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Saleem MM, Usman A, Saleem A, Mudassar M. Post-traumatic pulmonary embolism in the setting of cough-variant asthma. Radiol Case Rep 2024; 19:6225-6229. [PMID: 39387036 PMCID: PMC11461929 DOI: 10.1016/j.radcr.2024.08.153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 08/28/2024] [Accepted: 08/29/2024] [Indexed: 10/12/2024] Open
Abstract
Post-traumatic pulmonary embolism (PE) poses diagnostic complexities, especially with underlying lung pathologies and delayed symptoms. We report a 43-year-old male who presented with cough, frothy sputum, and dyspnea following blunt chest trauma 2 weeks ago. Due to a history of asthma, an asthma exacerbation was suspected but he failed to respond to bronchodilator therapy. Doppler USG (ultrasonography) was negative for deep venous thrombi, however, elevated D-dimer levels prompted further investigation with computed tomography pulmonary angiography (CTPA), confirming the diagnosis of PE. Prompt initiation of anticoagulation and thrombolysis resulted in clinical improvement. This case underscores the need to rule out posttraumatic PE, irrespective of age, type of, or time since injury, and underlying lung disease, to ensure timely diagnosis and intervention.
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Affiliation(s)
| | - Aleena Usman
- King Edward Medical University, Lahore, Pakistan
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2
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Byrne JP, Schellenberg M. Venous thromboembolism chemoprophylaxis after severe polytrauma: timing and type of prophylaxis matter. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02651-3. [PMID: 39254696 DOI: 10.1007/s00068-024-02651-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Accepted: 08/14/2024] [Indexed: 09/11/2024]
Abstract
In this review, we provide recommendations as well as summarize available data on the optimal time to initiate venous thromboembolism chemoprophylaxis after severe trauma. A general approach to the severe polytrauma patient is provided as well as in-depth reviews of three high-risk injury subgroups: patients with traumatic brain injury, solid organ injury, and pelvic fractures.
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Affiliation(s)
- James P Byrne
- Division of Acute Care Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Morgan Schellenberg
- Division of Acute Care Surgery, University of Southern California, Los Angeles General Medical Center, Los Angeles, CA, USA.
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3
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Zhang K, Wang P, Huang W, Tang SH, Xue H, Wu H, Zhang Y, Rong Y, Dong SS, Chen JB, Zou Y, Tian D, Yang N, Liang Y, Liu C, Li D, Zhang K, Yang TL, Guo Y. Integrated landscape of plasma metabolism and proteome of patients with post-traumatic deep vein thrombosis. Nat Commun 2024; 15:7831. [PMID: 39244606 PMCID: PMC11380666 DOI: 10.1038/s41467-024-52262-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 09/02/2024] [Indexed: 09/09/2024] Open
Abstract
Deep vein thrombosis (DVT) is a leading cause of morbidity and mortality after trauma. Here, we integrate plasma metabolomics and proteomics to evaluate the metabolic alterations and their function in up to 680 individuals with and without DVT after trauma (pt-DVT). We identify 28 metabolites and 2 clinical parameter clusters associated with pt-DVT. Then, we develop a panel of 9 metabolites (hexadecanedioic acid, pyruvic acid, L-Carnitine, serotonin, PE(P-18:1(11Z)/18:2(9Z,12Z)), 3-Hydroxycapric acid, 5,6-DHET, 3-Methoxybenzenepropanoic acid and pentanenitrile) that can predict pt-DVT with high performance, which can be verified in an independent cohort. Furthermore, the integration analysis of metabolomics and proteomics data indicates that the upregulation of glycolysis/gluconeogenesis-TCA cycle may promote thrombosis by regulating ROS levels in red blood cells, suggesting that interfering with this process might be potential therapeutic strategies for pt-DVT. Together, our study comprehensively delineates the metabolic and hematological dysregulations for pt-DVT, and provides potential biomarkers for early detection.
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Affiliation(s)
- Kun Zhang
- Department of Trauma Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, P. R. China
- Key Laboratory of Biomedical Information Engineering of Ministry of Education, Biomedical Informatics & Genomics Center, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, Shaanxi, P. R. China
- Key Laboratory of Biology Multiomics and Diseases in Shaanxi Province Higher Education Institutions, Xi'an Jiaotong University, Xi'an, Shaanxi, P. R. China
| | - Pengfei Wang
- Department of Trauma Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, P. R. China
| | - Wei Huang
- Department of Trauma Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, P. R. China
- Key Laboratory of Biomedical Information Engineering of Ministry of Education, Biomedical Informatics & Genomics Center, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, Shaanxi, P. R. China
- Key Laboratory of Biology Multiomics and Diseases in Shaanxi Province Higher Education Institutions, Xi'an Jiaotong University, Xi'an, Shaanxi, P. R. China
| | - Shi-Hao Tang
- Key Laboratory of Biomedical Information Engineering of Ministry of Education, Biomedical Informatics & Genomics Center, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, Shaanxi, P. R. China
- Key Laboratory of Biology Multiomics and Diseases in Shaanxi Province Higher Education Institutions, Xi'an Jiaotong University, Xi'an, Shaanxi, P. R. China
| | - Hanzhong Xue
- Department of Trauma Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, P. R. China
| | - Hao Wu
- Key Laboratory of Biomedical Information Engineering of Ministry of Education, Biomedical Informatics & Genomics Center, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, Shaanxi, P. R. China
- Key Laboratory of Biology Multiomics and Diseases in Shaanxi Province Higher Education Institutions, Xi'an Jiaotong University, Xi'an, Shaanxi, P. R. China
| | - Ying Zhang
- Instrument Analysis Center, Xi'an Jiaotong University, Xi'an, Shaanxi, P. R. China
| | - Yu Rong
- Key Laboratory of Biomedical Information Engineering of Ministry of Education, Biomedical Informatics & Genomics Center, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, Shaanxi, P. R. China
- Key Laboratory of Biology Multiomics and Diseases in Shaanxi Province Higher Education Institutions, Xi'an Jiaotong University, Xi'an, Shaanxi, P. R. China
| | - Shan-Shan Dong
- Key Laboratory of Biomedical Information Engineering of Ministry of Education, Biomedical Informatics & Genomics Center, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, Shaanxi, P. R. China
- Key Laboratory of Biology Multiomics and Diseases in Shaanxi Province Higher Education Institutions, Xi'an Jiaotong University, Xi'an, Shaanxi, P. R. China
| | - Jia-Bin Chen
- Department of Trauma Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, P. R. China
| | - Yan Zou
- Key Laboratory of Biomedical Information Engineering of Ministry of Education, Biomedical Informatics & Genomics Center, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, Shaanxi, P. R. China
- Key Laboratory of Biology Multiomics and Diseases in Shaanxi Province Higher Education Institutions, Xi'an Jiaotong University, Xi'an, Shaanxi, P. R. China
| | - Ding Tian
- Department of Trauma Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, P. R. China
| | - Na Yang
- Department of Trauma Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, P. R. China
| | - Yifan Liang
- Department of Trauma Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, P. R. China
| | - Chungui Liu
- Department of Trauma Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, P. R. China
| | - Dongyang Li
- Department of Trauma Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, P. R. China
| | - Kun Zhang
- Department of Trauma Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, P. R. China.
| | - Tie-Lin Yang
- Key Laboratory of Biomedical Information Engineering of Ministry of Education, Biomedical Informatics & Genomics Center, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, Shaanxi, P. R. China.
- Key Laboratory of Biology Multiomics and Diseases in Shaanxi Province Higher Education Institutions, Xi'an Jiaotong University, Xi'an, Shaanxi, P. R. China.
| | - Yan Guo
- Department of Trauma Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, P. R. China.
- Key Laboratory of Biomedical Information Engineering of Ministry of Education, Biomedical Informatics & Genomics Center, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, Shaanxi, P. R. China.
- Key Laboratory of Biology Multiomics and Diseases in Shaanxi Province Higher Education Institutions, Xi'an Jiaotong University, Xi'an, Shaanxi, P. R. China.
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4
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Grigorian A, Schubl S, Swentek L, Barrios C, Lekawa M, Russell D, Nahmias J. Similar rate of venous thromboembolism (VTE) and failure of non-operative management for early versus delayed VTE chemoprophylaxis in adolescent blunt solid organ injuries: a propensity-matched analysis. Eur J Trauma Emerg Surg 2024; 50:1391-1398. [PMID: 38194094 PMCID: PMC11458733 DOI: 10.1007/s00068-023-02440-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 12/28/2023] [Indexed: 01/10/2024]
Abstract
BACKGROUND Early initiation of venous thromboembolism (VTE) chemoprophylaxis in adults with blunt solid organ injury (BSOI) has been demonstrated to be safe but this is controversial in adolescents. We hypothesized that adolescent patients with BSOI undergoing non-operative management (NOM) and receiving early VTE chemoprophylaxis (eVTEP) (≤ 48 h) have a decreased rate of VTE and similar rate of failure of NOM, compared to similarly matched adolescents receiving delayed VTE chemoprophylaxis (dVTEP) (> 48 h). METHODS The 2017-2019 Trauma Quality Improvement Program database was queried for adolescents (12-17 years of age) with BSOI (liver, kidney, and/or spleen) undergoing NOM. We compared eVTEP versus dVTEP using a 1:1 propensity score model, matching for age, comorbidities, BSOI grade, injury severity score, hypotension on arrival, and need for transfusions. We performed subset analyses in patients with isolated spleen, kidney, and liver injury. RESULTS From 1022 cases, 417 (40.8%) adolescents received eVTEP. After matching, there was no difference in matched variables (all p > 0.05). Both groups had a similar rate of VTE (dVTEP 0.6% vs. eVTEP 1.7%, p = 0.16), mortality (dVTEP 0.3% vs. eVTEP 0%, p = 0.32), and failure of NOM (eVTEP 6.7% vs. dVTEP 7.3%, p = 0.77). These findings remained true in all subset analyses of isolated solid organ injury (all p > 0.05). CONCLUSIONS The rate of VTE with adolescent BSOI is exceedingly rare. Early VTE chemoprophylaxis in adolescent BSOI does not increase the rate of failing NOM. However, unlike adult trauma patients, adolescent patients with BSOI receiving eVTEP had a similar rate of VTE and death, compared to adolescents receiving dVTEP.
