VTE prophylaxis in trauma
Keywords:
Venous thromboembolism, PE, DVT, VTE prophylaxis, TraumaAbstract
Venous thromboembolism (VTE) remains a significant clinical concern, with an estimated global incidence of 900,000 cases annually. In Thailand, the precise incidence is underreported, but studies from Level 1 trauma centers suggest a VTE rate of approximately 2.8% in trauma patients. VTE risk is strongly influenced by the Virchow triad, highlighting the importance of early detection and prevention in high-risk populations, such as those with spinal cord injuries, pelvic fractures, or lower extremity trauma. Current strategies for VTE prevention focus on mechanical methods and pharmacological prophylaxis, most commonly with low-molecular-weight heparin. Key considerations include the timing of initiation, dosage, duration of prophylaxis, and patient-specific factors such as age, renal function, history of bleeding or allergic reactions, and coexisting injuries that may affect hemodynamic stability. Risk stratification and individualized prophylactic approaches are crucial for balancing the benefits of VTE prevention with potential complications. Emerging technologies and protocols aim to optimize screening thresholds and enhance early detection in trauma settings.
References
Ruskin KJ. Deep vein thrombosis and venous thromboembolism in trauma. Curr Opin Anaesthesiol 2018;31(2):215-8.
Ley EJ, Brown CVR, Moore EE, Sava JA, Peck K, Ciesla DJ, et al. Updated guidelines to reduce venous thromboembolism in trauma patients: A Western Trauma Association critical decisions algorithm. J Trauma Acute Care Surg 2020;89(5):971-81.
Geerts WH, Jay RM, Code KI, Chen E, Szalai JP, Saibil EA, et al. A comparison of low-dose heparin with low-molecular-weight heparin as prophylaxis against venous thromboembolism after major trauma. N Engl J Med 1996;335(10):701-7.
Dhillon NK, Barmparas G, Lin TL, Linaval NT, Yang AR, Sekhon HK, et al. A Systems-based Approach to Reduce Deep Venous Thrombosis and Pulmonary Embolism in Trauma Patients. World J Surg 2021;45(3):738-45.
Barrera LM, Perel P, Ker K, Cirocchi R, Farinella E, Morales Uribe CH. Thromboprophylaxis for trauma patients. Cochrane Database Syst Rev 2013(3):Cd008303.
Bruns Pv. Ueber plotzliche Todesfalle nach knockenbruchen in Folge von Venenthrombose und Embolie. Klin ChirUeber 1886;2:1–18.
Sevitt S, Gallagher N. Venous thrombosis and pulmonary embolism. A clinico-pathological study in injured and burned patients. Br J Surg 1961;48:475-89.
Freeark RJ, Boswick J, Fardin R. Posttraumatic venous thrombosis. Arch Surg 1967;95(4):567-75.
Prevention of venous thrombosis and pulmonary embolism. NIH Consensus Development. Jama 1986;256(6):744-9.
Venous Thromboembolism (Blood Clots) [Internet]. Centers for Disease Control and Prevention. 2023 [cited 13 March 2024]. Available from: https://www.cdc.gov/ncbddd/dvt/data.html.
Akaraborworn O, Sangthong B, Thongkhao K, Chainiramol P, Kaewsaengrueang K. Adherence to Guideline of Venous Thromboembolism Prophylaxis in a Level 1 Trauma Center in Thailand. Archives of Trauma Research 2018;7(1):11-4.
Sriprayoon W SE, Siriwanitchaphan W. Prevalence of Venous Thromboembolism in Trauma Patients in a Private Tertiary Care Hospital. Bangkok Medical Journal 2020;16(Vol. 16 No. 1 (2020): February):1.
Yorkgitis BK, Berndtson AE, Cross A, Kennedy R, Kochuba MP, Tignanelli C, et al. American Association for the Surgery of Trauma/American College of Surgeons-Committee on Trauma Clinical Protocol for inpatient venous thromboembolism prophylaxis after trauma. J Trauma Acute Care Surg 2022;92(3):597-604.
Peng S, Zhang M, Jin J, MacCormick AD. The effectiveness of venous thromboembolism prophylaxis interventions in trauma patients: A systematic review and network meta-analysis. Injury 2023;54(12):111078.
Mi YH, Xu MY. Trauma-induced pulmonary thromboembolism: What's update? Chin J Traumatol 2022;25(2):67-76.
Bahloul M, Dlela M, Bouchaala K, Kallel H, Ben Hamida C, Chelly H, et al. Post-traumatic pulmonary embolism: incidence, physiopathology, risk factors of early occurrence, and impact outcome. A narrative review. Am J Cardiovasc Dis 2020;10(4):432-43.
