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Hindawi Publishing Corporation Thrombosis Volume 2011, Article ID 505373, 11 pages doi:10.


Review Article Deep Vein Thrombosis Prophylaxis in Trauma Patients
Serdar Toker,1 David J. Hak,2 and Steven J. Morgan2
1 2 Denver

Orthopaedic Trauma Research, Denver Health, University of Colorado, 777 Bannock Street MC 0188, Denver, CO 80204, USA Health, University of Colorado, 777 Bannock Street MC 0188, Denver, CO 80204, USA

Correspondence should be addressed to Serdar Toker, Received 1 November 2010; Accepted 10 March 2011 Academic Editor: Omer Iqbal Copyright © 2011 Serdar Toker et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Deep vein thrombosis (DVT) and pulmonary embolism (PE) are known collectively as venous thromboembolism (VTE). Venous thromboembolic events are common and potentially life-threatening complications following trauma with an incidence of 5 to 63%. DVT prophylaxis is essential in the management of trauma patients. Currently, the optimal VTE prophylaxis strategy for trauma patients is unknown. Traditionally, pelvic and lower extremity fractures, head injury, and prolonged immobilization have been considered risk factors for VTE; however it is unclear which combination of risk factors defines a high-risk group. Modalities available for trauma patient thromboprophylaxis are classified into pharmacologic anticoagulation, mechanical prophylaxis, and inferior vena cava (IVC) filters. The available pharmacologic agents include low-dose heparin (LDH), low molecular weight heparin (LMWH), and factor Xa inhibitors. Mechanical prophylaxis methods include graduated compression stockings (GCSs), pneumatic compression devices (PCDs), and A-V foot pumps. IVCs are traditionally used in high risk patients in whom pharmacological prophylaxis is contraindicated. Both EAST and ACCP guidelines recommend primary use of LMWHs in trauma patients; however there are still controversies regarding the definitive VTE prophylaxis in trauma patients. Large randomized prospective clinical studies would be required to provide level I evidence to define the optimal VTE prophylaxis in trauma patients.

1. Introduction
Deep vein thrombosis (DVT) and pulmonary embolism (PE), known collectively as venous thromboembolism (VTE), affect an estimated 900,000 people in the U.S. each year resulting in several hundred thousand hospitalizations and about 300,000 deaths [1]. About two-thirds of episodes manifest as DVT and one-third as PE with or without DVT [2, 3]. In general surgical patients without prophylaxis against VTE, the incidence of DVT has been reported to be as high as 30%, with an associated fatality risk of 1% [4]. Venous thromboembolic events are also common and potentially life-threatening complications after traumatic injury [5–10]. Coagulopathy is present immediately at admission in 25% of trauma patients, and it is associated with a 5-fold increase in mortality [11]. Sevitt and Gallagher’s [12] autopsy study of 125 patients revealed a 65% incidence of DVT and 16% incidence of PE. The incidence of DVT varies from 5 to 63% in trauma patients depending on patient’s risk factors, modality of prophylaxis, and methods of detection

[13, 14]. A general population study that followed 21,680 persons for occurrence of venous thrombosis over 7.6 years demonstrated that trauma was only present in 6%, revealing a relatively low potential number of cases globally that could be avoided with prophylaxis in this setting, while cancer was present in 48% and surgery was present in 42% [14]. Shackford et al. [15] also reported of an incidence of 7% in the high-risk trauma patient. Nevertheless two factors suggest an increasing incidence of thromboembolism after trauma. First, the average age of the population increases [16]; second, improvements in several fields have resulted in the survival of more seriously injured patients who are at high risk for VTE [16, 17]. Therefore VTE prophylaxis is warranted for patients sustaining traumatic injuries [9, 13, 18–20]. Without thromboprophylaxis, the rate of venous thrombosis and subsequent PE is substantial [18]. The optimal VTE prophylaxis strategy for trauma patients with a contraindication to pharmacological prophylaxis because of a risk of bleeding is unknown [6–9]. Methods of prophylaxis and detection continue to improve; however,