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Affiliation(s)
- Areg Grigorian
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 3800 Chapman Ave, Suite 6200, Orange, CA, 92868-3298, USA.
| | - Sebastian Schubl
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 3800 Chapman Ave, Suite 6200, Orange, CA, 92868-3298, USA
| | - Lourdes Swentek
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 3800 Chapman Ave, Suite 6200, Orange, CA, 92868-3298, USA
| | - Cristobal Barrios
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 3800 Chapman Ave, Suite 6200, Orange, CA, 92868-3298, USA
| | - Michael Lekawa
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 3800 Chapman Ave, Suite 6200, Orange, CA, 92868-3298, USA
| | - Dylan Russell
- Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Jeffry Nahmias
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 3800 Chapman Ave, Suite 6200, Orange, CA, 92868-3298, USA
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Argandykov D, Lagazzi E, Proaño-Zamudio JA, Rafaqat W, Abiad M, DeWane M, Paranjape CN, Kaafarani HMA, Velmahos GC, Hwabejire JO. Traumatic lower extremity amputation as a risk factor for venous thromboembolism. Am J Surg 2024; 232:95-101. [PMID: 38368239 DOI: 10.1016/j.amjsurg.2024.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Revised: 01/07/2024] [Accepted: 01/09/2024] [Indexed: 02/19/2024]
Abstract
BACKGROUND This study aimed to evaluate whether lower extremity (LE) amputation among civilian casualties is a risk factor for venous thromboembolism. METHODS All patients with severe LE injuries (AIS ≥3) derived from the ACS-TQIP (2013-2020) were divided into those who underwent trauma-associated amputation and those with limb salvage. Propensity score matching was used to mitigate selection bias and confounding and compare the rates of pulmonary embolism (PE) and deep vein thrombosis (DVT). RESULTS A total of 145,667 patients with severe LE injuries were included, with 3443 patients requiring LE amputation. After successful matching, patients sustaining LE amputation still experienced significantly higher rates of PE (4.2% vs. 2.5%, p < 0.001) and DVT (6.5% vs. 3.4%, p < 0.001). A sensitivity analysis examining patients with isolated major LE trauma similarly showed a higher rate of thromboembolic complications, including higher incidences of PE (3.2% vs. 2.0%, p = 0.015) and DVT (4.7% vs. 2.6%, p < 0.001). CONCLUSIONS In this nationwide analysis, traumatic lower extremity amputation is associated with a significantly higher risk of VTE events, including PE and DVT.
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Affiliation(s)
- Dias Argandykov
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA. https://twitter.com/argandykov
| | - Emanuele Lagazzi
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA. https://twitter.com/EmanueleLagazzi
| | - Jefferson A Proaño-Zamudio
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA. https://twitter.com/eljefe_md
| | - Wardah Rafaqat
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - May Abiad
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Michael DeWane
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA. https://twitter.com/michaeldewane
| | - Charudutt N Paranjape
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA. https://twitter.com/CharuParanjape
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA. https://twitter.com/hayfarani
| | - George C Velmahos
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - John O Hwabejire
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA.
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6
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Van Gent JM, Clements TW, Lubkin DE, Kaminski CW, Bates JK, Sandoval M, Puzio TJ, Cotton BA. 'Door-to-prophylaxis' as a novel quality improvement metric in prevention of venous thromboembolism following traumatic injury. Trauma Surg Acute Care Open 2024; 9:e001297. [PMID: 38666014 PMCID: PMC11043729 DOI: 10.1136/tsaco-2023-001297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 04/04/2024] [Indexed: 04/28/2024] Open
Abstract
Objective Venous thromboembolism (VTE) risk reduction strategies include early initiation of chemoprophylaxis, reducing missed doses, weight-based dosing and dose adjustment using anti-Xa levels. We hypothesized that time to initiation of chemoprophylaxis would be the strongest modifiable risk for VTE, even after adjusting for competing risk factors. Methods A prospectively maintained trauma registry was queried for patients admitted July 2017-October 2021 who were 18 years and older and received emergency release blood products. Patients with deep vein thrombosis or pulmonary embolism (VTE) were compared to those without (no VTE). Door-to-prophylaxis was defined as time from hospital arrival to first dose of VTE chemoprophylaxis (hours). Univariate and multivariate analyses were then performed between the two groups. Results 2047 patients met inclusion (106 VTE, 1941 no VTE). There were no differences in baseline or demographic data. VTE patients had higher injury severity score (29 vs 24), more evidence of shock by arrival lactate (4.6 vs 3.9) and received more post-ED transfusions (8 vs 2 units); all p<0.05. While there was no difference in need for enoxaparin dose adjustment or missed doses, door-to-prophylaxis time was longer in the VTE group (35 vs 25 hours; p=0.009). On multivariate logistic regression analysis, every hour delay from time of arrival increased likelihood of VTE by 1.5% (OR 1.015, 95% CI 1.004 to 1.023, p=0.004). Conclusion The current retrospective study of severely injured patients with trauma who required emergency release blood products found that increased door-to-prophylaxis time was significantly associated with an increased likelihood for VTE. Chemoprophylaxis initiation is one of the few modifiable risk factors available to combat VTE, therefore early initiation is paramount. Similar to door-to-balloon time in treating myocardial infarction and door-to-tPA time in stroke, "door-to-prophylaxis time" should be considered as a hospital metric for prevention of VTE in trauma. Level of evidence Level III, retrospective study with up to two negative criteria.
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Affiliation(s)
- Jan-Michael Van Gent
- Division of Trauma and Surgical Critical Care, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Thomas W Clements
- Division of Trauma and Surgical Critical Care, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - David E Lubkin
- Division of Trauma and Surgical Critical Care, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Carter W Kaminski
- Division of Trauma and Surgical Critical Care, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Jonathan K Bates
- The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Mariela Sandoval
- The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Thaddeus J Puzio
- Division of Trauma and Surgical Critical Care, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Bryan A Cotton
- Division of Trauma and Surgical Critical Care, The University of Texas Health Science Center at Houston, Houston, Texas, USA
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Lombardo S, McCrum M, Knudson MM, Moore EE, Kornblith L, Brakenridge S, Bruns B, Cipolle MD, Costantini TW, Crookes B, Haut ER, Kerwin AJ, Kiraly LN, Knowlton LM, Martin MJ, McNutt MK, Milia DJ, Mohr A, Rogers F, Scalea T, Sixta S, Spain D, Wade CE, Velmahos GC, Nirula R, Nunez J. Weight-based enoxaparin thromboprophylaxis in young trauma patients: analysis of the CLOTT-1 registry. Trauma Surg Acute Care Open 2024; 9:e001230. [PMID: 38420604 PMCID: PMC10900334 DOI: 10.1136/tsaco-2023-001230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 11/26/2023] [Indexed: 03/02/2024] Open
Abstract
Introduction Optimal venous thromboembolism (VTE) enoxaparin prophylaxis dosing remains elusive. Weight-based (WB) dosing safely increases anti-factor Xa levels without the need for routine monitoring but it is unclear if it leads to lower VTE risk. We hypothesized that WB dosing would decrease VTE risk compared with standard fixed dosing (SFD). Methods Patients from the prospective, observational CLOTT-1 registry receiving prophylactic enoxaparin (n=5539) were categorized as WB (0.45-0.55 mg/kg two times per day) or SFD (30 mg two times per day, 40 mg once a day). Multivariate logistic regression was used to generate a predicted probability of VTE for WB and SFD patients. Results Of 4360 patients analyzed, 1065 (24.4%) were WB and 3295 (75.6%) were SFD. WB patients were younger, female, more severely injured, and underwent major operation or major venous repair at a higher rate than individuals in the SFD group. Obesity was more common among the SFD group. Unadjusted VTE rates were comparable (WB 3.1% vs. SFD 3.9%; p=0.221). Early prophylaxis was associated with lower VTE rate (1.4% vs. 5.0%; p=0.001) and deep vein thrombosis (0.9% vs. 4.4%; p<0.001), but not pulmonary embolism (0.7% vs. 1.4%; p=0.259). After adjustment, VTE incidence did not differ by dosing strategy (adjusted OR (aOR) 0.75, 95% CI 0.38 to 1.48); however, early administration was associated with a significant reduction in VTE (aOR 0.47, 95% CI 0.30 to 0.74). Conclusion In young trauma patients, WB prophylaxis is not associated with reduced VTE rate when compared with SFD. The timing of the initiation of chemoprophylaxis may be more important than the dosing strategy. Further studies need to evaluate these findings across a wider age and comorbidity spectrum. Level of evidence Level IV, therapeutic/care management.
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Affiliation(s)
| | - Marta McCrum
- Surgery, University of Utah, Salt Lake City, Utah, USA
| | - M Margaret Knudson
- Surgery, University of California San Francisco, San Francisco, California, USA
| | | | - Lucy Kornblith
- Surgery, University of California San Francisco, San Francisco, California, USA
| | - Scott Brakenridge
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Brandon Bruns
- Department of Surgery, UT Southwestern Medical School, Dallas, Texas, USA
| | - Mark D Cipolle
- Lehigh Valley Health Network, Allentown, Pennsylvania, USA
| | - Todd W Costantini
- Surgery, University of California San Francisco, San Francisco, California, USA
| | - Bruce Crookes
- Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Elliott R Haut
- Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Andrew J Kerwin
- Surgery, University of Florida College of Medicine–Jacksonville, Jacksonville, Florida, USA
| | | | | | - Matthew J Martin
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, Los Angeles, California, USA
| | - Michelle K McNutt
- Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - David J Milia
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Alicia Mohr
- Surgery, University of Florida College of Medicine–Jacksonville, Jacksonville, Florida, USA
| | | | - Thomas Scalea
- University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Sherry Sixta
- St Anthony Hospital & Medical Campus, Lakewood, Colorado, USA
| | - David Spain
- Surgery, Stanford University, Stanford, California, USA
| | - Charles E Wade
- Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | | | - Ram Nirula
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Jade Nunez
- Surgery, University of Utah, Salt Lake City, Utah, USA
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8
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Zhang D, Yang Y, Yi Y, Wang D, Jiang L, Huang H, Jin L, Meng H, Xia F, Guo G. Incidence and influence factors of venous thromboembolism in traumatic rib fracture patient: a multicenter study. J Orthop Surg Res 2024; 19:152. [PMID: 38395963 PMCID: PMC10893601 DOI: 10.1186/s13018-024-04622-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 02/11/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND This study aimed to determine the incidence and influencing factors of venous thromboembolism (VTE) in patients with traumatic rib fractures. METHODS The retrospective study analyzed medical records of patients with traumatic rib fractures from 33 hospitals. RESULTS The overall incidence of VTE in hospitalized patients with traumatic rib fractures was 8.1%. Patients with isolated traumatic rib fractures had a significantly lower incidence of VTE (4.4%) compared to patients with rib fractures combined with other injuries (12.0%). Multivariate analysis identified the number of rib fractures as an independent risk factor for thrombosis. Surgical stabilization of isolated rib fractures involving three or more ribs was associated with a lower VTE incidence compared to conservative treatment. CONCLUSIONS Patients with rib fractures have a higher incidence of VTE, positively correlated with the number of rib fractures. However, the occurrence of thrombosis is relatively low in isolated rib fractures. Targeted thromboprophylaxis strategies should be implemented for these patients, and surgical stabilization of rib fractures may be beneficial in reducing the risk of VTE.
