Trauma-Related Thromboembolic Risk Factors
Injury Severity Score
Spinal Cord Injury
Nontraumatic Risk Factors
Chemical Prophylactic Options
Timing of Administration
Intermittent Pneumatic Devices
Inferior Vena Cava Filters
Authors’ Treatment Recommendations for Prophylaxis
p <0.001 for all factors.
Risk factors associated with univariate analysis of venous thromboembolic disease from the National Trauma Data Bank.
Reproduced with permission from: Knudson MM, Ikossi DG, Khaw L, et al. Thromboembolism after trauma: An analysis of 1602 episodes from the American College of Surgeons National Trauma Data Bank. Ann Surg. 2004;240(3):490–496.
The Caprini index can be used to sum the factors thought to be of additive risk in predisposition to venous thromboembolic disease. Patients with scores greater than 3 should have consideration given to prophylaxis.
BMI, Body mass index.
Reproduced with permission from: Caprini JA. Individual risk assessment is the best strategy for thromboembolic prophylaxis. Dis Mon. 2010;56(10):552–559.
≤4, LOW (or “PE Unlikely”) pretest probability; 4.5–6, MODERATE pretest probability; >6, HIGH pretest probability.
Adapted with permission from: Wells PS, Anderson DR, Rodger M, et al. Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: Increasing the models utility with the SimpliRED D-dimer. Thromb Haemost. 2000;83(3):416–420.
≤0, LOW pretest probability; 1 or 2, MODERATE pretest probability; ≥3, HIGH pretest probability.
It is universally recognized that trauma in general and skeletal trauma in particular are strong risk factors for VTE. Regardless of ultimate prophylactic intervention, it is incumbent upon the treating physician to carefully consider the patient’s risk of VTE morbidity and react to this risk with a commensurate prophylactic strategy.
Unfortunately, the multitude of patient and injury variables compounded by an incomplete body of scientific evidence makes dogmatic recommendations for VTE prophylaxis impossible. The quest for a set of routine universally accepted interventions is also challenged by the disparate views of clinicians. The ACCP has a long history of diligent review of existing evidence with regard to the prophylaxis of VTE. Their ninth edition of these guidelines was published in 2012 based on available evidence26 and is felt to be a significant improvement over previous versions as increasing acceptance of mechanical measures and bleeding complications are now incorporated into their recommendations. Also incorporated into the latest guidelines are the practical issues of patient acceptance with latitude provided based on patient desires.
The value of these guidelines is that they provide the clinician ready access to evidence- based conclusions that lie within an enormous body of scientific work. The disadvantage of strictly adhering to evidence-based guidelines is that there are likely prophylactic algorithms that safely, conveniently, and inexpensively provide adequate protection that have not been rigorously studied. The following section of author’s preferred guidelines will largely follow the recommendations of the ACCP and this is not the case, mention will be made.