Open Access DeMuro and Hanna, J Blood Disorders Transf 2013, 4:4 DOI: 10.4172/2155-9864.1000151 Open Access Volume 4 • Issue 4 • 1000151 J Blood Disorders Transf ISSN: 2155-9864 JBDT, an open access journal Prophylaxis of Deep Venous Thrombosis in Trauma Patients: A Review Jonas P DeMuro* and Adel F Hanna Department of Surgery, Division of Trauma, Critical Care and Emergency General Surgery, Winthrop University Hospital, USA *Corresponding author: Jonas P DeMuro, Department of Surgery, Division of Trauma, Critical Care and Emergency General Surgery, Winthrop University Hospital, USA. Tel: 516.663.8700; E-mail: jdemuro@winthrop.org Received May 28, 2013; Accepted July 29, 2013; Published August 04, 2013 Citation: DeMuro JP, Hanna AF (2013) Prophylaxis of Deep Venous Thrombosis in Trauma Patients: A Review. J Blood Disorders Transf 4:151. doi:10.4172/2155- 9864.1000151 Copyright: © 2013 DeMuro JP, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Keywords: Trauma; Deep venous thrombosis; Venous thromboembolism; Prophylaxis Introduction Venous thromboembolism (VTE) is a common disease in both medical and surgical patients. VTE is comprised of the entities of deep venous thrombosis (DVT) and pulmonary embolism (PE). It is the most common cause of preventable deaths in patients that are hospitalized [1]. VTE affects an estimated 900,000 patients annually in the United States, and approximately 300,000 mortalities annually [2]. It is known that in patients that develop a DVT, the risk of progression to a fatal PE is 1.68% [3]. In addition, the cost of each VTE event is considerable, ranging from $7594 to $16644 when analyzed [4]. Trauma patients have the risk factors of Virchow’s Triad, including stasis, injury and thrombophilia, whether or not they have undergone an operation. e natural history is that up to 58% of high risk trauma patients will develop a DVT with no prophylaxis [5,6]. DVT has been described to occur in 15% of trauma patients, despite chemical prophylaxis with subcutaneous heparin, when it is looked for with screening duplex in one series [7]. In many cases, DVT’s are not recognized clinically, and up to 75% of cases that are suspected clinically do not have a DVT on imaging [8]. e paucity of signs and symptoms, coupled with the unreliability of physical exam underscores the importance of prophylaxis for DVT and PE. erefore, the rationale for prophylaxis is based on the prevalence, the challenge in diagnosis, the morbidity and mortality of unprevented DVT’s, as well as the cost. Trauma patients taken in total, represent a higher risk subset of patients in terms of DVT and PE. PE is the third most common cause of death in trauma patients who survive beyond the first 24 hours of admission [9]. In a retrospective analysis by Knudson et al., the following risk factors were identified on multivariate regression analysis: age ≥ 40 years old, lower extremity fracture, head injury, ventilator days >3, venous injury, and major operative procedure [10]. In the guidelines from the Eastern Association for Trauma (EAST), in their meta-analysis, they found that the most significant risk factors were spinal fracture, and spinal cord injury [11]. In trauma patients, it is common for multiple risk factors to be present simultaneously [12]. Finally, central venous lines, in particular in the femoral position, which is common in trauma patients, are associated with DVT [13]. It is known that the critically injured patient, while initially coagulopathic due to traumatic bleeding, then goes into a hypercoagulable state, due to the systemic inflammatory response seen in post trauma patients, and specifically the increase in C reactive proteins in blood in these patients [14-16]. is phenomenon of a progression from coagulopathic to hypercoagulable, coupled with the dangers of ongoing hemorrhage in subgroups such nonoperative management of solid organ injury, or the traumatically brain injured patient with intracranial hemorrhage, make the prophylaxis for DVT and PE in trauma patients one of the most challenging issues in thromboprophylaxis. Although the risk of DVT increases with age, young trauma patients are still at risk for DVT and PE, and thromboprophylaxis should not be withheld simply for youth [17,18]. Current Recommendations e most recent guidelines to address prophylaxis of VTE in the trauma patient were published in 2012 from the American College of Chest Physicians. ey suggest that for “major trauma patients... the use of LDUH or LMWH, or mechanical prophylaxis, preferably over IPC, over no prophylaxis” [19]. e use of the Caprini risk assessment model is encouraged to stratify the level of risk [20]. e Eastern Association for the Surgery of Trauma (EAST) has practice management guidelines regarding DVT prophylaxis which were published in 2002 [11]. Using the Caprini risk assessment model, developed at the University of Michigan health system, assessing patients for risk of VTE is essential for initiating appropriate prophylaxis [20]. Patients are given a base risk assessment which results in a cumulative risk score, which is then correlated with the incidence of DVT. Based on this stratified risk assessment for each patient, appropriate prophylaxis is recommended, based on the current ACCP Guidelines (9 th Edition) [21]. ere are several challenging trauma patient subtypes that will be detailed below and their VTE prophylaxis issues. Abstract Trauma patients are at high risk for venous thromboembolism. While a variety of risk factors predispose them to deep venous thrombosis and pulmonary embolism, the goal of aggressive chemical prophylaxis needs to be balanced against the risk of hemorrhage, making this a most challenging population to adequately prophylax. The use of titration of the prophylaxis to ant factor Xa levels is discussed. Special consideration needs to be taken in some particularly challenging trauma subpopulations, including those with renal failure, nonoperatively managed solid organ injury, traumatic brain injury with intracranial hemorrhage, spinal cord injury and the bariatric trauma patient, which are reviewed. Journal of Blood Disorders & Transfusion J o u r n a l o f B l o o d D i s o r d e r s & T r a n s f u s i o n ISSN: 2155-9864 Review Article