Geerts et al. Kudsk et al. Risk Factors for DVT in Trauma Patients Numerous different factors have been cited in the literature as posing a high risk for VTE in trauma patients. head injury. or some combination of these [2]. venous injury. . The effect of blood transfusion alone on DVT development has also been investigated. However. the difficulty in determining optimal treatment is further complicated by the presence of occult DVTs at a 60% rate of occurrence [17. and prolonged immobilization have been considered risk factors for VTE [8]. [25] using radiofibrinogen uptake test in a group of patients with SCI found the overall incidence of DVT to be as higher as 57%. Despite these numerous risk factors associated with the development of DVT. [9] in their prospective clinical trial found that major head injury was not associated with DVT. They also did not find significant association between DVT and sex. the specific age at which risk increases is unclear [8]. <75 ≥75 Points 2 2 2 3 2 2 2 3 2 2 2 3 3 4 4 4 2 3 4 2. immobilization. Fujii et al.375 patients in the American College of Surgeons (ACS) National Data Bank found six factors to be independently significant for VTE in trauma patients. fracture of the femur or tibia. [24] found that in trauma patients transfused 5 or more units of RBCs. risk factors. guidelines. In this paper we aim to investigate the various approaches for VTE prophylaxis in trauma patients and report what appears to be the best practice for optimal VTE prophylaxis in trauma patients. trauma patients often have all three of these factors leading to a high risk of thromboembolism. have been recognized as Virchow’s triad [29]. According to Hak [16]. In a retrospective cohort study. Patients with acute spinal cord injury (SCI)) and paralysis are at considerable risk for developing DVT [25–27]. Early coagulopathy after traumatic brain injury has been thought to be the result of the injury-mediated local release of TF which activates the extrinsic pathway of blood coagulation [23]. which is abundant in the brain. Selby et al. They reported that the independent predictors of DVT were age. pelvic and lower extremity fractures. and paralysis. Spinella et al. and spinal cord injury. lower extremity fracture with AIS (abbreviated injury score) ≥ 3. but may relate to increasing presence of other illnesses predisposing to thrombosis. 21]. [22] supported the results of this pilot study which showed patients with a RAP score of 5 or more were 3 times more likely to experience the development of VTE than patients with a RAP score of less than 5. Underlying condition Obesity Malignancy Abnormal coagulation History of thromboembolism Iatrogenic factors Femoral venous line Transfusion > 4 units Operation > 2 hours Major venous repair Injury-related factors Chest AIS > 2 Abdomen AIS > 2 Head AIS > 2 Spinal fractures Glascow coma score < 8 Severe lower extremity fracture Pelvic fracture Spinal cord injury Age (years) ≥40. In addition. it is unclear which individual or combination of risk factors defines a high-risk group [22]. Traditionally. A risk assessment profile (RAP) score was developed by Greenfield et al. Direct injury to blood vessels can cause intimal damage leading to thrombosis and prolonged bed rest. plays an important role in initiating coagulopathy following head trauma.2 a significant proportion of patients still develop VTE [8. DVT and in-hospital mortality was increased with the transfusion of old RBCs when compared with a group of patients similar severity of injury who were transfused RBCs of decreased storage age. [28] (Table 1). The reasons for an increased thrombosis risk with age are not understood. These factors were age ≥ 40. Specific search terms used included DVT. [17] also did not find an increase of DVT incidence with injury severity score but they found that it increased with increasing age. Major trauma often precipitates one or all of these risk factors in Virchow’s triad of hypercoagulability. ventilator days > 3. but the amount of transfusion was not associated with DVT. The study by Gearhart et al. however. trauma. all promote venous stasis [8]. blood transfusion. Knudson et al. pelvic fracture. older age increases risk. blood component and blood vessels. According to this study the presence of blood transfusion was important. [3] in an analysis of 450. three important factors. blood flow. 22]. and venous stasis [20]. injury severity score (ISS). 3. and a major operative procedure. Several prospective studies have examined the risk of DVT after trauma [9]. DVT Mechanism in Trauma For thrombus formation. [10] in their prospective cohort study found that the increasing age was the single most important independent predictor of VTE in trauma patients. In general. and prophylaxis. <60 ≥60. A detailed literature search was completed to extrapolate articles that described DVT and DVT prophylaxis. to increase in coagulation potential. hypoperfusion. endothelial injury. Tissue factor. head injury with AIS ≥ 3. and amount of blood transfused. surgery. Thrombosis Table 1: Individual risk factors and points allotted to calculate the RAP score.

