DVT Risk Reduction - Trauma, Pelvic Fractures, and Extremity Fractures

Prevention:
     - coumadin, low molecular weight dextran, adjusted dose heparin, or low molecular weight heparin are proven effective for patients undergoing elective surgery

Low Risk Trauma Patients w/ Lower Extremity Fracture:
      - prophylaxis may be considered for patients with risk factors (female, obese, birth control, smoking ect).
      - references:
              - Prophylaxis of deep-vein thrombosis in fractures below the knee: a prospective randomised controlled trial.
              - Efficacy and safety of rivaroxaban versus low-molecular-weight heparin therapy in patients with lower limb fractures.
              - Symptomatic venous thromboembolism following fractures distal to the knee: a nationwide danish cohort study.
              - UK national survey of venous thromboembolism prophylaxis in ankle fracture patients treated with plaster casts.
              - Incidence of deep-vein thrombosis in patients with fractures of the ankle treated in a plaster cast.
              -
Deep vein thrombosis following below knee immobilization: the need for chemoprophylaxis.
              -
Risk factors of venous thrombosis in patients with ankle fractures.

High Risk Trauma Patients:
      Vena cava filter

             - in multi-trauma patients consider prophylactic placement of a vena cava filter
             - decrease in incidence of pulmonary embolism can be expected
             - filters should remove 98% of emboli
             - filters can be expected to prevent fatal emboli in about 2-4% of patients undergoing major acetabular fixation (as compared to patients
                        who receive other forms of DVT prophylaxis)
             - long-term patency rate of IVC is about 94% at 1-2 years
             - sudden severe leg edema following filter insertion may indicate the occurance of a large embolus
             - criteria for filter placement (2/5 criteria must be met)
                      - age greater than 55 yrs
                      - ISS greater than 16
                      - complex pelvic fracture
                      - long bone and pelvic fracture
                      - fracture (pelvic / lower extremity) requiring prolonged bed rest
   - in the study by Wojcik, et al. (2000), long-term complications of VCF placement  were 191 VCFs,  mean follow-up of 28.9 months
       - 41 VCFs were placed in patients with DVT or pulmonary embolism, and 64 were placed in patients for prophylactic
       - there were no pulmonary embolisms detected after VCF insertion
       - only one filter (0.95%) migrated, and this was minimal (1 cm cephalad)
       - 1 (0.95%) vena cava was occluded, based on duplex ultrasonography, and 11 patients (10.4%) had signs or symptoms
                   of leg swelling after hospital discharge
       - 28 (44%) of the 64 patients with prophylactic VCFs developed a DVT after filter placement
       - VCFs placed in trauma patients have acceptable short- and long-term complication rates
        - consideration should be given to prophylactic VCF placement in patients at high risk for VTE
        - randomized controlled trials are needed to evaluate whether VCF insertion increases the risk for subsequent DVT
 
reference:
      - Long-Term Follow-Up of Trauma Patients with a Vena Caval Filter
      - Magnetic resonance venography to evaluate the deep venous system of the pelvis in patients who have an acetabular fracture.
      - Prophylactic vena cava filter insertion in selected high risk orthopaedic trauma patients.
      - Greenfield filter prophylaxis of pulmonary embolism in patients undergoing surgery for acetabular fracture.
      - Thromboembolism following multiple trauma.
      - Risk of pulmonary emboli in patients with pelvic fractures.
      - Prophylaxis against deep-vein thrombosis following trauma: a prospective, randomized comparison of mechanical and pharmacologic prophylaxis.
      - Long-term consequences of pelvic trauma patients with thromboembolic disease treated with inferior vena caval filters.



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Tuesday, April 21, 2015 11:31 am