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Affiliation(s)
- Dongsheng Zhang
- Department of Cardiothoracic Surgery, Shijiazhuang Third Hospital, Shijiazhuang, 050000, Hebei, China.
| | - Yi Yang
- Department of Thoracic Surgery, Shanghai Jiao Tong University School of Medicine Affiliated Sixth People's Hospital, Shanghai, 200233, China.
| | - Yunfeng Yi
- Department of Cardiothoracic Surgery, Dongnan Hospital of Xiamen University, School of Medicine, Xiamen University, Zhangzhou, 363000, Fujian, China
| | - Dongbin Wang
- Department of Cardiothoracic Surgery, Tianjin Hospital Affiliated to Tianjin University, Tianjin, 300211, China
| | - Lei Jiang
- The Second Department of Surgery (Thoracic and Breast Department), Foshan Hospital of Traditional Chinese Medicine, Foshan, 528000, Guangdong, China
| | - Hai Huang
- Department of Thoracic Surgery, Fuzhou Second Hospital, Fuzhou, 350007, Fujian, China
| | - Longyu Jin
- Department of Thoracic Surgery, The Third Xiangya Hospital of Central South University, Changsha, 410000, Hunan, China
| | - Hui Meng
- Department of Thoracic Surgery, The Fifth Affiliated Hospital of Zunyi Medical University, Zhuhai, 519100, Guangdong, China
| | - Fei Xia
- Department of Emergency Surgery, The Affiliated Hospital of Guizhou Medical University, Guiyang, 550001, Guizhou, China
| | - Guangwei Guo
- Department of Cardiothoracic Surgery, Second Hospital of Shanxi Medical University, Taiyuan, 030000, Shanxi, China
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9
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Huang J, Kong J, Zhang X, Liu C, Zhao Z, Liu L, Xiao L, Han X. Risk factors for inferior vena cava filter thrombosis in traumatic fracture patients with deep venous thrombosis of lower extremity: A single-center experience. Vascular 2024; 32:182-189. [PMID: 36171637 DOI: 10.1177/17085381221128056] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To explore the risk factors for inferior vena cava filter (IVCF) thrombus in orthopedic trauma patients who underwent filter placement with ongoing anticoagulation in clinical settings. METHODS We retrospectively analyzed clinical data from fracture patients with lower extremity acute deep vein thrombosis (DVT) implanted with an IVCF admitted to Tianjin Hospital from January 2017 to December 2019. Potential risk factors, such as gender, age, diabetes, hypertension, fracture sites, thrombus location, free-floating thrombus, filter type, Injury Severity Score (ISS), and postoperative D-dimer values, were analyzed by the Chi-square test, t-test, logistic regression, and receiver operating characteristic (ROC) curve analysis. RESULTS A total of 662 patients were included in our study, and filter-related thrombosis was present in 67 (10.1%) patients. No significant differences were observed in age, gender, hypertension, diabetes, fracture site, free-floating thrombus, filter type, indwelling time, and postoperative D-dimer level. Thrombus location and ISS were significantly different (p < 0.05). Popliteal DVT (P-DVT) (odds ratio [OR]: 2.130, p = 0.018) and ISS (OR: 1.135, p = 0.000) were associated with filter thrombus. Patients with P-DVT were prone to a small filter thrombus (OR: 3.231, p = 0.037). From the ROC curve analysis, the diagnostic value of ISS was 24.5 and 26.5 for patients with filter and massive filter thrombus, respectively. CONCLUSION Thrombus location and ISS were independent risk factors for filter thrombus in patients with traumatic fractures. P-DVT had a higher potential to result in a small filter thrombus and an ISS value >26.5, which was considered a significant massive filter thrombus predictor.
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Affiliation(s)
| | | | | | | | | | | | - Lei Xiao
- Tianjin Hospital, Tianjin, China
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10
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Barrett CD, Moore HB, Moore EE, Chandler J, Sauaia A. Combination of aspirin and rosuvastatin for reduction of venous thromboembolism in severely injured patients: a double-blind, placebo-controlled, pragmatic randomized phase II clinical trial (The STAT Trial). Blood Coagul Fibrinolysis 2023; 34:499-507. [PMID: 37942744 PMCID: PMC10655842 DOI: 10.1097/mbc.0000000000001258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2023]
Abstract
INTRODUCTION Venous thromboembolism (VTE) remains a significant source of postinjury morbidity and mortality. Beta-hydroxy beta-methylglutaryl-CoA (HMG-CoA) reductase inhibitors (rosuvastatin) significantly reduced pathologic clotting events in healthy populations in a prior trial. Furthermore, acetylsalicylic acid (ASA) has been shown to be noninferior to prophylactic heparinoids for VTE prevention following orthopedic surgery. We hypothesized that a combination of rosuvastatin/ASA, in addition to standard VTE chemoprophylaxis, would reduce VTE in critically ill trauma patients. METHODS This was a double-blind, placebo-controlled, randomized trial, evaluating VTE rates in two groups: ASA + statin (Experimental) and identical placebos (Control). Injured adults, 18-65 years old, admitted to the surgical intensive care unit without contraindications for VTE prophylaxis were eligible. Upon initiation of routine VTE chemoprophylaxis (i.e. heparin/heparin-derivatives), they were randomized to the Experimental or Control group. VTE was the primary outcome. RESULTS Of 112 potentially eligible patients, 33% (n = 37, median new injury severity scale = 27) were successfully randomized, of whom 11% had VTEs. The Experimental group had no VTEs, while the Control group had 6 VTEs (4 PEs and 2 DVTs) in 4 (22%) patients (P = 0.046). The Experimental treatment was not associated with any serious adverse events. Due to the COVID-19 pandemic, the study was interrupted at the second interim analysis at <10% of the planned enrollment, with significance declared at P < 0.012 at that stage. DISCUSSION The combination of ASA and rosuvastatin with standard VTE prophylaxis showed a favorable trend toward reducing VTEs with no serious adverse events. An appropriately powered phase III multicenter trial is needed to further investigate this therapeutic approach. LEVEL OF EVIDENCE Level II, Therapeutic.
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Affiliation(s)
| | | | - Ernest E Moore
- University of Colorado Denver, Department of Surgery
- Shock and Trauma Center at Denver Health, Denver, Colorado
| | | | - Angela Sauaia
- School of Public Health, University of Colorado Denver, Aurora, Colorado, USA
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11
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Lammers D, Scerbo M, Davidson A, Pommerening M, Tomasek J, Wade CE, Cardenas J, Jansen J, Miller CC, Holcomb JB. Addition of aspirin to venous thromboembolism chemoprophylaxis safely decreases venous thromboembolism rates in trauma patients. Trauma Surg Acute Care Open 2023; 8:e001140. [PMID: 37936904 PMCID: PMC10626753 DOI: 10.1136/tsaco-2023-001140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 10/03/2023] [Indexed: 11/09/2023] Open
Abstract
Background Trauma patients exhibit a multifactorial hypercoagulable state and have increased risk of venous thromboembolism (VTE). Despite early and aggressive chemoprophylaxis (CP) with various heparin compounds ("standard" CP; sCP), VTE rates remain high. In high-quality studies, aspirin has been shown to decrease VTE in postoperative elective surgical and orthopedic trauma patients. We hypothesized that inhibiting platelet function with aspirin as an adjunct to sCP would reduce the risk of VTE in trauma patients. Methods We performed a retrospective observational study of prospectively collected data from all adult patients admitted to an American College of Surgeons Level I Trauma center from January 2012 to June 2015 to evaluate the addition of aspirin (sCP+A) to sCP regimens for VTE mitigation. Cox proportional hazard models were used to assess the potential benefit of adjunctive aspirin for symptomatic VTE incidence. Results 10,532 patients, median age 44 (IQR 28 to 62), 68% male, 89% blunt mechanism of injury, with a median Injury Severity Score (ISS) of 12 (IQR 9 to 19), were included in the study. 8646 (82%) of patients received only sCP, whereas 1886 (18%) patients received sCP+A. The sCP+A cohort displayed a higher median ISS compared with sCP (13 vs 11; p<0.01). The overall median time of sCP initiation was hospital day 1 (IQR 0.8 to 2) and the median day for aspirin initiation was hospital day 3 (IQR 1 to 6) for the sCP+A cohort. 353 patients (3.4%) developed symptomatic VTE. Aspirin administration was independently associated with a decreased relative hazard of VTE (HR 0.57; 95% CI 0.36 to 0.88; p=0.01). There were no increased bleeding or wound complications associated with sCP+A (point estimate 1.23, 95% CI 0.68 to 2.2, p=0.50). Conclusion In this large trauma cohort, adjunctive aspirin was independently associated with a significant reduction in VTE and may represent a potential strategy to safely mitigate VTE risk in trauma patients. Further prospective studies evaluating the addition of aspirin to heparinoid-based VTE chemoprophylaxis regimens should be sought. Level of evidence Level III/therapeutic.
