Knudson et al identified risk factors associated with venous thromboembolism in trauma patients enrolled in the American College of Surgeons National Trauma Data Bank. These can help identify patients most likely to benefit from prophylactic interventions. The authors are from the University of California in San Francisco.
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 |
Contraindications to Heparin |
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.
Specialty: Hematology Oncology, Clinical Laboratory
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