Is Upper Extremity Deep Venous Thrombosis Underdiagnosed in Trauma Patients? KONSTANTINOS SPANIOLAS, M.D.,* GEORGE C. VELMAHOS, M.D., PH.D., M.S.ED.,* STEPHAN WICKY, M.D.,† KAREN NUSSBAUMER, R.D.M.S., R.V.T.,† LAURIE PETROVICK,* ALICE GERVASINI, R.N., PH.D.,* MARC DE MOYA, M.D.,* HASAN B. ALAM, M.D.* From the *Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery and the †Division of Cardiovascular Imaging and Intervention, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts It has been suggested that upper extremity deep venous thrombosis (UEDVT) is as common and dangerous as lower extremity deep venous thrombosis. Pulmonary embolism (PE) is often found with no evidence of associated lower extremity deep venous thrombosis and could have origi- nated from UEDVT. Routine screening is well accepted for lower extremity deep venous throm- bosis but not for UEDVT. We hypothesized that UEDVT in trauma is frequent but undetected; therefore, routine screening of trauma patients at risk will increase the UEDVT rate and decrease the PE rate due to early diagnosis and treatment. We evaluated the incidence of UEDVT and PE over 6 months before (Group BEFORE) and 6 months after (Group AFTER) implementing a policy of screening patients at high risk for deep venous thrombosis with Duplex ultrasonography. Group BEFORE was evaluated retrospectively and group AFTER prospectively. There were 1110 BEFORE and 911 AFTER patients. The two groups were similar. Of the AFTER patients, 86 met predetermined screening criteria and were evaluated routinely by a total of 130 Duplex exams. One patient in each group developed UEDVT (0.09% vs 0.11%, P = 1.00). The brachial vein was involved in both patients. Six BEFORE (0.54%) and 1 AFTER (0.11%) patients developed PE (P = 0.137). The single AFTER patient with PE was not screened for UEDVT because he had no high-risk criteria. UEDVT is an uncommon event with unclear significance in trauma. Aggressive screening did not result in a higher rate of UEDVT diagnosis, nor an opportunity to prevent PE. T HE PATHOPHYSIOLOGY OF venous thromboembolism includes the relationship between lower extremity deep venous thrombosis (DVT) and pulmonary embo- lism (PE). 1, 2 Thrombi are thought to be generated in the pelvis or lower extremities, dislodge from the ve- nous wall, and occlude vessels of the pulmonary cir- culation. However, many studies report on patients with PE and no evidence of lower extremity DVT (LEDVT). 3–5 Clot origination in the pelvis or the upper extremi- ties may potentially explain this discrepancy. How- ever, the evaluation of pelvic veins by CT venography has failed to identify an association between PE and pelvic DVT. 6, 7 Recent studies have shown that DVT in the upper extremities (UEDVT) occurs in five per cent of critically ill patients. 8 It has also been sug- gested that PE can develop in up to 36 per cent of patients with UEDVT. 9 We hypothesized that UEDVT is a frequent event in trauma that evolves undetected. Aggressive screening of trauma patients for UEDVT would allow early diagnosis and treatment, and there- fore reduce the rate of PE. Methods This study was conducted in a Level 1 academic trauma center over the 12-month period of May 2004 to April 2005. Our center has a policy of routine weekly Duplex ultrasonography (DUS) of lower ex- tremity veins in trauma patients at high risk of DVT, as specified by predetermined criteria (Table 1). In November 2004 the policy was expanded to include weekly routine DUS of the upper extremity, upper torso, and neck veins (UPPER DUS) in addition to the lower extremity veins (LOWER DUS). In this study we compare the 6-month period before the policy of UPPER DUS (May 2004–October 2004) with the 6-month period after the policy (November 2004–April 2005). Data collected after the policy was collected prospectively and data collected before the policy retrospectively from the trauma registry and Address correspondence and reprint requests to George Velma- hos, M.D., Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA 02114. E-mail: gvelmahos@partners.org. 124