acidosis and hypothermia leading to reduced activity [39]. [39] stated that acute traumatic coagulopathy is not due to coagulation factor consumption or dysfunction because of acidosis. 53–56]. Prophylaxis for DVT in Trauma Patients Most methods of VTE prophylaxis that are effective in nontrauma patients are ineffective for multiply injured patients [8. 47]. [34] found that plasma levels of D-dimer and soluble fibrin monomer complex was higher than normal in hip fracture patients. Several studies have established that thromboplastin (Tissue factor. Increased hematocrits. 5. However definitive randomized controlled clinical studies of prophylactic measures in trauma patients with multiple injuries are limited [3] since this heterogenous population necessitates a very large study size. and this may further influence blood flow [44].000 units subcutaneously two or three times daily. Peetz et al. 16] because the factors leading to thrombosis likely develop immediately after the injury. LMWHs have significantly greater activity towards factor Xa than UHs [58]. Besides consumption of clotting factors. 9. Thus controversy exists as to the optimal method of prophylaxis in patients following trauma [16. [51] also concluded that for the prophylaxis of thromboembolic complications especially in the highrisk areas of orthopedics and trauma surgery. represents one pharmacologic treatment modality for prophylaxis against DVT/PE [50]. double blind. Low-dose heparin (LDH) given in doses of 5. unfractioned standard heparin (UFH) is insufficiently effective and associated with a high risk of side-effects. Ruiz et al.2. 43]. and dilution from intravenous fluids and packed cell administration [39. 46. LMWHs are generated from the chemical depolymerization of unfractioned heparin (UH). leading to DVT [41]. Additionally. Multiple studies have demonstrated the efficacy of DVT prophylaxis [3. TF) and markers of thrombin generation increase after trauma [36–38] and that levels of natural anticoagulants such as antithrombin (AT). However regarding the early phase of coagulopathy in trauma. Geerts et al. 48]. and treatment algorithms have been established (Figure 1). no significant difference was reported. In some other studies comparing LDH with no prophylaxis [3. This suggests that acute coagulopathy is due to systemic anticoagulation through activation of the protein C pathway [39]. and weight. subcutaneous heparin dosed three times a day may be as effective as standard-dose 30 mg bid enoxaparin for VTE prophylaxis without increased complications. 17. associations with immobilization and obesity suggest that VTE after injury is a systemic hypercoagulable disorder with local manifestations of thrombosis related to lower extremity stasis. [10] concluded that major trauma leads to significantly increased and persistent thrombin with disruption of its regulation. and this was associated with significant pharmaceutical cost savings. moderate hypothermia.Thrombosis Decreased levels of antithrombin III [30. In a recent study. Multiple studies have investigated 4. 37]. or dilution. mechanical prophylaxis. Decreased blood flow could lead to endothelial damage. and von Willebrand factor macromolecular complex levels increase blood viscosity [42. [36]. contraindications arising from associated injuries often limit the potential options for prophylaxis in patients . Low-Dose Heparin (LDH). 22. 45]. Despite the similar results showing the inefficacy of LDH in all these studies. Pharmacologic Prophylaxis 5. 5. Selby et al. Secondary to their smaller size. all increasing coagulability of the blood [25]. elevated fibrinogen. 50]. Brohi et al. and local decrease in inhibitor levels. local accumulation of activation products of coagulation. charge. [35] also showed more increased levels of D-dimer in high-risk orthopaedic surgery patients when compared with low-risk group. Immobility is also a recognized cause of VTE. 40] are also accepted causes of traumatic coagulopathy. a recent study by Arnold et al. Immobility due to paralysis is one of the major contributing factors for the development of DVT in patients with trauma to the spinal cord [25]. before administration of any type of prophylactic therapy is possible [16. The authors concluded that in trauma patients. However it is reported that without thromboprophylaxis overall DVT rates exceed 50% [9. 15. 47]. prospective trial comparing LDH with LMWH found that LDH was significantly insufficient in DVT prevention. [57] showed comparable rates of DVT in trauma patients receiving standard-dose 30 mg bid enoxaparin versus 5000 U three times a day heparin. This reduces their size. A review of the general surgical literature shows that the incidence of DVT can be diminished by as much as 20% to 40% with minidose prophylactic heparin [49]. and inferior vena cava (IVC) filters [18. According to Meissner et al. which rarely has been achieved in previous studies [16]. 