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. Â 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) –Â 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. Â 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. Â 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.
References
- Schaible EV, Thal SC. Anticoagulation in patients with traumatic brain injury. Curr Opin Anesthesiol. 2013 Aug; 26:529–534.
- Brain Trauma Foundation; American Association of Neurological Surgeons; Congress of Neurological Surgeons; Joint Section on Neurotrauma and Critical Care, AANS/CNS, Bratton SL, Chestnut RM, Ghajar J, et al. Guidelines for the management of severe traumatic brain injury. V. Deep vein thrombosis prophylaxis. J Neurotrauma. 2007;24 Suppl 1:S32-6.
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