Knudson MM, Gomez D, Haas B, Cohen MJ, Nathens AB. Three thousand seven hundred thirty-eight posttraumatic pulmonary emboli: a new look at an old disease. Ann Surg 2011;254(4):625-32.
Moore EE, Moore HB, Kornblith LZ, Neal MD, Hoffman M, Mutch NJ, et al. Trauma-induced coagulopathy. Nat Rev Dis Primers 2021;7(1):30.
Coleman JR, Kay AB, Moore EE, Moore HB, Gonzalez E, Majercik S, et al. It's sooner than you think: Blunt solid organ injury patients are already hypercoagulable upon hospital admission - Results of a bi-institutional, prospective study. Am J Surg 2019;218(6):1065-73.
Bösch J, Bachler M, Fries D. Thrombosis prophylaxis following trauma. Current Opinion in Anesthesiology 2024;37(2).
Knudson MM, Ikossi DG, Khaw L, Morabito D, Speetzen LS. Thromboembolism after trauma: an analysis of 1602 episodes from the American College of Surgeons National Trauma Data Bank. Ann Surg 2004;240(3):490-6; discussion 6-8.
Rogers FB, Shackford SR, Horst MA, Miller JA, Wu D, Bradburn E, et al. Determining venous thromboembolic risk assessment for patients with trauma: the Trauma Embolic Scoring System. J Trauma Acute Care Surg 2012;73(2):511-5.
Hegsted D, Gritsiouk Y, Schlesinger P, Gardiner S, Gubler KD. Utility of the risk assessment profile for risk stratification of venous thrombotic events for trauma patients. Am J Surg 2013;205(5):517-20; discussion 20.
Pannucci CJ, Fleming KI. Comparison of face-to-face interaction and the electronic medical record for venous thromboembolism risk stratification using the 2005 Caprini score. J Vasc Surg Venous Lymphat Disord 2018;6(3):304-11.
Zhang X, Hao A, Lu Y, Huang W. Deep vein thrombosis and validation of the Caprini risk assessment model in Chinese orthopaedic trauma patients: a multi-center retrospective cohort study enrolling 34,893 patients. Eur J Trauma Emerg Surg 2023;49(4):1863-71.
Caprini JA. Thrombosis risk assessment as a guide to quality patient care. Dis Mon 2005;51(2-3):70-8.
Rogers FB, Cipolle MD, Velmahos G, Rozycki G, Luchette FA. Practice management guidelines for the prevention of venous thromboembolism in trauma patients: the EAST practice management guidelines work group. J Trauma 2002;53(1):142-64.
Rogers FB. Venous thromboembolism in trauma patients. Surg Clin North Am 1995;75(2):279-91.
Knudson MM, Collins JA, Goodman SB, McCrory DW. Thromboembolism following multiple trauma. J Trauma 1992;32(1):2-11.
Macatangay C, Todd SR, Tyroch AH. Thromboembolic Prophylaxis With Intermittent Pneumatic Compression Devices in Trauma Patients: A False Sense of Security? J Trauma Nurs. 2008;15(1):12-15.
Amer M, Alshahrani MS, Arabi YM, Al-Jedai A, Alshaqaq HM, Al-Sharydah A, et al. Saudi Critical Care Society clinical practice guidelines on the prevention of venous thromboembolism in adults with trauma: reviewed for evidence-based integrity and endorsed by the Scandinavian Society of Anaesthesiology and Intensive Care Medicine. Ann Intensive Care 2023;13(1):41.
Gould MK, Garcia DA, Wren SM, Karanicolas PJ, Arcelus JI, Heit JA, et al. Prevention of VTE in nonorthopedic surgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141(2 Suppl):e227S-e77S.
Toker S, Hak DJ, Morgan SJ. Deep vein thrombosis prophylaxis in trauma patients. Thrombosis 2011;2011:505373.
Jacobs BN, Cain-Nielsen AH, Jakubus JL, Mikhail JN, Fath JJ, Regenbogen SE, et al. Unfractionated heparin versus low-molecular-weight heparin for venous thromboembolism prophylaxis in trauma. J Trauma Acute Care Surg 2017;83(1):151-8.
Sidawy AN, Perler BA. Rutherford's vascular surgery and endovascular therapy, 2-Volume Set: Elsevier Health Sciences, 2022.
Hecht JP, Han EJ, Cain-Nielsen AH, Scott JW, Hemmila MR, Wahl WL. 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.