31] and suppression of fibrinolysis [32. They stated that shock itself is associated with a coagulopathy that is due to the systemic activation of anticoagulant and fibrinolytic pathways. Ganzer et al. [52] in a randomized. studied on 100 consecutive patients with multiple trauma in order to determine the efficacy of low-dose heparin and found that it did not provide adequate protection in trauma patients with an ISS > 10. Low Molecular Weight Heparin (LMWH). 46. 3 with trauma [16]. 20]. The lack of pumping action of the contracting muscles results in blood flow reduction and pooling of blood in the intramuscular sinuses of the calf. Modalities available for trauma patient thromboprophylaxis are classified into pharmacologic anticoagulation. 33] may lead the trauma patient to become hypercoagulable. Increased severity of hypoperfusion was associated with an increase in plasma thrombomodulin and a reduction in protein C levels. LMWHs gained popularity as prophylactic agents for VTE in early 1990s [59] and have emerged in the late 1990s as the most (or only) effective method of DVT prophylaxis in trauma patients [8. protein C (PC) and protein S (PS) are reduced [31.1. [20] pointing out that these data have since been applied to trauma patients without substantiation [17]. Okamura et al.

60–63]. Geerts et al. 52. In 1990. [65] found no difference in the incidence of DVT between the patients who received standard and body-weightadjusted dose of LMWH. Fondaparinux. 21]. search for new solutions is ongoing. American College of Chest Physcians (ACCP) recommended DVT prophylaxis in multiple trauma patients with LMWH for the first time. [66] showed that standard dosing of enoxaparin leads to low anti-Xa levels which are associated with a significant increase in the risk of DVT in half of surgical intensive care unit (ICU) patients. and authors concluded that these data support future studies using adjusted-dose enoxaparine. 68]. Green et al. safe.4 Thrombosis RAP score Underlying condition Obesity Malignancy High-risk RAP ≥ 5 Abnormal coagulation 2 2 Low-risk RAP < 5 2 History of thromboembolism 2 Injury-related factors Chest AIS > 2 2 2 2 3 3 4 4 4 2 2 2 3 2 3 4 Abdomen AIS > 2 Head AIS > 2 Spinal fractures GCS < 8 Contraindication to prophylactic anticoagulation? No Yes Severe lower extr. <60 60. 5. 67. In 2007.014) of DVT. In 1994 Knudson et al.012) of proximal DVT respectively. Cothren et al. ftx. in a study of patients with spinal cord injury. [60] showed that LMWH (enoxaparin 30 mg bid) was safe and effective in preventing DVT in high-risk trauma patients. In one of the most cited studies on this topic.1% incidence of DVT on duplex ultrasound examination and concluded that this incidence does not exceed historical controls. They found a 2. found that LMWH was safe and effective for VTE prevention in complete motor paralysis and was superior to subcutaneous heparin.3. In severely injured patients. In 1998. recognizing that DVT and PE rates are lowered in trauma patients who are treated with LMWH [46. Because of the fact that safer and more effective prophylactic measures are needed for high-risk trauma patients. In a recent study. [52] comparing LDH with LMWH found an incidence of 44% and 31% (P = . and 15% and 6% (P = . [64] favored the protocol of early joint spanning external fixation with the concurrent use of LMWH in patients with highenergy lower extremity trauma. the optimal method of prophylaxis for DVT. [46] in a prospective study including 6247 trauma patients found that once-daily dosing of prophylactic LMWH dalteparin was feasible. [62]. However a recent study by Malinoski et al. There is a controversy in dosing of LMWHs. VTE remains a major cause of potentially preventable death despite considerable prophylactic efforts particularly in those who are believed to have contraindications to receiving a heparin drug [8. Fondaparinux is a nonheparin drug and the first synthetic pentasaccharide selectively inhibiting Factor Xa [21. Along with its antithrombotic efficacy in preventing VTE after elective orthopaedic operations and . Pelvic fracture Spinal cord injury Latrogenic factors Femoral line Transfusion > 4 units Operation > 2 hours Major venous repair Reevaluate Age (years) in 24–48 hours >40. 59] suggested dose adjustment according to the levels of D-Dimer in prevention of DVT in trauma patients. <75 >75 Enoxaparine 30 mg sq bid Consider SCD or dalteparin 5000 IU or foot pumps sq/day No prophylactic theraphy required Encourage early mobilization No Consider IVC filter Continued/prolonged contraindication to anticoagulation Yes Figure 1: Algorithm for VTE prophylaxis [8]. and effective in high-risk trauma patients allowing to “operate through” systemic prophylaxis and ensuring timely prophylaxis for brain-injured and multisystem trauma patients. Sems et al. They concluded that LMWH should be considered the method of choice for the prophylaxis of trauma patients. Some authors [35.