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Affiliation(s)
- Daniel Lammers
- Division of Trauma and Acute Care Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Michelle Scerbo
- Surgery/Center for Injury Research, The University of Texas Health Science Center McGovern School of Medicine, Houston, Texas, USA
| | - Annamaria Davidson
- Surgery/Center for Injury Research, The University of Texas Health Science Center McGovern School of Medicine, Houston, Texas, USA
| | - Matthew Pommerening
- Surgery/Center for Injury Research, The University of Texas Health Science Center McGovern School of Medicine, Houston, Texas, USA
| | - Jeffrey Tomasek
- Surgery/Center for Injury Research, The University of Texas Health Science Center McGovern School of Medicine, Houston, Texas, USA
| | - Charles E Wade
- Surgery/Center for Injury Research, The University of Texas Health Science Center McGovern School of Medicine, Houston, Texas, USA
| | - Jessica Cardenas
- Surgery/Center for Injury Research, The University of Texas Health Science Center McGovern School of Medicine, Houston, Texas, USA
| | - Jan Jansen
- Division of Trauma and Acute Care Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Charles C Miller
- Surgery/Center for Injury Research, The University of Texas Health Science Center McGovern School of Medicine, Houston, Texas, USA
| | - John B Holcomb
- Division of Trauma and Acute Care Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Kalkwarf KJ, Yang Y, Mora S, Wolf DA, Robertson RD, Holcomb JB, Drake SA. The silent killer: Previously undetected pulmonary emboli that result in death after discharge. Injury 2023; 54:111016. [PMID: 37717493 DOI: 10.1016/j.injury.2023.111016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 08/19/2023] [Accepted: 09/02/2023] [Indexed: 09/19/2023]
Abstract
INTRODUCTION Pulmonary embolism (PE) is a recognized cause of death in hospitalized trauma patients, yet less is known about PE after discharge. PATIENTS & METHODS All post-discharge, autopsy-demonstrated, fatal PE resulting from trauma within a large US county over six years were analyzed. Counts, percentages, mean values, SD, and IQR were calculated for all variables. RESULTS 1848 trauma deaths were reviewed, of which 85% had an autopsy. Eighty-five patients died from PE after discharge from their initial injury. 53% were initially treated at non-trauma centers, and 9% did not seek medical assistance. 75% were injured by falling, and most injuries occurred in the lower extremities. 86% had an ISS <16, but 87% needed assistance or were bed-bound after injury, despite 75% having no mobility limitations before the injury. 53% died within one month of injury, and 91% within the first year. Before death, only 11% were prescribed chemical thromboprophylaxis or an antiplatelet agent, and only 8% were diagnosed with venous thromboembolism before death. CONCLUSIONS Fatal PE after discharge typically occurred following activity-limiting lower extremity injuries with an ISS<16.
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Affiliation(s)
- Kyle J Kalkwarf
- The University of Arkansas for Medical Sciences, Department of General Surgery, Division of Trauma and Acute Care Surgery, 4301W. Markham St. Slot 520-1, Little Rock, Arkansas 72205, United States.
| | - Yijiong Yang
- The University of Texas Health Science Center at Houston, 7000 Fannin St, Houston, Texas 77030, United States; Florida State University College of Nursing, Vivian M. Duxbury Hall, 98 Varsity Way, Office 412, Tallahassee, Florida, 32306-4310, United States
| | - Stephen Mora
- Harris Health System, 1504 Taub Loop, Houston, Texas 77030, United States
| | - Dwayne A Wolf
- Harris County Institute of Forensic Sciences, 1861 Old Spanish Trail, Houston, Texas 77030, United States; Lucas County Coroner's Office, 2595 Arlington Avenue, Toledo, Ohio 43614, United States
| | - Ronald D Robertson
- The University of Arkansas for Medical Sciences, Department of General Surgery, Division of Trauma and Acute Care Surgery, 4301W. Markham St. Slot 520-1, Little Rock, Arkansas 72205, United States
| | - John B Holcomb
- The University of Alabama at Birmingham, Department of Surgery, Center for Injury Science, 619 19th St S, Birmingham, Alabama 35249, United States
| | - Stacy A Drake
- Texas A&M College of Nursing, 2121W. Holcombe Blvd, Houston, Texas 77030, United States; Bowling Green State University, College of Health and Human Services, School of Nursing, 332 Central Hall, Bowling Green, Ohio 43403, United States
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13
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Wu YT, Chien CY, Matsushima K, Schellenberg M, Inaba K, Moore EE, Sauaia A, Knudson MM, Martin MJ. Early venous thromboembolism prophylaxis in patients with trauma intracranial hemorrhage: Analysis of the prospective multicenter Consortium of Leaders in Traumatic Thromboembolism study. J Trauma Acute Care Surg 2023; 95:649-656. [PMID: 37314427 DOI: 10.1097/ta.0000000000004007] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND The optimal time to initiate venous thromboembolism prophylaxis (VTEp) for patients with intracranial hemorrhage (ICH) is controversial and must balance the risks of VTE with potential progression of ICH. We sought to evaluate the efficacy and safety of early VTEp initiation after traumatic ICH. METHODS This is a secondary analysis of the prospective multicenter Consortium of Leaders in the Study of Thromboembolism study. Patients with head Abbreviated Injury Scale score of > 2 and with immediate VTEp held because of ICH were included. Patients were divided into VTEp ≤ or >48 hours and compared. Outcome variables included overall VTE, deep vein thrombosis (DVT), pulmonary embolism, progression of intracranial hemorrhage (pICH), or other bleeding events. Univariate and multivariate logistic regressions were performed. RESULTS There were 881 patients in total; 378 (43%) started VTEp ≤48 hours (early). Patients starting VTEp >48 hours (late) had higher VTE (12.4% vs. 7.2%, p = 0.01) and DVT (11.0% vs. 6.1%, p = 0.01) rates than the early group. The incidence of pulmonary embolism (2.1% vs. 2.2%, p = 0.94), pICH (1.9% vs. 1.8%, p = 0.95), or any other bleeding event (1.9% vs. 3.0%, p = 0.28) was equivalent between early and late VTEp groups. On multivariate logistic regression analysis, VTEp >48 hours (odds ratio [OR], 1.86), ventilator days >3 (OR, 2.00), and risk assessment profile score of ≥5 (OR, 6.70) were independent risk factors for VTE (all p < 0.05), while VTEp with enoxaparin was associated with decreased VTE (OR, 0.54, p < 0.05). Importantly, VTEp ≤48 hours was not associated with pICH (OR, 0.75) or risk of other bleeding events (OR, 1.28) (both p = NS). CONCLUSION Early initiation of VTEp (≤48 hours) for patients with ICH was associated with decreased VTE/DVT rates without increased risk of pICH or other significant bleeding events. Enoxaparin is superior to unfractionated heparin as VTE prophylaxis in patients with severe TBI. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Yu-Tung Wu
- From the Division of Trauma, Emergency Surgery, and Surgical Critical Care (Y.-T.W., C.-Y.C., K.M., M.S., K.I., M.J.M.), LAC+USC Medical Center, University of Southern California, Los Angeles, California; Department of Trauma and Emergency Surgery (Y.-T.W.), Chang Gung Memorial Hospital, Linkou; Department of General Surgery (C.-Y.C.), Chang Gung Memorial Hospital, Keelung, Taiwan; Department of Surgery (E.E.M.), Ernest E Moore Shock Trauma Center at Denver Health Center; School of Public Health (A.S.), University of Colorado, Denver, Colorado; and Department of Surgery (M.M.K.), University of California San Francisco, San Francisco, California
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14
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Knowlton LM, Arnow K, Trickey AW, Sauaia A, Knudson MM. Does tranexamic acid increase venous thromboembolism risk among trauma patients? A prospective multicenter analysis across 17 level I trauma centers. Injury 2023; 54:111008. [PMID: 37669883 DOI: 10.1016/j.injury.2023.111008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 08/09/2023] [Accepted: 08/21/2023] [Indexed: 09/07/2023]
Abstract
IMPORTANCE The early use of tranexamic acid (TXA) has demonstrated benefit among some trauma patients in hemorrhagic shock. The association between TXA administration and thromboembolic events (including deep vein thrombosis (DVT), pulmonary embolism (PE) and pulmonary thrombosis (PT)) remains unclear. We aimed to characterize the risk of venous thromboembolism (VTE) subtypes among trauma patients receiving TXA and to determine whether TXA is associated with VTE risk and mortality. METHODS We analyzed a prospective, observational, multicenter cohort data from the Consortium of Leaders in the Study of Traumatic Thromboembolism (CLOTT) study group. The study was conducted across 17 US level I trauma centers between January 1, 2018, and December 31,2020. We studied trauma patients ages 18-40 years, admitted for at least 48 h with a minimum of 1 VTE risk factor and followed until hospital discharge or 30 days. We compared TXA recipients to non-recipients for VTE and mortality using inverse probability weighted Cox models. The primary outcome was the presence of documented venous thromboembolism (VTE). The secondary outcome was mortality. VTE was defined as DVT, PE, or PT. RESULTS Among the 7,331 trauma patients analyzed, 466 (6.4%) received TXA. Patients in the TXA group were more severely injured than patients in the non-TXA group (ISS 16+: 69.1% vs. 48.5%, p < 0.001) and a higher percentage underwent a major surgical procedure (85.8% vs. 73.6%, p < 0.001). Among TXA recipients, 12.5% developed VTE (1.3% PT, 2.4% PE, 8.8% DVT) with 5.6% mortality. In the non-TXA group, 4.6% developed VTE (1.1% PT, 0.5% PE, 3.0% DVT) with 1.7% mortality. In analyses adjusting for patient demographic and clinical characteristics, TXA administration was not significantly associated with VTE (aHR 1.00, 95%CI: 0.69-1.46, p = 0.99) but was significantly associated with increased mortality (aHR 2.01, 95%CI: 1.46-2.77, p < 0.001). CONCLUSION TXA was not clearly identified as an independent risk factor for VTE in adjusted analyses, but the risk of VTE among trauma patients receiving TXA remains high (12.5%). This supports the judicious use of TXA in resuscitation, with consideration of early initiation of DVT prophylaxis in this high-risk group.
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Affiliation(s)
- Lisa Marie Knowlton
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, United States; Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), United States.
| | - Katherine Arnow
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), United States
| | - Amber W Trickey
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), United States
| | - Angela Sauaia
- School of Public Health and Department of Surgery, University of Colorado Denver, Aurora, CO, United States
| | - M Margaret Knudson
- Department of Surgery, University of California San Francisco, San Francisco, CA, United States
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15
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Feng L, Xie Z, Zhou X, Hou C, Liang Z, Lu H, Liu L, Zhang D. Diagnostic value of D-dimer for lower extremity deep venous thrombosis caused by rib fracture: a retrospective study. J Orthop Surg Res 2023; 18:515. [PMID: 37475021 PMCID: PMC10357766 DOI: 10.1186/s13018-023-03997-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 07/10/2023] [Indexed: 07/22/2023] Open
Abstract
OBJECTIVE This study aimed to investigate the role of D-dimer in the diagnosis of lower extremity deep venous thrombosis (DVT) in patients with rib fractures. METHOD Retrospective analysis was conducted on the clinical data of 499 patients with rib fractures who were admitted to the Third Hospital of Shijiazhuang between October 2020 and September 2021. These patients were divided into the DVT and the non-DVT groups. D-dimer levels were compared between the two groups at 24, 48, and 72 h after the injury. Receiver operating characteristic curves were utilized to evaluate the diagnostic efficacy of dynamically monitoring changes in D-dimer for DVT. RESULTS The D-dimer levels in the DVT group were significantly higher than those in the non-DVT group at 24, 48, and 72 h after the injury. The area under the curve values for predicting DVT based on D-dimer level at 24, 48, and 72 h after injury in patients with rib fractures were 0.788, 0.605, and 0.568, respectively. CONCLUSION Detecting D-dimer levels 24 h after the injury can enhance diagnostic efficacy and sensitivity for DVT, thereby reducing the rate of missed diagnoses, which is of great clinical value.
