Prevention of venous thromboembolism in traumatology

Authors: Petr Kessler 1;  Leopold Pleva 2;  Jindřich Dvořák 3;  Jaromír Gumulec 4
Authors‘ workplace: Odd. hematologie a transfuziologie Nemocnice Pelhřimov ;  Department of hematology and transfusion medicine, Hospital Pelhrimov 1;  Traumatologické centrum FN Ostrava, Ústav medicíny katastrof LF OU 2;  Trauma center, University hospital Ostrava, Department of disaster, Medical faculty University of Ostrava 2;  Traumatologické oddělení Nemocnice Jihlava 3;  Department of traumatology, Hospital Jihlava 3;  Klinika hematoonkologie FN Ostrava 4;  Hemato-oncological clinic, University hospital Ostrava 4
Published in: Úraz chir. 22., 2014, č.2


Venous thromboembolism is a major complication in patients with trauma. Based on results of randomized controlled trials, the prophylactic measures are well established in patients with hip fracture. In most other injuries, the high heterogeneity of cases precludes an arrangement of large randomized controlled trials, thus the strength of available evidence is lower, and resulting in skepticism in formulation of evidence based clinical guidelines. The lack of strong recommendations leads often to the omission of thromboprophylaxis even in patients with accumulation of risk factors for thrombosis. A manual which is applicable in clinical practice is thus required.

To summarize current knowledge on thromboprophylaxis in trauma patients and form a suitable guide for clinical practice.

Relevant publications were searched using Medline database, the level of evidence was evaluated, and 2 level statements were formulated. Statements based on randomized controlled trials, on a meta-analysis, or on a large sophisticated registry were formulated as recommendations, and statements based on lower level evidence or on consensual expert opinion were formulated as suggestions.

Guidelines on thromboprophylaxis were formulated covering 4 groups of injuries: Hip fracture, lower extremity injury, spinal trauma and major trauma. The role of mechanical and pharmacological measures was defined, considering the risk of thrombotic and bleeding complications in distinct injuries.

The principles stated in this article should not be applied automatically; an individualized ap-proach should be preferred in patients with accumulation of thrombotic risk factors and in patients with apparently high risk of bleeding.

Key words:
Thromboprophylaxis, trauma, low molecular weight heparin, fondaparinux, guidelines.


1. ABELSETH, G., BUSKLEY, RE., PINEO, G.E. et al. Incidence of deep-vein thrombosis in patients with fractures of the lower extremity distal to the hip. J Orthop Trauma. 1996, 10, 230–235.

2. AITO, S., PIERI, A., D’ANDREA, M. et al. Primary prevention of deep venous thrombosis and pulmonary embolism in acute spinal cord injured patients. Spinal Cord. 2002, 40, 300–303.

3. ALSAWADI, A., LOEFFLER, M. Graduated compression stockings in hip fractures. Ann R Coll Surg Engl. 2012, 94, 463–471.

4. BARRERA, LM., PEREL, P., KER, K. et al. Thromboprophylaxis for trauma patients. Cochrane Database Syst Rev. 2013, 28, CD008303.

5. BERGQVIST, D., LOWE, G. Venous thromboembolism in patients undergoing laparoscopic and arthroscopic surgery and in leg casts. Arch Intern Med. 2002, 162, 2173–2176.

6. Cardiovascular Disease Educational and Research Trust; Cyprus Cardiovascular Disease Educational and Research Trust; European Venous Forum; International Surgical Thrombosis Forum; International Union of Angiology; Union Internationale de Phlébologie. Prevention and treatment of venous thromboembolism. International Consensus Statement (guidelines according to scientific evidence). Int Angiol. 2006, 25, 101–161.

7. DEVIVO, MJ., KRAUSE, JS., LAMMERTSE, DP. Recent trends in mortality and causes of death among persons with spinal cord injury. Arch Phys Med Rehabil. 1999, 80, 1411–1419.

8. ERIKSSON, BI., BAUER, KA., LASSEN, MR. et al. Fondaparinux compared with enoxaparin for the prevention of venous thromboembolism after hip-fracture surgery. N Engl J Med. 2001, 345, 1298-1304.

9. ERIKSSON, BI., LASSEN, MR. PENTasaccharide in HIp-FRActure Surgery Plus (PENTHIFRA Plus) Invetigators. Duration of prophylaxis against venous thromboembolism with fondaparinux after hip fracture surgery: a multicenter, randomized, placebo-controlled, double-blind study. Arch Intern Med. 2003, 163,1337–1342.

10. ETTEMA, HB., KOLLEN, BJ., VERHEYEN, CC. et al.: Prevention of venous thromboembolism in patients with immobilization of the lower extremities: a meta-analysis of randomized controlled trials. J Thromb Haemost. 2008, 7, 1093–1098.

11. EVANS, HL., CUSCHIERI, J., MOORE, EE. et al. Inflammation and the host response to injury, a Large-Scale Collaborative Project: patient-orien-ted research core standard operating procedures for clinical care IX. Definitions for complications of clinical care of critically injured patients. J Trauma. 2009, 67, 384–388.

12. FALCK-YTTER,Y., FRANCIS, CHV., JOHANSON, NA. et al. Prevention of VTE in Orthopedic Surgery Patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012, 141, e278S–e325S.

13. FISHER,WD., AGNELLI., G., GEORGE, DJ. et al.: Extended venous thromboembolism prophylaxis in patients undergoing hip fracture surgery - the SAVE-HIP3 study. Bone Joint J. 2013, 95-B, 459–466.