further research on this agent is needed. LDH. [86] found no significant difference in DVT rates between the two groups. Thus in trauma patients with contraindications to chemoprophylaxis and mechanical prophylaxis [18. these filters have been placed in patients with acute proximal DVT or a recent PE who have either a contraindication to receive heparin. 79–81]. Despite these studies. Pneumatic Compression Devices. P > .4% was found in the fondaparinux group versus enoxaparine group. sequential pneumatic compression devices (PCDs). the safety of fondaparinux has been documented in several Phase II and III clinical trials [68]. thrombocytopenia. authors found a 4. Venous duplex color-flow Doppler sonography of the lower extremities was performed each week of hospitalization and 1 week after discharge. In this study. and they concluded that PCD can be used safely for prophylaxis of VTE in head/spinal trauma patients. and Anglen et al. 77]. GCSs are widely used for prevention and treatment of DVT in nontrauma patients [71–77].7% for enoxaparine plus foot pumps group. or bleeding attributable to fondaparinux.04. 50]. 2. 6. with PCDs at 7% and AV foot pumps at 3%. a meta-analysis by Velmahos et al. 6. There were eleven large or occlusive clots (prevalence. Spain et al.9%) in enoxaparine plus foot pumps group (P = . Despite the findings that PCDs were comparable to the effect of LDH in significantly lowering DVT incidence compared with controls with no prophylaxis [56. Kurtoglu et al. and they are commonly utilized in trauma setting because of ease of use and inherently low risk of associated bleeding [18]. 6. and their efficacy was compared with PCD and LMWH. Unfortunately VCFs are not without risks and potentially transient nature of the hypercoagulable states in the majority of trauma patients has made this a less attractive option [88]. enoxaparine treatment was compared with enoxaparine plus foot pumps treatment.4% incidence of DVT following a hip fracture surgery [70]. They function by reducing the luminar diameter of a vein resulting in an increase in venous flow velocity. a risk reduction of 56. [78] concluded that GCSs are effective in diminishing the risk of DVT in hospitalized patients. [87]. or a combination of these [79]. and pneumatic plantar (A-V) foot pumps [16]. and its use is recommended only in combination with LMWH prophylaxis [83] or when anticoagulant DVT prophylaxis is contraindicated [18].4% for enoxaparine group. These devices include graduated compression stockings (GCS). Vena Cava Filters (VCFs) The effectiveness of a VCF in the prevention of pulmonary embolism in patients with proximal DVT has been well established. In the first study by Eriksson et al. The authors concluded early mechanical prophylaxis with foot pumps and the addition of enoxaparin on a delayed basis was a very successful strategy for prophylaxis against venous thromboembolic disease following serious musculoskeletal injury. [56] showed that PCD offered no benefit over no prophylaxis.). However. or who have had a PE despite anticoagulation [3]. who had bleeding during heparin treatment.05. the authors found a 2. however. or mortality between groups (P = .2.7% incidence of DVT in a group of patients following total hip or total knee arthroplasty. Sachdeva et al. Authors concluded that this agent appears to offer protection against VTE in high-risk trauma patients. Two studies were performed to detect the efficacy of fondaparinux in hip fracture surgery [69. Its once-daily dosing regimen can improve compliance and reduce cost and eliminate risk of heparin-induced thrombocytopenia. 81] and despite the given same rate of DVT for clinically injured patients prophylaxed with either Sequental Compression Device (SCD). 