VTE Prophylaxis in TBI

A 32 year old male is admitted to your trauma ICU after a head on motor vehicle collision. He was intubated in the resuscitation unit for altered mental status and was found to have bilateral subdural hematomas as well as a traumatic subarachnoid hemorrhage.  At this point, the patient does not need an operation and the plan is to repeat the head CT at 6 and 24 hours to look for interval change.

Clinical question: At what point should you consider starting venous thromboembolic (VTE) prophylaxis in this patient?

Risk of VTE in patients with TBI

  • Independent of pharmacological thromboprophylaxis strategy, VTE rate increases after TBI to 25% compared to the natural population.
  • Severe head injury is in itself an independent risk factor for VTE.

Recommendations by the Brain Trauma Foundation (2007) – Level III Evidence

  • Graduated compression stockings or intermittent pneumatic compression stockings (IPC’s) are recommended unless LE injury precludes use until the patient is ambulatory.
  • Low molecular weight heparin (LMWH) or low dose unfractionated heparin (UFH) should be used in combination with mechanical prophylaxis.  However, there is an increased risk for expansion in ICH.
  • There is insufficient evidence to support recommendations regarding the preferred agent, dose, or timing of pharmacologic prophylaxis for DVT.

Current Evidence & Recommendations

  • Mechanical compression boots are generally superior to compression stockings, and still recommended first line for patients with isolated TBI.
  • Which medication: There is no definitive evidence that UFH or LMWH is superior in VTE prophylaxis in TBI.  Both treatments appear to adequately reduce the risk of VTE.
  • Timing of anticoagulation: Treatment with low-dose pharmacological thromboprophylaxis should be considered within 24-hours in low-risk patients.  Analysis of a 24-hour follow-up CT scan for progression of ICH appears to be the safest strategy to identify patients at low-risk of hemorrhage formation/progression.

 

About the Author

John Greenwood

Creator of the PressorDex & http://CCProject.com . Resuscitationist, Heart & Vascular ICU Intensivist. Focus in mechanical circulatory support & medical education #FOAMcc #FOAMed Twitter: @johngreenwoodmd Email: johncgreenwood@gmail.com

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