Basic overview

1. Thromboembolic Disease in
Trauma
Prepared by Dr Madan Mohan based on
Orthop Clin N Am 47 (2016) 335–344

2. • Serum levels of inflammatory cytokines including interleukin-6
(IL-6), IL-8, and tumor necrosis factor-alpha (TNF-a) are increased
following traumatic injury and result in a hypercoagulable state
• This hypercoagulability combined with endothelial injury and
venous stasis, 2 other conditions often noted in trauma patients,
completes the Virchow Triad.
• The presence of all 3 elements contributes to venous
thrombosis

3. • Both chemical and mechanical thromboprophylaxis has
been shown to decrease rates of VTE in the setting of
trauma
• Compared with the abundance of data relevant to venous
thromboembolism in the general trauma population, high-
quality evidence specific to VTE prophylaxis and treatment
in the orthopedic trauma population is relatively limited

4. • The overall incidence of PE was 0.46%, and the in-hospital
mortality rate among patients who developed PE was 12%
• Mechanical thromboprophylaxis significantly decreased VTE
incidence from 11% to 4%
• The most recent Cochrane database systematic review found
that pharmacologic prophylaxis was more effective than
mechanical prophylaxis at reducing DVT risk

5. • Thromboprophylaxis in orthopedic trauma patients does
not completely eliminate the risk of VTE, however.
• Using duplex ultrasound and magnetic resonance
venography, Stannard and colleagues reported a DVT rate
of 11.5% in patients who sustained high-energy skeletal
trauma despite pharmacologic prophylaxis.

6. •All recent evidence-based guidelines
recommend LMWH as the preferred
pharmacologic prophylactic agent for VTE
prophylaxis following trauma.
•Several new oral anticoagulants have been
developed that function either as direct
thrombin inhibitors or direct factor Xa inhibitors

7. • The most common complication of anticoagulation
was surgical site bleeding, occurring at a rate of 10%.
• Other complications reported include gastrointestinal
bleeding, anemia, wound complications,
compartment syndrome, and death

8. • A delay in initiation of thromboprophylaxis beyond 4 days was
associated with a relative risk of 3.0 for VTE compared with the
initiation within 48 hours of injury.
• Developing an effective system for regular communication
between services can facilitate initiation of VTE prophylaxis as
soon as possible while preventing premature anticoagulation in
the setting of medical contraindications and avoiding delays in
planned surgical interventions

9. IVC filters should be reserved for PE
prophylaxis in high-risk trauma patients
with a contraindication to
anticoagulation.