5 difference regarding a reduction in DVT. 11. A-V foot pumps were studied in several trauma patient groups.2% incidence of DVT in patients receiving fondaparinux. these devices have not been reported in the trauma population [18].3%) in enoxaparine group. Graduated Compression Stockings. The second study by the same group in 2004 revealed a 1. some authors have advocated the placement of VCFs in high-risk patients . Mechanical VTE prophylaxis by graduated compression stockings or intermittent pneumatic compression provides suboptimal protection. 56.3. [85] found an incidence of 4% of DVT with foot pumps and 0% with PCD. Knudson et al. The prevalence of deep-vein thrombosis was 13. In 1983. P > . VCFs offer one option to reduce morbidity and mortality associated with embolism. Traditionally. A-V Foot Pumps.6% overall incidence of DVT and a 1.025).05. [21] in 2009. However with concern about the ineffectiveness of available VTE prophylaxis in injured patients. The prevalence of pulmonary embolism was 2. [69] in 2001. PCDs for prophylaxis against DVT has been studied and increasingly used in trauma patients [53. 70]. [84] found higher rates of DVT with foot pumps when compared with PCD and LMWH. Fondaparinux has never been used in trauma patients until a pilot study was performed by Lu et al. [82] also prospectively randomized 120 head/spinal traumatized patients for comparison of IPC with LMWH as a prophylaxis modality against VTE. In a recent study by Pitto and Young [76. 6. compared with only three (prevalence. As this is a pilot study with a lack of a control group and with a relatively small size.1% in enoxaparine group and 0% in enoxaparine plus foot pumps group. In a recent study by Stannard et al. Gardner and Fox first described the physiologic pumping mechanism of the sole of the foot and in 1990 Laverick demonstrated that arteriovenous (A-V) foot pump increases venous blood flow in popliteal vein by 250% [50].Thrombosis in selected high-risk abdominal surgical patients [21]. PE. and 8. resp. There were no episodes of pulmonary embolism. There was no statistically significant 7. Mechanical Prophylaxis Various types of external compression devices are available to provide DVT prophylaxis in the immobilized patient.1. In a recent systemic review of 18 randomised clinical trials (RCTs).

authors concluded that VCFs were safe and effective in preventing PE.8%).1%). Recommendations of EAST about VCFs. 102]. ACCP recommends the use of LMWH for major trauma patients as soon as it is considered safe to do so. According to Level III recommendation. and an individual decision should be made when considering prophylaxis [50]. and the risk of recurrent DVT was low. the safety of LDH has not been established. An acceptable alternative is the combination of LMWH and the optimal use of a mechanical method. (3) spinal cord injury. [93] demonstrated that 6282 of 617. According to Level III recommendation.1. and second the option of filter removal thus avoiding late complications [96].2. What Do the Latest ACCP and EAST Guidelines Recommend for DVT Prophylaxis in Trauma For more than 20 years. however. [97] using these filters in 113 trauma patients concluded that retrievable filters were safe and effective in preventing PE in high-risk patients. Level III recommendation is that for patients in whom bleeding could worsen injuries.5. Velmahos and collegues [26] in their meta-analysis found that patients with prophylactic vena cava filters had a lower incidence of PE (0. 