14. FISHER, CG., BLAUCHT, PA., SALVIAN, AJ., et al. Effectiveness of leg compression devices for the prevention of thromboembolic disease in orthopaedic trauma patients: a prospective, randomized study of compression alone versus no prophylaxis. J Orthop Trauma. 1995, 9, 1–7.

15. GEERTS, WH., BERGQVIST, D., PINEO, GF. et al. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). American College of Chest Physicians. Chest. 2008, 133, 381S–453S.

16. GEERTS,WH., CODE, KI., JAY, RM. et al. A prospective study of venous thromboembolism after major trauma. N Engl J Med. 1994, 15, 1601–1606.

17. GEERTS,WH., PINEO, GF., HEIT, JA. et al. Prevention of Venous Thromboembolism. Chest. 2004, 126, 338S–400S.

18. GIORGI PM., DONADINI, MP., DENTALI, F. et al. The short- and long-term risk of venous thromboembolism in patients with acute spinal cord injury: a prospective cohort study. Thromb Haemost. 2013, 109, 34–38.

19. GOULD, MK., GARCIA, DA., WREN, SM. et al. Prevention of VTE in nonorthopedic surgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012, 141, e227S–e277S.

20. CHEN, HL., WANG, XD. Heparin for venous thromboembolism prophylaxis in patients with acute spinal cord injury: a systematic review and meta-analysis. Spinal Cord. 2013, 51, 596–602.

21. CHRISTIE, S., THIBAULT-HALMAN, G., CASHA, S. Acute pharmacological DVT prophylaxis after spinal cord injury. J Neurotrauma. 2011, 28, 1509–1514.

22. JONES,T., UGALDE,V., FRANKS, P., et al. Venous thromboembolism after spinal cord injury: incidence, time course, and associated risk factors in 16,240 adults and children. Arch Phys Med Rehabil. 2005, 86, 2240–2247.

23. JORGENSEN, PS., WARMING,T., HANSEN, K. et al. Low molecular weight heparin (Innohep) as thromboprophylaxis in outpatients with a plaster cast: a venografic controlled study. Thromb Res. 2002, 15, 477–480.

24. STRUILK-MULDER, MC., ETTEMA, HB., VERHEYEN, CC. et al. Comparing consensus guidelines on thromboprophylaxis in orthopedic surgery. J Thromb Haemost. 2010, 8, 678–683.

25. 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, 490–496.

26. KOCK, HJ., SCHMIT-NEUERBURG, KP., HANKE, J. et al. Thromboprophylaxis with low-molecular-weight heparin in outpatients with plaster-cast immobilisation of the leg. Lancet. 1995, 346, 459–461.

27. KUJATH, P., SPANAGEL, U., HABSCHEID, W. Incidence and prophylaxis of deep venous thrombosis in outpatients with injury of the lower limb. Haemostasis. 1993, 23, 20–26.

28. KURTOGLU, M., YANAR, H., BILSEL,Y. et al. Venous thromboembolism prophylaxis after head and spinal trauma: intermittent pneumatic compression devices versus low molecular weight heparin. World J Surg. 2004,28, 807–811.

29. KWIATT, ME., PATEL, MS., ROSS, SE. et al. Is low-molecular-weight heparin safe for venous thromboembolism prophylaxis in patients with traumatic brain injury? A Western Trauma Association multicenter study. J Trauma Acute Care Surg. 2012, 73, 625–628.

30. LASSEN, MR., BORRIS, LC., NAKOV, RL. Use of the low-molecular-weight heparin reviparin to prevent deep-vein thrombosis after leg injury requiring immobilization. N Engl J Med. 2002, 347, 726–730.

31. MAUNG, AA., SCHUSTER, KM., KAPLAN, LJ. et al. Risk of venous thromboembolism after spinal cord injury: not all levels are the same. J Trauma. 2011, 71, 1241–1245.

32. NATHENS, AB., MCMURRAY, MK., CUSCHIERI, J. et al. The practice of venous thromboembolism prophylaxis in the major trauma patient. J Trauma. 2007, 62, 557–562.

33. PLOUMIS, A., PONNAPPAN, RK., MALTENFORT, MG. et al. Thromboprophylaxis in patients with acute spinal injuries: an evidence-based analysis. J Bone Joint Surg Am. 2009, 91, 2568–2576.

34. Pulmonary Embolism Prevention (PEP) Trial Collaborative Group. Prevention of pulmonary embolism and deep vein thrombosis with low dose aspirin: Pulmonary Embolism Prevention (PEP) Trial. Lancet. 2000, 355, 1295–1302.

35. RANDELLI, FE., ROMANINI, FB et al.: II Italian intersociety consensus statement on antithrombotic prophylaxis in orthopaedics and traumatology. Arthroscopy, traumatology, leg immobilization, minor orthopaedic procedures and spine surgery. J Orthop Traumatol. 2013, 14, 1–13.

36. RUBIN-ASHER, D., ZEILIG, G., RATHER, A. et al. Risk factors for failure of heparin thromboprophylaxis in patients with acute traumatic spinal cord injury. Thromb Res. 2010, 125, 501–504.

37. STANNARD, JP., LOPEZ, RR., VOLGAS, DA. et al. Prophylaxis against deep-vein thrombosis following trauma: a prospective, randomized comparison of mechanical and pharmacologic prophylaxis. J Bone Joint Surg Am. 2006, 88, 261–266.

38. TESTROOTE, M., STIGTER, W., DE VISSER, DC. et al. Low molecular weight heparin for prevention of venous thromboembolism in patients with lower-leg immobilization. Cochrane Database Syst Rev. 2008, 8, CD006681.

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