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Affiliation(s)
- Lei Feng
- Department of Cardiothoracic Surgery, The Third Hospital of Shijiazhuang, Shijiazhuang, 050011, Hebei, China
| | - Zexin Xie
- Department of Cardiothoracic Surgery, The Third Hospital of Shijiazhuang, Shijiazhuang, 050011, Hebei, China
| | - Xuetao Zhou
- Department of Cardiothoracic Surgery, The Third Hospital of Shijiazhuang, Shijiazhuang, 050011, Hebei, China
| | - Chunjuan Hou
- Department of Cardiothoracic Surgery, The Third Hospital of Shijiazhuang, Shijiazhuang, 050011, Hebei, China
| | - Zheng Liang
- Department of Cardiothoracic Surgery, The Third Hospital of Shijiazhuang, Shijiazhuang, 050011, Hebei, China
| | - Huiqing Lu
- Department of Cardiothoracic Surgery, The Third Hospital of Shijiazhuang, Shijiazhuang, 050011, Hebei, China
| | - Lili Liu
- Department of Cardiology, The Third Hospital of Shijiazhuang, Shijiazhuang, China
| | - Dongsheng Zhang
- Department of Cardiothoracic Surgery, The Third Hospital of Shijiazhuang, Shijiazhuang, 050011, Hebei, China.
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Tran A, Fernando SM, Gates RS, Gillen JR, Droege ME, Carrier M, Inaba K, Haut ER, Cotton B, Teichman A, Engels PT, Patel RV, Lampron J, Rochwerg B. Efficacy and Safety of Anti-Xa-Guided Versus Fixed Dosing of Low Molecular Weight Heparin for Prevention of Venous Thromboembolism in Trauma Patients: A Systematic Review and Meta-Analysis. Ann Surg 2023; 277:734-741. [PMID: 36413031 DOI: 10.1097/sla.0000000000005754] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
PURPOSE Trauma patients are at high risk of venous thromboembolism (VTE). We summarize the comparative efficacy and safety of anti-Xa-guided versus fixed dosing for low molecular weight heparin (LMWH) for the prevention of VTE in adult trauma patients. METHODS We searched Medline and Embase from inception through June 1, 2022. We included randomized controlled trials or observational studies comparing anti-Xa-guided versus fixed dosing of LMWH for thromboprophylaxis in adult trauma patients. We incorporated primary data from 2 large observational cohorts. We pooled effect estimates using a random-effects model. We assessed risk of bias using the ROBINS-I tool for observational studies and assessed certainty of findings using GRADE methodology. RESULTS We included 15 observational studies involving 10,348 patients. No randomized controlled trials were identified. determined that, compared to fixed LMWH dosing, anti-Xa-guided dosing may reduce deep vein thrombosis [adjusted odds ratio (aOR); 0.52, 95% CI: 0.40-0.69], pulmonary embolism (aOR: 0.48, 95% CI: 0.30-0.78) or any VTE (aOR: 0.54, 95% CI: 0.42-0.69), though all estimates are based on low certainty evidence. There was an uncertain effect on mortality (aOR: 1.06, 95% CI: 0.85-1.32) and bleeding events (aOR: 0.84, 95% CI: 0.50-1.39), limited by serious imprecision. We used several sensitivity and subgroup analyses to confirm the validity of our assumptions. CONCLUSION Anti-Xa-guided dosing may be more effective than fixed dosing for prevention of deep vein thrombosis, pulmonary embolism, and VTE for adult trauma patients. These promising findings justify the need for a high-quality randomized study with the potential to deliver practice changing results.
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Affiliation(s)
- Alexandre Tran
- Division of General Surgery, Department of Surgery, University of Ottawa, Ottawa, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Division of Critical Care, University of Ottawa, Ottawa, Canada
| | - Shannon M Fernando
- Division of Critical Care, University of Ottawa, Ottawa, Canada
- Department of Critical Care, Lakeridge Health Corporation, Oshawa, Ontario, Canada
| | - Rebecca S Gates
- Carilion Clinic, Virginia Tech Carilion School of Medicine, Roanoke, VA
| | - Jacob R Gillen
- Carilion Clinic, Virginia Tech Carilion School of Medicine, Roanoke, VA
| | - Molly E Droege
- Department of Pharmacy Services, UC Health - University of Cincinnati Medical Center, Cincinnati, OH
| | - Marc Carrier
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Kenji Inaba
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Elliott R Haut
- Division of Acute Care Surgery, Departments of Surgery, Anesthesiology and Critical Care, Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Health Policy and Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Bryan Cotton
- Red Duke Trauma Institute, Memorial Hermann Hospital, Houston, TX
| | - Amanda Teichman
- Department of Surgery, Robert Wood Johnson University Hospital, New Brunswick, NJ
| | - Paul T Engels
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Rakesh V Patel
- Division of Critical Care, University of Ottawa, Ottawa, Canada
| | - Jacinthe Lampron
- Division of General Surgery, Department of Surgery, University of Ottawa, Ottawa, Canada
| | - Bram Rochwerg
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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Alshaqaq HM, Al-Sharydah AM, Alshahrani MS, Alqahtani SM, Amer M. Prophylactic Inferior Vena Cava Filters for Venous Thromboembolism in Adults With Trauma: An Updated Systematic Review and Meta-Analysis. J Intensive Care Med 2023; 38:491-510. [PMID: 36939472 DOI: 10.1177/08850666231163141] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
Background: Trauma is an independent risk factor for venous thromboembolism (VTE). Due to contraindications or delay in starting pharmacological prophylaxis among trauma patients with a high risk of bleeding, the inferior vena cava (IVC) filter has been utilized as alternative prevention for pulmonary embolism (PE). Albeit, its clinical efficacy has remained uncertain. Therefore, we performed an updated systematic review and meta-analysis on the effectiveness and safety of prophylactic IVC filters in severely injured patients. Methods: Three databases (MEDLINE, EMBASE, and Cochrane) were searched from August 1, 2012, to October 27, 2021. Independent reviewers performed data extraction and quality assessment. Relative risk (RR) at 95% confidence interval (CI) pooled in a randomized meta-analysis. A parallel clinical practice guideline committee assessed the certainty of evidence using the GRADE approach. The outcomes of interest included VTE, PE, deep venous thrombosis, mortality, and IVC filter complications. Results: We included 10 controlled studies (47 140 patients), of which 3 studies (310 patients) were randomized controlled trials (RCTs) and 7 were observational studies (46 830 patients). IVC filters demonstrated no significant reduction in PE and fatal PE (RR, 0.27; 95% CI, 0.06-1.28 and RR, 0.32; 95% CI, 0.01-7.84, respectively) by pooling RCTs with low certainty. However, it demonstrated a significant reduction in the risk of PE and fatal PE (RR, 0.25; 95% CI, 0.12-0.55 and RR, 0.09; 95% CI, 0.011-0.81, respectively) by pooling observational studies with very low certainty. IVC filter did not improve mortality in both RCTs and observational studies (RR, 1.44; 95% CI, 0.86-2.43 and RR, 0.63; 95% CI, 0.3-1.31, respectively). Conclusion: In trauma patients, moderate risk reduction of PE and fatal PE was demonstrated among observational data but not RCTs. The desirable effect is not robust to outweigh the undesirable effects associated with IVC filter complications. Current evidence suggests against routinely using prophylactic IVC filters.
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Affiliation(s)
- Hassan M Alshaqaq
- Emergency Medicine Department, King Saud Medical City, Riyadh, Saudi Arabia
| | - Abdulaziz M Al-Sharydah
- Diagnostic and Interventional Radiology Department, King Fahd Hospital of the University, 48023Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Mohammed S Alshahrani
- Department of Emergency and Critical Care, King Fahd Hospital of the University, 48023Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Saad M Alqahtani
- Department of Orthopedics surgery, 48102King Fahd Hospital of the University, 48023Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Marwa Amer
- Medical/Critical Pharmacy Division, 37852King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.,College of Medicine, 101686Alfaisal University, Riyadh, Saudi Arabia
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Haut ER, Byrne JP, Price MA, Bixby P, Bulger EM, Lake L, Costantini T. Proceedings from the 2022 Consensus Conference to Implement Optimal Venous Thromboembolism Prophylaxis in Trauma. J Trauma Acute Care Surg 2023; 94:461-468. [PMID: 36534056 PMCID: PMC9974764 DOI: 10.1097/ta.0000000000003843] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
ABSTRACT On May 4 and 5, 2022, a meeting of multidisciplinary stakeholders in the prevention and treatment of venous thromboembolism (VTE) after trauma was convened by the Coalition for National Trauma Research, funded by the National Heart, Lung, and Blood Institute of the National Institutes of Health, and hosted by the American College of Surgeons in Chicago, Illinois. This consensus conference gathered more than 40 in-person and 80 virtual attendees, including trauma surgeons, other physicians, thrombosis experts, nurses, pharmacists, researchers, and patient advocates. The objectives of the meeting were twofold: (1) to review and summarize the present state of the scientific evidence regarding VTE prevention strategies in injured patients and (2) to develop consensus on future priorities in VTE prevention implementation and research gaps.To achieve these objectives, the first part of the conference consisted of talks from physician leaders, researchers, clinical champions, and patient advocates to summarize the current state of knowledge of VTE pathogenesis and prevention in patients with major injury. Video recordings of all talks and accompanying slides are freely available on the conference website ( https://www.nattrauma.org/research/research-policies-templates-guidelines/vte-conference/ ). Following this curriculum, the second part of the conference consisted of a series of small-group breakout sessions on topics potentially requiring future study. Through this process, research priorities were identified, and plans of action to develop and undertake future studies were defined.The 2022 Consensus Conference to Implement Optimal VTE Prophylaxis in Trauma answered the National Trauma Research Action Plan call to define a course for future research into preventing thromboembolism after trauma. A multidisciplinary group of clinical champions, physicians, scientists, and patients delineated clear objectives for future investigation to address important, persistent key knowledge gaps. The series of papers from the conference outlines the consensus based on the current literature and a roadmap for research to answer these unanswered questions.
