Thromboprophylaxis in severely injured patient

VTE: venous thromboembolism; TBI: traumatic brain injury; DVT: deep vein thrombosis; CrCL: creatinine clearance; Hb: hemoglobin; IVC: inferior vena cava; PE: pulmonary embolism; LMWH: low-molecular-weight herapins; UFH: unfractionated herapin; HIT: heparin-induced thrombocytopenia.
* This algorithm is designed for adult trauma patients 18 years and older.
¶ Assessment of VTE risk will assist in determining which patients require pharmacologic prophylaxis.
Δ Patients with minor trauma may not require pharmacologic prophylaxis.
◊ Appropriate delays in pharmacologic prophylaxis may occur for those patients with an active bleed, coagulopathy, hemodynamic instability, solid organ injury, traumatic brain injury, or spinal trauma.
§ Mechanical prophylaxis for moderate to high VTE risk patients is encouraged regardless of concurrent pharmacologic prophylaxis.
¥ Weekly venous compression duplex should be considered in patients at high VTE risk who cannot be started or maintained on pharmacologic prophylaxis.
‡ Pharmacologic prophylaxis must be initiated as soon as possible and for most trauma patients may be initiated within 24 hours.
† After deciding to start pharmacologic prophylaxis, the specific anticoagulant and initial dose should be determined for each patient. Enoxaparin is the recommended choice for most trauma patients with higher doses now considered the standard of care.
** Many trauma patients require dose adjustment after initiating enoxaparin.
¶¶ The continuous, uninterrupted dosing of pharmacologic prophylaxis should be the standard for most trauma patients throughout their hospital stay.
ΔΔ Inferior vena cava filters may be considered in the setting of proximal DVT or PE when there is a contraindication to appropriate therapeutic anticoagulation.
◊◊ Trauma patients with TBI, orthopedic or spine injuries, and those who undergo major surgery are at particular VTE risk and should be considered for postdischarge pharmacologic prophylaxis.