High risk factors:
(1) age >= 40 years
(2) pelvic fracture
(3) lower extremity fracture
(4) shock
(5) injury to the spinal cord
(6) head injury with AIS >= 3
Very high risk factors:
(1) >= 2 high risk factors (from previous list)
(2) major operative procedure (operation lasting > 2 hours)
(3) venous injury
(4) > 3 days on the mechanical ventilator
These risk factors would identify 90% of patients in the trauma data bank who developed thromboembolism. The odds ratio for venous thromboembolism is 2 to 3 if a high risk factor is present, and 4 to 10 if the very high risk criteria is met.
|
Risk Criteria
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Contraindications to Heparin
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Management
|
|
very high risk
|
none
|
low molecular weight heparin and mechanical compression
|
|
very high risk
|
present
|
(1) mechanical compression and serial color flow Doppler imaging OR (2) temporary inferior vena cava filter
|
|
high risk
|
none
|
low molecular weight heparin
|
|
high risk
|
present
|
mechanical compression
|
|
low risk
|
NA
|
monitor the patient
|
Low molecular weight heparin is administered in a prophylactic dose (enoxaparin 30 mg bid).
Contraindications to heparin included:
(1) head injury with documented intracranial hemorrhage pending neurosurgical consultation and evidence of stability of bleeding
(2) history or development of heparin-induced thrombocytopenia
(3) uncontrolled coagulopathy or uncontrolled surgical bleeding
Sequential compression devices include stockings, sleeves and pump.
Inferior vena cava filters were used only when there was a very high risk of venous thromboembolism and contraindications to low molecular weight heparin.
Management that can further reduce risk of thromboembolism:
(1) early fracture fixation
(2) aggressive fluid resuscitation
(3) early ambulation
(4) early hospital discharge
Limitations:
• The algorithm needs to be validated in a multi-institution study.