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Affiliation(s)
- Elliott R Haut
- From the Division of Acute Care Surgery, Department of Surgery (E.R.H., J.P.B.), Department of Anesthesiology and Critical Care Medicine (E.R.H.), and Department of Emergency Medicine (E.R.H.), Johns Hopkins University School of Medicine; Armstrong Institute for Patient Safety and Quality (E.R.H.), Johns Hopkins Medicine; Department of Health Policy and Management (E.R.H.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Coalition for National Trauma Research (M.A.P., P.B.), San Antonio, Texas; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington, DC; National Blood Clot Alliance (L.L.), Philadelphia, Pennsylvania; Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery (T.C.), University of California San Diego School of Medicine, San Diego, California
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Bokenkamp M, Dorken Gallastegi A, Brown T, Hwabejire JO, Fawley J, Mendoza AE, Saillant NN, Fagenholz PJ, Kaafarani HMA, Velmahos GC, Parks JJ. Angioembolization in Severe Pelvic Trauma is Associated with Venous Thromboembolism. J Surg Res 2023; 283:540-549. [PMID: 36442253 DOI: 10.1016/j.jss.2022.10.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 10/22/2022] [Accepted: 10/24/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Management of hemorrhage from pelvic fractures is complex and requires multidisciplinary attention. Pelvic angioembolization (AE) has become a key intervention to aid in obtaining definitive hemorrhage control. We hypothesized that pelvic AE would be associated with an increased risk of venous thromboembolism (VTE). METHODS All adults (age >16) with a severe pelvic fracture (Abbreviated Injury Scale ≥ 4) secondary to a blunt traumatic mechanism in the 2017-2019 American College of Surgeons Trauma Quality Improvement Program database were included. Patients who did not receive VTE prophylaxis during their admission were excluded. Patients who underwent pelvic AE during the first 24 h of admission were compared to those who did not using propensity score matching. Matching was performed based on patient demographics, admission physiology, comorbidities, injury severity, associated injuries, other hemorrhage control procedures, and VTE prophylaxis type, and time to initiation of VTE prophylaxis. The rates of VTE (deep vein thrombosis and pulmonary embolism) were compared between the matched groups. RESULTS Of 72,985 patients with a severe blunt pelvic fracture, 1887 (2.6%) underwent pelvic AE during the first 24 h of admission versus 71,098 (97.4%) who did not. Pelvic AE patients had a higher median Injury Severity Score and more often required other hemorrhage control procedures, with laparotomy being most common (24.7%). The median time to initiation of VTE prophylaxis in pelvic AE versus no pelvic AE patients was 60.1 h (interquartile range = 36.6-98.6) versus 27.7 h (interquartile range = 13.9-52.4), respectively. After propensity score matching, pelvic AE patients were more likely to develop VTE compared to no pelvic AE patients (11.8% versus 9.5%, P = 0.03). CONCLUSIONS Pelvic AE for control of hemorrhage from severe pelvic fractures is associated with an increased risk of in-hospital VTE. Patients who undergo pelvic AE are especially high risk for VTE and should be started as early as safely possible on VTE prophylaxis.
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Affiliation(s)
- Mary Bokenkamp
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Ander Dorken Gallastegi
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Tommy Brown
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - John O Hwabejire
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Jason Fawley
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - April E Mendoza
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Noelle N Saillant
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Peter J Fagenholz
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - George C Velmahos
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Jonathan J Parks
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts.
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20
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Roumeliotis L, Kanakaris NK, Papadopoulos IN. Incidence, risk factors and potential timing of occurrence of pulmonary embolism in fatal trauma: An autopsy based case-control study on 2705 victims. Surgeon 2023; 21:8-15. [PMID: 35317982 DOI: 10.1016/j.surge.2022.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 02/11/2022] [Accepted: 03/02/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Pulmonary embolism (PE) following trauma is a potentially preventable but highly lethal complication. We sought to investigate the incidence, risk factors and potential timing of occurrence of post-traumatic PE in a large cohort of trauma fatalities. METHODS A case-control study on 9266 consecutive trauma fatalities (between 1996 and 2005) from a regional autopsy-based trauma registry. Injuries were classified according to the Abbreviated Injury Scale-1990 edition (AIS-90) and the Injury Severity Score (ISS) was calculated. Hospitalized victims were categorized according to the presence or absence of PE on autopsy. Univariate comparisons and multivariate logistic regression analysis for probabilities of association (odds ratios-OR) were performed. RESULTS Out of 2705 subjects who met the inclusion criteria, 116 had autopsy findings of PE and constituted the PE group (incidence of 4,3%), while the remaining victims formed the control group. The survival time of the PE group ranged from 0.66 to 104.73 days. Victims in the PE group were older (median age 69.5 vs 59), had lower ISS values (median 16 vs 26) and longer post-injury survival times (median 13.6 vs 5.7 days). Positively associated risk factors were AIS2-5 pelvic ring injuries (OR:2.23) and secondary deaths following an uneventful hospital discharge (OR:3.97), while AIS2-5 head (OR:0.33) and abdominal injuries (OR:0.23) showed a reverse association. CONCLUSIONS Trauma fatalities with autopsy findings of PE were associated with less severe trauma indicating that PE was likely detrimental to the fatal outcome. Both the early and delayed occurrence of PE was reaffirmed. Prophylactic measures should be initiated promptly and extended post discharge for high risk patients to prevent secondary deaths.
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Affiliation(s)
- Leonidas Roumeliotis
- 4th Department of Surgery, School of Medicine, National and Kapodistrian University of Athens, University General Hospital 'Attikon', Athens, Greece.
| | - Nikolaos K Kanakaris
- Leeds Major Trauma Centre, Leeds Teaching Hospitals NHS Trust, Leeds, Yorkshire, UK
| | - Iordanis N Papadopoulos
- 4th Department of Surgery, School of Medicine, National and Kapodistrian University of Athens, University General Hospital 'Attikon', Athens, Greece
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21
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Thivaharan Y, Dayapala A, Thanushan M. A case of early pulmonary embolism following blunt trauma to chest and a long bone fracture: a case report. EGYPTIAN JOURNAL OF FORENSIC SCIENCES 2023; 13:9. [PMID: 36712698 PMCID: PMC9869291 DOI: 10.1186/s41935-023-00327-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 01/10/2023] [Indexed: 01/24/2023] Open
Abstract
Background After substantial trauma, pulmonary embolism (PE) carries a high risk of morbidity and mortality. Early post-traumatic PE in the absence of deep vein thrombosis (DVT) is a distinct entity that might be connected to rare mechanisms or unidentified biochemical processes. Case presentation A driver of a car was presented with worsening chest pain and shortness of breath (SOB) following a road traffic accident in which he suffered an impact on the chest against the steering wheel and a closed fracture of the right femur. Radiological investigations revealed a pulmonary embolism in the left posterior segment pulmonary artery, without evidence of internal chest injuries or DVT within 12 h from the incident. D-dimer, troponin I, and creatinine kinase were elevated without evidence of myocardial infarction or myocardial injury. Other parameters were within the normal range. Conclusions Possibilities of early PE in the absence of detectable DVT could be due to hyper-coagulability states, clots from the lower extremity completely getting detached and embolizing to the pulmonary circulation, screening errors, and "de novo" thrombi in the pulmonary circulation. Chest trauma is an identified risk factor for early or late pulmonary embolism. Action of the post-traumatic adrenergic response causing vascular endothelial inflammation and the synthesis of circulating adhesion molecules leading to localized thrombosis have also been suggested as causes for this phenomenon. A greater understanding of rare risk factors for early PE and the possibility of rare complications of chest trauma is useful in detecting and treating them in time, reducing morbidity and mortality.
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Affiliation(s)
- Yalini Thivaharan
- grid.512965.c0000 0004 0635 2736Colombo South Teaching Hospital, Kalubowila, Sri Lanka
| | - Asurappulige Dayapala
- grid.512965.c0000 0004 0635 2736Colombo South Teaching Hospital, Kalubowila, Sri Lanka
| | - Muthulingam Thanushan
- Department of Forensic Medicine, Faculty of Medicine, University of Sri Jayawardhanapura, Sri Jayawardhanapura, Sri Lanka
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22
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Gogayeva OK, Rudenko ML, Nudchenko OO. The Occurrence of Thrombotic Complications Due to Combat Trauma Against the Background of the COVID-19 Pandemic. UKRAINIAN JOURNAL OF CARDIOVASCULAR SURGERY 2022. [DOI: 10.30702/ujcvs/22.30(04)/gr058-115121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
An important point in the provision of highly specialized cardiac surgical care for combat trauma is determination of the optimal time, method and volume of surgical intervention, taking into account the persisting threat of infection with the SARS-COV-2 virus and associated thrombotic complications.
The aim. To investigate the mechanism of development and methods of prevention of thrombotic complications resulting from combat trauma against the background of the COVID-19 pandemic.
Materials and methods. We analyzed clinical case of patient R., a 37-year-old soldier with a postinfarction thrombosed aneurysm of the left ventricle. The patient underwent standard clinical and laboratory tests, electrocardiography, echocardiography, coronary angiography, computed tomography of the chest, duplex scanning of carotid arteries, arteries and veins of the upper and lower extremities. It was established that 4 months ago, during a combat mission, the service-man received a mine-explosive injury, shrapnel wounds of lower extremities, multifragmentary fracture of the right ϐibula and a gunshot wound to the right chest. The causes of post-traumatic myocardial infarction are mine-explosive injury, intramural course of the left anterior descending artery, youngage, poorly developed collaterals of coronary arteries, long-term transportation during the stages of medical evacuation and post-traumatic stress disorder. A month ago, the patient was diagnosed with COVID-19, thromboembolism of the right main branch of the pulmonary artery, for which thrombolytic therapy was performed. Follow-up computed tomography showed the signs of thromboembolism of the pulmonary arteries. Ultrasound examination revealed thromboses of upper and lower limbs. Thrombotic complications against the background of combat polytrauma are the result of hypercoagulation, acute inϐlammation with the release of proinϐlammatory cytokines and damage of the endothelium. SARS-COV-2 infection triggers a state of hypercoagulation and creates additional conditions for the occurrence of arterial and venous thrombosis. Considering the nature of the thrombotic lesions, was made a decision to postpone the cardiosurgical intervention for 3 months.