8. According to Level III recommendation. concluded that permanent filters should be the choice for elderly patients. the optimal use of PCD and/or GCS is recommended. In a recent study by Toro et al. ACCP recommends thromboprophylaxis until hospital discharge. Gorman et al. however. new solutions might be required.4. patients with an ISS > 9 should receive LMWH primarily. American College of Chest Physicians (ACCP) has published guidelines for the prevention of VTE [101. PCDs may have some benefit in isolated studies 8. low complication rate (0. ACCP recommends thromboprophylaxis with LMWH. [40]. If anticoagulant therapy is contraindicated.2%) compared with those without filters (1. [99] concluded that retrievable VCFs could even be placed in bedside in ICU in critically ill trauma patients and it was a safe and simple technique that was avoiding the transportation of the patient out of ICU. Recommendations of EAST about A-V Foot Pumps. According to Level III recommendation. Since most of the trauma patients are relatively younger. mechanical thromboprophylaxis with PCD or possibly with GCS . With the approval of retrievable systems. Cherry et al. these devices may be used as a substitute for pneumatic compression devices in those highrisk trauma patients who cannot wear PCDs. [100] using the prophylactic retrievable VCFs in trauma patients. a retrospective analysis of data from the National Trauma Data Bank of the American College of Surgeons by Shackford et al. Khansarinia [94] found significant differences in both PE and PE-related death when compared high-risk trauma patients with prophylactic Greenfield filter placement with injury-matched controls without filters. 8. a practice management guidelines for the prevention of venousthromboembolism in trauma patients were published in July 2002 (Table 2) [50]. EAST group has no Level I recommendation for LDH. Rosenthal et al. high retrieval rate (59%). Recommendations of EAST about LDH. combined PCD and either LDH or LMWH.5%) versus historical controls (5. There is no Level I and Level II recommendation about A-V foot pumps because of insufficient data. As level II recommendation. Some recent studies reported good results of retrievable VCFs. ACCP recommends against the use of a VCF as thromboprophylaxis for trauma and SCI patients.6% PE rate. According to Level II recommendations LMWH can be used with the following injury patterns: (1) pelvic fractures (operative or prolonged bed rest). 8. and satisfactory compliance with traditional Eastern Association for the Surgery of Trauma (EAST) guidelines. EAST group has no Level I recommendation for LMWH. insertion of a prophylactic VCF should be considered in very-high-risk trauma patients who cannot receive anticoagulation because of increased bleeding risk and have to be immobilized for a long time [50]. Phelan et al. Recommendations of EAST about PCDs. alternatively. in the subset of head-injured patients. (2) complex lower extremity fractures (operative or prolonged bed rest). and 86% of these were placed prophylactically. reported 1. For major trauma patients with impaired mobility. Thrombosis alone was recommended. little evidence exist to support the benefit of LDH in the trauma patient. The use of retrievable VCFs offers a dual advantage: first protection against PE during the risk period.3. Recommendations of EAST about LMWH.349 patients received a VCF (1%) between 1991 and 2002. For patients with acute SCI. 8. Several reports exist in the literature on the use of prophylactic VCFs in trauma patients with some of them demonstrating a significant reduction in the incidence of PE. some authors reported that permanent VCFs had some disadvantages such as increasing the long-term risk of DVT [95–97]. 8. The Eastern Association for the Surgery of Trauma (EAST) has taken a leadership role in the development of evidenced-based guidelines for trauma [103]. [98] in a long-term study regarding the follow-up of permanent VCF in trauma patients. There is no Level I and Level II recommendation about PCDs because of insufficient data. there has been renewed interest in VCFs. This is certainly controversial [55].6 who have neither PE nor DVT [88–92]. There is no Level I and Level II recommendation about PCDs because of insufficient data. According to the latest ACCP guidelines published in 2008 [101]. If there is a contraindication for LMWHs.

