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Thomas J Moore MD
Richard Thomas MD
Atlanta Trauma Symposium
April 26, 2013
No Conflicts
Introduction
Introduction
Pelvis
Hip
Knee
Multiple trauma involving lower
extremity fractures
Spinal cord injury
Virchows Triad
Endothelial injury
Venous stasis
Hypercoagulable state
Endothelial injury alone can induce thrombosis
Examples:
Kinking of veins during total hip and
knee surgery
Use of a tourniquet
Limb positioning during surgery
Poor mobility after surgery leads to stasis,
which leads to platelet adhesion to
endothelium
Mechanism by which hypercoagulable state
leads to clot formation is poorly understood
Risk Factors
Inherited thrombophilia
Bed rest or immobility for
more than 5 days
Malignancy
Estrogen or hormone
replacement therapy
History of MI or stroke
Obesity
History of smoking
Prior VTE
Thromboembolic Prophylaxis
HIERARCHY OF EVIDENCE
Basic
Science
Clinical
Relevance
Economic
Metaanalysis
Less Bias
Meta-analysis
1. Enoxaprin vs new agents (fondaparinux, dabigatran,
apixaban, rivaoxabin) : relative equivalence in DVT and PE
prophylasis but difference in bleeding complications and cost
Ann Vasc Surg 2913
2. LMWH vs other anticoagulents (unfractionated heparin, Vit K
antagonists, Factor Xa inhibitors, direct thrombin inhibitors):
additional benefits with LMWH with less harm Pharmotherapy
2012
3. Pharmacologic agents plus IPCD vs IPCD alone: no difference in
DVT or PE rates Pharmacotherapy 2013
Pharmacologic Prophylaxis
Rivaroxaban (Xarelto)
First oral selective Xa inhibitor
Approved for DVT prophylaxis in patients undergoing
total knee and hip arthroplasty surgery
Taken once daily
Relatively low cost
No monitoring needed
Shown to reduce the risk of VTEs after total knee and
hip surgery
May be associated with increased wound bleeding
complications
Jameson JBJS 2012
Conclusions
2.
3.
Recommendations for
Thromboprophylasis in Major Trauma
1. Peri-operative: pharmacologic (Lovenox) with IPCD
2. Outpatient Rx: ASA 325mg daily for 28 days
3. If significant risk of bleeding (ie liver contusion, epidural
head bleed) no pharmacologic antithrombotic Rx, IPCD if
possible
4. No indication for IVC filter placement for prophylaxis
5. No indication for radiographic imaging to r/o DVT at
discharge from initial hospitization