Byrne JP, Mason SA, Gomez D, Hoeft C, Subacius H, Xiong W, et al. Timing of Pharmacologic Venous Thromboembolism Prophylaxis in Severe Traumatic Brain Injury: A Propensity-Matched Cohort Study. J Am Coll Surg 2016;223(4):621-31.e5.
Benjamin E, Aiolfi A, Recinos G, Inaba K, Demetriades D. Timing of venous thromboprophylaxis in isolated severe pelvic fracture: Effect on mortality and outcomes. Injury 2019;50(3):697-702.
Sumislawski JJ, Kornblith LZ, Conroy AS, Callcut RA, Cohen MJ. Dynamic coagulability after injury: Is delaying venous thromboembolism chemoprophylaxis worth the wait? J Trauma Acute Care Surg 2018;85(5):907-14.
Ko A, Harada MY, Barmparas G, Chung K, Mason R, Yim DA, et al. Association Between Enoxaparin Dosage Adjusted by Anti-Factor Xa Trough Level and Clinically Evident Venous Thromboembolism After Trauma. JAMA Surg 2016;151(11):1006-13.
Olson EJ, Bandle J, Calvo RY, Shackford SR, Dunne CE, Van Gent JM, et al. Heparin versus enoxaparin for prevention of venous thromboembolism after trauma: A randomized noninferiority trial. J Trauma Acute Care Surg 2015;79(6):961-8; discussion 8-9.
Skarupa D, Hanna K, Zeeshan M, Madbak F, Hamidi M, Haddadin Z, et al. Is early chemical thromboprophylaxis in patients with solid organ injury a solid decision? J Trauma Acute Care Surg 2019;87(5):1104-12.
Schellenberg M, Inaba K, Biswas S, Heindel P, Benjamin E, Strumwasser A, 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):2797-803.
Pastorek RA, Cripps MW, Bernstein IH, Scott WW, Madden CJ, Rickert KL, et al. The Parkland Protocol's modified Berne-Norwood criteria predict two tiers of risk for traumatic brain injury progression. J Neurotrauma 2014;31(20):1737-43.
Kim DY, Kobayashi L, Chang D, Fortlage D, Coimbra R. Early pharmacological venous thromboembolism prophylaxis is safe after operative fixation of traumatic spine fractures. Spine (Phila Pa 1976) 2015;40(5):299-304.
Zeeshan M, Khan M, O'Keeffe T, Pollack N, Hamidi M, Kulvatunyou N, et al. Optimal timing of initiation of thromboprophylaxis in spine trauma managed operatively: A nationwide propensity-matched analysis of trauma quality improvement program. J Trauma Acute Care Surg 2018;85(2):387-92.
Rappold JF, Sheppard FR, Carmichael Ii SP, Cuschieri J, Ley E, Rangel E, et al. Venous thromboembolism prophylaxis in the trauma intensive care unit: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document. Trauma Surg Acute Care Open 2021;6(1):e000643.
Goldhaber SZ, Leizorovicz A, Kakkar AK, Haas SK, Merli G, Knabb RM, et al. Apixaban versus enoxaparin for thromboprophylaxis in medically ill patients. N Engl J Med 2011;365(23):2167-77.
Kingdon LK, Miller EM, Savage SA. The Utility of Rivaroxaban as Primary Venous Thromboprophylaxis in an Adult Trauma Population. J Surg Res 2019;244:509-15.
Raskob GE, Gallus AS, Pineo GF, Chen D, Ramirez LM, Wright RT, et al. Apixaban versus enoxaparin for thromboprophylaxis after hip or knee replacement: pooled analysis of major venous thromboembolism and bleeding in 8464 patients from the ADVANCE-2 and ADVANCE-3 trials. J Bone Joint Surg Br 2012;94(2):257-64.
Berndtson AE, Cross A, Yorkgitis BK, Kennedy R, Kochuba MP, Tignanelli C, et al. American Association for the Surgery of Trauma/American College of Surgeons Committee on trauma clinical protocol for post-discharge venous thromboembolism prophylaxis after trauma. J Trauma Acute Care Surg 2024.
Allen CJ, Murray CR, Meizoso JP, Ginzburg E, Schulman CI, Lineen EB, et al. Surveillance and Early Management of Deep Vein Thrombosis Decreases Rate of Pulmonary Embolism in High-Risk Trauma Patients. J Am Coll Surg 2016;222(1):65-72.
Ho KM, Rao S, Honeybul S, Zellweger R, Wibrow B, Lipman J, et al. A Multicenter Trial of Vena Cava Filters in Severely Injured Patients. N Engl J Med 2019;381(4):328-37.
