To Provide Guidelines for Deep Vein Thrombosis Prophylaxis (DVT) in the Trauma Patient

Objective:

To provide guidelines for deep vein thrombosis prophylaxis (DVT) in the trauma patient

Goal:

Prevention of DVT and the sequelae.

Approach:

1. The following patients should be considered high risk for a TED:

a. Prolonged immobilization (> 72 hrs)

b. Severe head injury (GCS<8)

c. Spinal cord injury

d. Pelvic fracture

e. Spinal fracture (requiring fixation or bracing)

f. Lower extremity fracture

g. Femoral venous line or major venous repair

h. Hypercoagulable state

2. The following prophylaxis should be considered:

a. Mobilize all patients as soon as possible.

b. Low molecular weight heparin (LMWH) Enoxaparin 30 mg SQ every 12 hrs or 40mg

SQ qday and sequential compression devices (SCDs) unless contraindications exist.

c. Contraindications to LMWH are (and in these pts, unfractionated Heparin should be

considered):

• Severe head injury (first 72 hours)

• Spinal cord injury (first 2-3 days)

• Bleeding diathesis (first 2-3 days)

• Uncorrected coagulopathy

d. SCD’s for all patients in whom anti-coagulation is contraindicated (in these patients

unfractionated heparin should be considered).

e. If SCD’s are not able to be placed on lower extremities due to injury, place foot pumps.

3. If a DVT is detected, start systemic heparin according to the IHC Heparin Protocol if

no contraindications exist.

4. Duplex scan should be performed if a DVT or PE is suspected. Although routines screening duplex scans are not recommended, a weekly duplex scan should be considered in high risk hospitalized patients.

5. A contrast venogram should be ordered for an unequivocal duplex scan.

6. Vena Cava Filters (removable) are indicated for the following conditions:

a. RecurrentPE despite full anticoagulation.

b. Proximal DVT and contraindications to anticoagulation.

c. Proximal DVT and major bleeding while on anticoagulation therapy.

d. Progression of a femoral clot despite anticoagulation therapy.

e. Large free floating thrombus of the iliac vein or IVC.

f. When possible, systemic anticoagulation should be administered concomitantly with

the use of an Vena Cava filter.

7. Patient undergoing major anterior approach pelvic surgery > 72 hours after injury without

TED prophylaxis requires either screening with magnetic resonance venogram (MRV) for pelvic thrombus or placement of IVC filter.

Emergency General Surgery

DVT Prophylaxis Practice Guidelines

High Risk for DVT:

Increasing Age

Prolonged Immobility

Stroke

Paralysis

Previous VTE

Cancer

Major Surgery (abdomen, pelvis, lower extremities)

Trauma

Obesity

Varicose Veins

Cardiac Dysfunction

Indwelling Central Venous Catheters

Inflammatory Bowel Disease

Nephrotic Syndrome

Pregnancy

Estrogen Use

For surgical patients, the incidence of DVT is affected by the preexisting factors listed above and by factors relating to the procedure itself, including the site, technique, and duration of the procedure, the type of anesthetic, the presence of infection, and the degree of postoperative immobilization (Geerts, Heit, Clagett, Pineo, Colwell, Anderson, & Wheeler, 2001).

Low Risk General Surgery Patient:

Minor surgery in patients < 40 yr. with no additional risk factors

Moderate Risk General Surgery Patient:

Minor surgery in patients with additional risk factors

Nonmajor surgery in patients 40-60 yr. with no additional risk factors

Major surgery in patients < 40 yr. with no additional risk factors

High Risk General Surgery Patient:

Nonmajor surgery in patients > 60 yr. or with additional risk factors

Major surgery in patients > 40 yr. or with additional risk factors

Highest Risk General Surgery Patient:

Major surgery in patients > 40 yr. plus prior VTE, cancer, or molecular hypercoagulable state

Hip or knee or knee arthroplasty

Hip fracture surgery

Major trauma

Spinal cord injury

The abdominal general surgery patient is considered major surgery, so the patient begins at moderate risk level and then goes to high or highest risk depending on age and risk factors.

Moderate RiskHigh RiskHighest Risk

Heparin 5000 U SCHeparin 5000 U SCLovenox 40

q12hq8h mg SC qd

Or elastic stockings Or IPCAnd ES or IPC

Or IPC

(Grade 1A)(Grade 1A)(Grade 1C)