Is Early Venous Thromboembolism Prophylaxis Safe in Trauma Patients With Intracranial Hemorrhage
ABSTRACT Patients with traumatic brain injuries (TBIs) are at high risk for venous thromboembolic sequelae; however, prophylaxis is often delayed because of the perceived risk of intracranial hemorrhagic exacerbation. The goal of this study was to determine whether enoxaparin for early venous thromboembolism (VTE) prophylaxis is safe for hemodynamically stable patients with TBIs.
This is a retrospective cohort study from a Level I Trauma Center of patients with TBIs receiving early (0-72 hours) or late (>72 hours) VTE prophylaxis. Inclusion criteria included evidence of acute intracranial hemorrhagic injury (IHI) on admission computed tomography, head/neck abbreviated injury score≥3, age≥16 years, and hospital length of stay≥72 hours. Exclusion criteria included intracranial pressure monitor/ventriculostomy, current systemic anticoagulation, pregnancy, coagulopathy, history of DVT, ongoing intra-abdominal hemorrhage 24 hours postadmission, and preexisting inferior vena cava filter. Progression of IHI defined as lesion expansion/new IHI on repeat computed tomography.
Totally, 669 patients were identified: 268 early (40.1%) and 401 late (59.9%), with a mean injury severity score of 27.8±10.2 and 29.4±11, respectively. Head neck abbreviated injury score of 3 (47% vs. 34%), 4 (42% vs. 46%), 5 (11% vs. 19%), and 6 (0% vs. 1%) were reported for the early and late treatment groups, respectively. Mean time to prophylaxis was 2.77 days±0.49 days and 5.31 days±1.97 days. IHI progression before prophylaxis was 9.38% versus 17.41% (p<0.001) and after prophylaxis was 1.46% versus 1.54% (p>0.9). Proportions of proximal DVT were 1.5% versus 3.5% (p=0.117) and pulmonary embolism were 1.5% versus 2.2% (p=0.49). There were no differences in injury severity score, age, and pelvic and/or long bone fractures.
We found no evidence that early VTE prophylaxis increases the rate of IHI progression in hemodynamically stable patients with TBIs. The natural rate of IHI progression observed is comparable with previous studies. Although not powered to detect differences in the incidence of DVT and pulmonary embolism, the data trend toward increased proportions of both VTE outcomes in the late group.
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ABSTRACT: Background:Venous thromboembolic prophylaxis (VTEp) is often delayed following traumatic brain injury (TBI), yet animal data suggest that it may reduce cerebral inflammation and improve cognitive recovery. We hypothesized that earlier VTEp initiation in severe TBI patients would result in more rapid neurologic recovery and reduced progression of brain injury on radiologic imaging.Study Design:Medical charts of severe TBI patients admitted to a level 1 trauma center in 2009-2010 were queried for admission Glasgow Coma Scale (GCS), head Abbreviated Injury Scale, Injury Severity Score (ISS), osmotherapy use, emergency neurosurgery, and delay to VTEp initiation. Progression (+1 = better, 0 = no change, −1 = worse) of brain injury on head CTs and neurologic exam (by bedside MD, nurse) was collected from patient charts. Head CT scan Marshall scores were calculated from the initial head CT results.Results:A total of 22, 34, and 19 patients received VTEp at early (<3 days), intermediate (3-5 days), and late (>5 days) time intervals, respectively. Clinical and radiologic brain injury characteristics on admission were similar among the three groups (P > 0.05), but ISS was greatest in the early group (P < 0.05). Initial head CT Marshall scores were similar in early and late groups. The slowest progression of brain injury on repeated head CT scans was in the early VTEp group up to 10 days after admission.Conclusion:Early initiation of prophylactic heparin in severe TBI is not associated with deterioration neurologic exam and may result in less progression of injury on brain imaging. Possible neuroprotective effects of heparin in humans need further investigation.Journal of Emergencies Trauma and Shock 03/2014; 7(3):141-148. DOI:10.4103/0974-2700.136846
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ABSTRACT: There is considerable practice variation and clinical uncertainty about the choice of prophylaxis for preventing venous thromboembolism in patients with traumatic brain injury. We performed a systematic review to assess both the effectiveness and safety of pharmacologic and mechanical prophylaxis, and the optimal time to initiate pharmacologic prophylaxis in hospitalized patients with traumatic brain injury.01/2013; 2:132. DOI:10.12688/f1000research.2-132.v1
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ABSTRACT: Purpose of review A major challenge in the treatment of brain-injured patients is the decision on indication and timing of prophylactic anticoagulation. In addition, an increasing number of patients suffering from traumatic brain injury (TBI) are on preinjury anticoagulation therapy. Despite clear evidence for an increased risk of venous thromboembolic events and pulmonary embolism in traumatized patients without prophylactic anticoagulation, there is a lack of distinct recommendations and standardized clinical practice guidelines. This review summarizes current research evidence regarding post-traumatic prophylactic anticoagulation and management of patients with prehospital use of anticoagulants. Recent findings In addition to nonpharmacological techniques like compression stockings, use of low-dose unfractionated heparin or low-molecular-weight heparin is effective in different studies in terms of thromboprophylaxis. If follow-up computed tomography scans and clinical neurological examinations do not show progression within 24 h after initial evaluation, prophylactic anticoagulation does not increase risk for hemorrhage progression and therefore seems to be safe after TBI. Summary Stratification scores for identification of TBI patients with low, moderate, or high risk for spontaneous cerebral bleeding may help to allow early thromboprophylaxis while maintaining a good risk–benefit ratio. So far, these scores require validation by prospective trials. Therefore, current evidence requires control computed tomography scans prior to early pharmacological thromboprophylaxis.Current Opinion in Anaesthesiology 10/2013; 26(5):529-534. DOI:10.1097/01.aco.0000432519.16586.6b · 2.53 Impact Factor