Conclusions. Thrombotic complications are an urgent problem after combat trauma. COVID-19 is an additional risk factor for hypercoagulation and a reason for delaying elective cardiac surgery. Conducting an electrocardiography to the wounded, regardless of age, is crucial for timely diagnosis andtreatment of acute coronary events. It is important to initiate anticoagulant therapy after eliminating all possible sources of bleeding due to the high risk of thrombotic complications against the background of chest trauma and limb fractures.
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23
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Patching of the Inferior Vena Cava Following Lateral Venorrhaphy in Penetrating Traumatic Injury. Case Rep Surg 2022; 2022:5488752. [PMID: 36590927 PMCID: PMC9803579 DOI: 10.1155/2022/5488752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 11/24/2022] [Accepted: 12/10/2022] [Indexed: 12/24/2022] Open
Abstract
Penetrating injury to the inferior vena cava (IVC) is associated with high morbidity and mortality. Luminal narrowing can occur following lateral venorrhaphy and can lead to future morbidity. This case report discusses the success of patch repair following lateral venorrhaphy in two trauma patients. We describe the use of patch repair to eliminate stenosis of the IVC resulting from primary repair in the setting of traumatic injury. Furthermore, trauma patients are known to be at high risk for venous thromboembolism, and we describe the use of low molecular weight heparin as chemical prophylaxis for prevention of this complication following patch repair.
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24
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Parks JJ, Naar L, Bokenkamp M, van Erp IAM, Mikdad S, Maurer LR, Fawley J, Saillant NN, Kaafarani HMA, Velmahos GC. Preperitoneal Pelvic Packing is Associated With Increased Risk of Venous Thromboembolism. J Surg Res 2022; 280:85-93. [PMID: 35964486 DOI: 10.1016/j.jss.2022.06.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 06/23/2022] [Accepted: 06/30/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Preperitoneal pelvic packing (PPP) is an important intervention for control of severe pelvic hemorrhage in blunt trauma patients. We hypothesized that PPP is associated with an increased incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE). METHODS A retrospective cohort analysis of blunt trauma patients with severe pelvic fractures (AIS ≥4) using the 2015-2017 American College of Surgeons-Trauma Quality Improvement Program database was performed. Patients who underwent PPP within four hours of admission were matched to patients who did not using propensity score matching. Matching was performed based on demographics, comorbidities, injury- and resuscitation-related parameters, vital signs at presentation, and initiation and type of prophylactic anticoagulation. The rates of DVT and PE were compared between the matched groups. RESULTS Out of 5129 patients with severe pelvic fractures, 157 (3.1%) underwent PPP within four h of presentation and were matched with 157 who did not. No significant differences were detected between the two matched groups in any of the examined baseline variables. Similarly, mortality and end-organ failure rates were not different. However, PPP patients were significantly more likely to develop DVT (12.7% versus 5.1%, P = 0.028) and PE (5.7% versus 0.0%, P = 0.003). CONCLUSIONS PPP in severe pelvic fractures secondary to blunt trauma is associated with an increased risk of DVT and PE. A high index of suspicion and a low threshold for screening for these conditions should be maintained in patients who undergo PPP.
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Affiliation(s)
- Jonathan J Parks
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts.
| | - Leon Naar
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Mary Bokenkamp
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Inge A M van Erp
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Sarah Mikdad
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Lydia R Maurer
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Jason Fawley
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Noelle N Saillant
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - George C Velmahos
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
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25
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Siddiqui T, Asim M, Ahmed K, Mathradikkal S, Bakhsh Z, Masood M, Al-Hassani A, Nabir S, Ahmed N, Strandvik G, El-Menyar A, Al-Thani H. Clinical Characteristics and Risk Factors for Early versus Late Pulmonary Embolism in Trauma Patients: A Retrospective, Observational Study. Int J Gen Med 2022; 15:7867-7878. [PMID: 36304673 PMCID: PMC9596190 DOI: 10.2147/ijgm.s387880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 10/12/2022] [Indexed: 11/23/2022] Open
Abstract
Background We sought to evaluate the clinical characteristics and risk factors for early versus late pulmonary embolism (PE) in trauma patients. Methods This was a retrospective analysis of injured patients who presented with a confirmed PE between 2013 and 2019. Data were analysed and compared for patients with early PE (≤4 days) versus late PE (>4 days post-trauma). Results The study included 82 consecutive trauma patients with confirmed diagnosis of PE. The mean age of patients was 42.3 ± 16.2 years. The majority were males (79.3%) and the median time from injury to PE was 10 days. Of the PE cases, 24 (29.3%) had early PE, while 58 (70.7%) had late PE. The early PE group had higher rates of surgical intervention within 24 hours of admission than the late PE group (p = 0.001). Also, the rate of sub-segmental thrombi was significantly higher in the early PE group (p = 0.01). The late PE group sustained more moderate-to-severe injuries ie, GCS ED <13 (p = 0.03) and the median time from injury to PE diagnosis was 15 days (p = 0.001). After adjusting for the potential covariates, surgery within 24 hours of admission [adjusted odds ratio 37.58 (95% confidence interval 3.393-416.20), p = 0.003] was found to be significant independent predictor of early PE in trauma patients. Conclusion One-third of post-trauma PEs occurs early after trauma and the surgical intervention within the first 24 hours of admission is a major risk factor. A prospective study is needed to develop an objective risk assessment for the prevention and detection of early and late PE post-trauma.
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Affiliation(s)
- Tariq Siddiqui
- Trauma Surgery Section, Hamad General Hospital (HGH), Doha, Qatar
| | - Mohammad Asim
- Clinical Research, Trauma & Vascular Surgery, Hamad General Hospital, Doha, Qatar
| | - Khalid Ahmed
- Trauma Surgery Section, Hamad General Hospital (HGH), Doha, Qatar
| | | | - Zeenat Bakhsh
- Trauma Surgery Section, Hamad General Hospital (HGH), Doha, Qatar
| | - Maarij Masood
- Trauma Surgery Section, Hamad General Hospital (HGH), Doha, Qatar
| | - Ammar Al-Hassani
- Trauma Surgery Section, Hamad General Hospital (HGH), Doha, Qatar
| | - Syed Nabir
- Radiology Department, Hamad General Hospital, Doha, Qatar
| | - Nadeem Ahmed
- Radiology Department, Hamad General Hospital, Doha, Qatar
| | - Gustav Strandvik
- Trauma Surgery Section, Hamad General Hospital (HGH), Doha, Qatar
| | - Ayman El-Menyar
- Clinical Research, Trauma & Vascular Surgery, Hamad General Hospital, Doha, Qatar,Clinical Medicine, Weill Cornell Medical College, Doha, Qatar,Correspondence: Ayman El-Menyar, Trauma & Vascular Surgery Section, Hamad Medical Corporation & Weill Cornell Medical College, PO Box 3050, Doha, Qatar, Tel +97444396130, Email
| | - Hassan Al-Thani
- Trauma Surgery Section, Hamad General Hospital (HGH), Doha, Qatar
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26
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Störmann P, Osinloye W, Verboket RD, Schindler CR, Woschek M, Marzi I, Lustenberger T. Early start of thromboprophylaxis does not increase risk of intracranial hematoma progression in multiply injured patients with traumatic brain injury. Brain Inj 2022; 36:1046-1052. [PMID: 35923095 DOI: 10.1080/02699052.2022.2105951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) in severely injured patients with severe traumatic brain injury (TBI) is a risk during the clinical course. Data on the safety of an early initiation of pharmacological VTE prophylaxis in severely injured patients with concomitant severe TBI is sparse. METHODS Admissions to our level-1-trauma center between January 2015 and December 2018 were screened. Patients suffering from severe TBI (Abbreviated Injury Scale (AIS) of the head ≥3) and at least one further AIS ≥ 3 in any other body region were included. Demographic data, thromboembolic events, and progression of the intracranial hemorrhage were extracted from the patient's charts. According to the first application of pharmacological thromboprophylaxis (VTEp), patients were categorized either to the early, the late (later than 24 h) or the no therapy group. RESULTS In 79 patients (early: n = 35, late: n = 29, no therapy: n = 15) the Injury Severity Score (ISS) was 36.7 ± 12.7 points (AIShead 4.1 ± 0.8). No differences were found regarding the progression of the intracranial hemorrhage after initiation of the VTE prophylaxis (adj. p = 0.8). The VTE rate was low (n = 1, 1.6%). CONCLUSION In severely injured patients with severe TBI, the early administration of pharmacological thromboprophylaxis did not result in a higher rate of intracranial hematoma progression.
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Affiliation(s)
- Philipp Störmann
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Johann Wolfgang Goethe - University Frankfurt am Main, Frankfurt/Main, Germany
| | - William Osinloye
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Johann Wolfgang Goethe - University Frankfurt am Main, Frankfurt/Main, Germany
| | - René D Verboket
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Johann Wolfgang Goethe - University Frankfurt am Main, Frankfurt/Main, Germany
| | - Cora R Schindler
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Johann Wolfgang Goethe - University Frankfurt am Main, Frankfurt/Main, Germany
| | - Mathias Woschek
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Johann Wolfgang Goethe - University Frankfurt am Main, Frankfurt/Main, Germany
| | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Johann Wolfgang Goethe - University Frankfurt am Main, Frankfurt/Main, Germany
| | - Thomas Lustenberger
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Johann Wolfgang Goethe - University Frankfurt am Main, Frankfurt/Main, Germany
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Early bilateral pulmonary embolism in a polytrauma patient: About a case report. Ann Med Surg (Lond) 2022; 78:103868. [PMID: 35734707 PMCID: PMC9207082 DOI: 10.1016/j.amsu.2022.103868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 05/20/2022] [Accepted: 05/22/2022] [Indexed: 11/20/2022] Open
Abstract
Introduction and importance: Venous thromboembolism (VTE) is a well-known complication in polytrauma patients, associated with a high rate of mortality and morbidity. Generally pulmonary embolism (PE) is most common between the fifth and seventh days following a significant trauma, and it is uncommon before the fourth day. Their management remains a challenge to physicians given the nature and risk of blood loss from the accompanying injuries must be considered while using anticoagulant therapy. Case presentation Here we present a case of acute pulmonary embolism in a previously healthy young woman that developed two days after a traumatic brain injury (TBI) and varying degrees of additional blunt thoracic trauma. An angio CT scan was used to make the diagnosis, and the patient was given anticoagulant medication with close monitoring and satisfactory outcomes. Conclusion Evidence suggests that early after trauma, a considerable number of trauma patients are hypercoagulable. In patients with unexplained dyspnea/hypoxia, clinicians should maintain a high index of suspicion and explore PE early after injury. In the case of traumatic brain injury patients with cerebral contusions, intraparenchymal haemorrhages, or subdural/extradural haemorrhages, the existence of post-traumatic PE adds to the problems. Our aim was to investigate the (PE) in polytrauma patients: incidence, risk factors of early occurrence, management and outcomes. Decision to anti-coagulate post traumatic PE is controversial, especially in polytrauma patients. Anticoagulation decision is guided by interval repeat CT scan and clinical picture. The presence of post traumatic PE poses further challenges in the management of traumatic brain injury patients with cerebral contusions, intraparenchymal haemorrhages or subdural/extradural haemorrhages.