Paffrath. “Surveillance for deep vein thrombosis and pulmonary embolism: recommendations from a national workshop. H. two important guidelines. Johnson. Shin. risk factors and outcome. according to new research we think that LDH may gain importance again as it is shown that it might be as effective as LMWHs in trauma patients with an adjustment of dosage and that might provide an advantage of lower costs. and R. Larger and qualified studies are required to be able to recommend the usage of LDH again instead of LMWH. Moore. PCDs may have some benefit in isolated studies Very-high-risk trauma patients who cannot receive anticoagulation 9. no. Wafaisade. there is an insufficiency of high-qualified clinical studies to let clinicians to decide the definite way for prophylaxis in this group of patients. 38.. [4] R. pp. 2009. “Thromboembolism after trauma: an analysis of 1602 episodes from the American College of Surgeons National Trauma Data Bank. Eppsteiner. VTE prophylaxis in trauma patients is necessary and with benefit to the patient. 6. and R. White. J.” PLoS Medicine. None None None None None Level II recom. In conclusion. However. 1251–1270. C. 2007. 4. pp. [2] M. Article ID e1000098. Lefering et al. P. Bullington. R. Heit. 6.” American Journal of Preventive Medicine. Ikossi. 1. Cushman. Griffin. P. Traditionally it is being used for PE prophylaxis where there is a contraindication for LMWH prophylaxis. N. pp. Knudson.. Large qualified randomized prospective clinical trials would be required to diminish controversy and to further determine the ideal prophylaxis for VTE in trauma patients. 3. vol. 2010. 240. “A prospective study of venous thromboembolism after major . J. Manns. M. “Venous thromboembolism after severe trauma: incidence. it is clear that without prophylaxis the incidence of occult and nonoccult DVT would be higher with the potential for increased risk of VTE-related morbidity and mortality. 2. S502–S509. Feliciano. J. McGwin. “Bleeding and coagulation complications. “Traumatic brain injury is associated with the development of deep vein thrombosis independent of pharmacological prophylaxis. L. R. M. D. however it is mostly stated that this methods should mostly be used as an adjuvant therapy to LMWHs or they are recommended to be used where there is a contraindication for LMWHs. W. Currently EAST guidelines recommend the use of VCFs in very-highrisk major trauma patients in case of a contraindication for LMWHs. 2009. no. ACCP and EAST. As demonstrated in the extended body of literature on prophylaxis of VTE in trauma patients. Haricharan. and H. Van Dam. W. M.” in Trauma. also recommend primary use of LMWHs in trauma patients.. completely eliminated mortality or morbidity of VTE. 2010. no. pp. Silverstein. 2004. H. Mattox. and L. Raskob. E. Stelfox. K.” Annals of Surgery. None None None 7 Level III recom. J. Mechanical prophylaxis was also advocated by many studies and ACCP and EAST guidelines. J. E. M. D. Individual decision should be made when considering prophylaxis Patients with an ISS > 9 should receive LMWH primarily Substitude for PCDs in those high-risk trauma patients who cannot wear PCDs In head-injured patients. 66. R. V. [8] S.Thrombosis Table 2: Recommendations of EAST group for the VTE prophylaxis in trauma patients. “Epidemiology and risk factors for venous thrombosis. E. ACCP does not recommend the use of VCFs in major trauma patients. no. [3] M. vol. E. McGraw-Hill. vol. 10–19. A. vol. Reiff. 1. Little evidence exist to support the benefit of LDH in the trauma patient (1) Pelvic fractures (2) Complex lower extremity fractures (3) Spinal cord injury. 34. no. Rue. Jay. 44. “An economic evaluation of venous thromboembolism prophylaxis strategies in critically ill trauma patients at risk of bleeding. Code. vol.” Seminars in Hematology. Geerts. A. The diminishment of VTE with prophylaxis has not. however. Conclusions It is clear that VTE is one of the major problems of trauma patients. R. A. “Mechanical compression versus subcutaneous heparin therapy in postoperative and posttrauma patients: a systematic review and meta-analysis. G. Bratzler. L. and J. Despite the fact that none of the methods of the prophylaxis provide complete prevention from VTE. B. and K. I. T. however it is widely discussed that this device could be used for primary prophylaxis in major trauma patients. D. Michetti. [7] D. M. R. G. Most recent clinical studies advocate the use of LMWHs in the prevention of VTE in trauma patients.” The Journal of Trauma. Chiasson. vol.” Injury. pp. There is increasing number of studies about VCFs. L. 2004. no. 5. Additionally the nature of the major trauma itself can be a contraindication to use such devices such as requirement for external fixators on lower extremities would prevent application of GCSs or PCDs. W. pp. [9] W. [6] T. Chen. Szalai. Prophylaxis LDH LMWH A-V foot pump PCDs VCFs Level I recom. 2010. pp. 97–101.” World Journal of Surgery. Eds. However. Fakhry and C. no. 490–498. [5] T. Disclosure The authors have nothing to disclose. References [1] G. 41. 62– 69. 1436–1440. vol. Khaw et al. N.

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