurocrit Care. 2016;25(2):215-223. DOI:10.1007/s12028-016-0280-8; Fehlings MG, Tetreault LA, Aarabi B, et al. A clinical practice guideline for the management of patients with acute spinal cord injury: recommendations on the type and timing of anticoagulant thromboprophylaxis. Global Spine J. 2017;7(3 Suppl):212S-220S. DOI:10.1177/2192568217702107; Hecht JP, Han EJ, Cain-Nielsen AH, et al. Association of timing of initiation of pharmacologic venous thromboembolism prophylaxis with outcomes in trauma patients. J Trauma Acute Care Surg. 2021;90(1):54-63. DOI:10.1097/TA.0000000000002912; Khan M, Jehan F, O'Keeffe T, et al. Optimal timing of initiation of thromboprophylaxis after nonoperative blunt spinal trauma: a propensity-matched analysis. J Am Coll Surg. 2018;226(5):760-768. DOI:10.1016/j.jamcollsurg.2018.01.006; Kwok AM, Davis JW, Dirks RC, et al. Time is now: venous thromboembolism prophylaxis in blunt splenic injury. Am J Surg. 2016;212(6):1231-1236. DOI:10.1016/j.amjsurg.2016.09.026; Schellenberg M, Inaba K, Biswas S, et al. When is it safe to start VTE prophylaxis after blunt solid organ injury? A prospective study from a level I trauma center. World J Surg. 2019;43(11):2797-2803. DOI:10.1007/s00268-019-05096-7.

Disclosures

For this program, the following relevant financial relationships were disclosed and mitigated to ensure that no commercial bias has been inserted into this content: Dr. Schreiber is a consultant for and receives grant support from Haemonetics and CSL Behring. Members of the planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Schreiber was recorded at Trauma, Critical Care & Acute Care Surgery, held in Las Vegas, NV from September 12-14, 2021, and presented by the Trauma and Critical Care Foundation. For information on upcoming CME activities from this presenter, please visit trauma-criticalcare.com. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

Lecture ID:

EM391401

Qualifies for:

Trauma

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.