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28
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Zinoune L, Darar C, Aichouni N, Nasri S, Skiker I, El Ouafi N, Bazid Z. Early bilateral pulmonary embolism following a moderate blunt chest trauma: A case report. Radiol Case Rep 2022; 17:759-762. [PMID: 35003476 PMCID: PMC8718493 DOI: 10.1016/j.radcr.2021.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 11/29/2021] [Accepted: 12/03/2021] [Indexed: 11/27/2022] Open
Abstract
Post-traumatic pulmonary embolism (PE) remains a major problem in cardio-pulmonary diseases and represent the third most common cause of death in trauma patients. Traditional PE occur most commonly between the fifth and the seventh day after a major trauma and are rare before the fourth day. Here, we report a case of acute pulmonary embolism developing 1 day after a moderate thoracic injury in a previously well young man. The diagnosis was made by non-invasive methods and the patient was given anticoagulation therapy with good outcome. The circumstances and the early occurrence of PE in this case is at odds with what is generally reported after trauma.
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Affiliation(s)
- Lamyae Zinoune
- Faculty of Medicine and Pharmacy, Mohammed Ist University, Oujda, Morocco.,Department of Cardiology, Mohammed VI University Hospital/Mohammed I University, Oujda, Morocco
| | - Charmake Darar
- Faculty of Medicine and Pharmacy, Mohammed Ist University, Oujda, Morocco.,Department of Cardiology, Mohammed VI University Hospital/Mohammed I University, Oujda, Morocco
| | - Narjisse Aichouni
- Faculty of Medicine and Pharmacy, Mohammed Ist University, Oujda, Morocco.,Department of Radiology, Mohammed VI University Hospital/Mohammed I University, Oujda, Morocco
| | - Siham Nasri
- Faculty of Medicine and Pharmacy, Mohammed Ist University, Oujda, Morocco.,Department of Radiology, Mohammed VI University Hospital/Mohammed I University, Oujda, Morocco
| | - Imane Skiker
- Faculty of Medicine and Pharmacy, Mohammed Ist University, Oujda, Morocco.,Department of Radiology, Mohammed VI University Hospital/Mohammed I University, Oujda, Morocco
| | - Noha El Ouafi
- Faculty of Medicine and Pharmacy, Mohammed Ist University, Oujda, Morocco.,Department of Cardiology, Mohammed VI University Hospital/Mohammed I University, Oujda, Morocco.,Laboratory of Epidemiology, Clinical Research and Public Health, Faculty of Medicine and Pharmacy, Oujda, Morocco
| | - Zakaria Bazid
- Faculty of Medicine and Pharmacy, Mohammed Ist University, Oujda, Morocco.,Department of Cardiology, Mohammed VI University Hospital/Mohammed I University, Oujda, Morocco.,Laboratory of Epidemiology, Clinical Research and Public Health, Faculty of Medicine and Pharmacy, Oujda, Morocco
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Byrne JP, Witiw CD, Schuster JM, Pascual JL, Cannon JW, Martin ND, Reilly PM, Nathens AB, Seamon MJ. Association of Venous Thromboembolism Prophylaxis After Neurosurgical Intervention for Traumatic Brain Injury With Thromboembolic Complications, Repeated Neurosurgery, and Mortality. JAMA Surg 2021; 157:e215794. [PMID: 34910096 DOI: 10.1001/jamasurg.2021.5794] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance There is a lack of evidence regarding the effectiveness and safety of pharmacologic venous thromboembolism (VTE) prophylaxis among patients who undergo neurosurgical interventions for traumatic brain injury (TBI). Objective To measure the association between timing of VTE prophylaxis after urgent neurosurgical intervention for TBI and thromboembolic and intracranial complications. Design, Setting, and Participants This retrospective cohort study included adult patients (aged ≥16 years) who underwent urgent neurosurgical interventions (craniotomy/craniectomy or intracranial monitor/drain insertion within 24 hours after admission) for TBI at level 1 and 2 trauma centers participating in the American College of Surgeons Trauma Quality Improvement Program between January 1, 2012, and December 31, 2016. Data were analyzed from January to August 2020. Exposures Timing of pharmacologic VTE prophylaxis initiation after urgent neurosurgical intervention (prophylaxis delay) measured in days (24-hour periods). Main Outcomes and Measures The primary outcome was VTE (deep vein thrombosis or pulmonary embolism). Secondary outcomes were repeated neurosurgery (neurosurgical reintervention after initiation of VTE prophylaxis) and mortality. Hierarchical logistic regression models were used to evaluate the association between prophylaxis delay and each outcome at the patient level and were adjusted for patient baseline and injury characteristics. Results The study included 4951 patients (3676 [74%] male; median age, 50 years [IQR, 31-64 years]) who underwent urgent neurosurgical intervention for TBI at 304 trauma centers. The median prophylaxis delay was 3 days (IQR, 1-5 days). After adjustment for patient baseline and injury characteristics, prophylaxis delay was associated with increased odds of VTE (adjusted odds ratio [aOR], 1.08 per day; 95% CI, 1.04-1.12). Earlier initiation of prophylaxis was associated with increased risk of repeated neurosurgery. During the first 3 days, each additional day of prophylaxis delay was associated with a 28% decrease in odds of repeated neurosurgery (aOR, 0.72 per day; 95% CI, 0.59-0.88). After 3 days, each additional day of prophylaxis delay was associated with an additional 15% decrease in odds of repeated neurosurgery (aOR, 0.85 per day; 95% CI, 0.80-0.90). Earlier prophylaxis was associated with greater mortality among patients who initially underwent intracranial monitor/drain procedures, such that each additional day of prophylaxis delay was associated with decreased odds of death (aOR, 0.94 per day; 95% CI, 0.89-0.99). Conclusions and Relevance In this cohort study of patients who underwent urgent neurosurgical interventions for TBI, early pharmacologic VTE prophylaxis was associated with reduced risk of thromboembolism. However, earlier initiation of prophylaxis was associated with increased risk of repeated neurosurgery. These findings suggest that although timely initiation of prophylaxis should be prioritized, caution should be used particularly during the first 3 days after the index procedure, when this risk appears to be highest.
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Affiliation(s)
- James P Byrne
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Christopher D Witiw
- Division of Neurosurgery and Spinal Program, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - James M Schuster
- Department of Neurosurgery, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania
| | - Jose L Pascual
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Jeremy W Cannon
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Niels D Martin
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Patrick M Reilly
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Avery B Nathens
- Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Mark J Seamon
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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Knudson MM, Moore EE, Kornblith LZ, Shui AM, Brakenridge S, Bruns BR, Cipolle MD, Costantini TW, Crookes BA, Haut ER, Kerwin AJ, Kiraly LN, Knowlton LM, Martin MJ, McNutt MK, Milia DJ, Mohr A, Nirula R, Rogers FB, Scalea TM, Sixta SL, Spain DA, Wade CE, Velmahos GC. Challenging Traditional Paradigms in Posttraumatic Pulmonary Thromboembolism. JAMA Surg 2021; 157:e216356. [PMID: 34910098 DOI: 10.1001/jamasurg.2021.6356] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Importance Pulmonary clots are seen frequently on chest computed tomography performed after trauma, but recent studies suggest that pulmonary thrombosis (PT) and pulmonary embolism (PE) after trauma are independent clinical events. Objective To assess whether posttraumatic PT represents a distinct clinical entity associated with the nature of the injury, different from the traditional venous thromboembolic paradigm of deep venous thrombosis (DVT) and PE. Design, Setting, and Participants This prospective, observational, multicenter cohort study was conducted by the Consortium of Leaders in the Study of Traumatic Thromboembolism (CLOTT) study group. The study was conducted at 17 US level I trauma centers during a 2-year period (January 1, 2018, to December 31, 2020). Consecutive patients 18 to 40 years of age admitted for a minimum of 48 hours with at least 1 previously defined trauma-associated venous thromboembolism (VTE) risk factor were followed up until discharge or 30 days. Exposures Investigational imaging, prophylactic measures used, and treatment of clots. Main Outcomes and Measures The main outcomes of interest were the presence, timing, location, and treatment of any pulmonary clots, as well as the associated injury-related risk factors. Secondary outcomes included DVT. We regarded pulmonary clots with DVT as PE and those without DVT as de novo PT. Results A total of 7880 patients (mean [SD] age, 29.1 [6.4] years; 5859 [74.4%] male) were studied, 277 with DVT (3.5%), 40 with PE (0.5%), and 117 with PT (1.5%). Shock on admission was present in only 460 patients (6.2%) who had no DVT, PT, or PE but was documented in 11 (27.5%) of those with PE and 30 (25.6%) in those with PT. Risk factors independently associated with PT but not DVT or PE included shock on admission (systolic blood pressure <90 mm Hg) (odds ratio, 2.74; 95% CI, 1.72-4.39; P < .001) and major chest injury with Abbreviated Injury Score of 3 or higher (odds ratio, 1.72; 95% CI, 1.16-2.56; P = .007). Factors associated with the presence of PT on admission included major chest injury (14 patients [50.0%] with or without major chest injury with an Abbreviated Injury Score >3; P = .04) and major venous injury (23 [82.1%] without major venous injury and 5 [17.9%] with major venous injury; P = .02). No deaths were attributed to PT or PE. Conclusions and Relevance To our knowledge, this CLOTT study is the largest prospective investigation in the world that focuses on posttraumatic PT. The study suggests that most pulmonary clots are not embolic but rather result from inflammation, endothelial injury, and the hypercoagulable state caused by the injury itself.
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Affiliation(s)
| | | | | | - Amy M Shui
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Scott Brakenridge
- Department of Surgery, University of Florida, Gainesville.,Now with Department of Surgery, University of Washington, Seattle
| | - Brandon R Bruns
- Department of Surgery, University of Maryland, Baltimore.,Now with the Department of Surgery, University of Texas Southwestern, Dallas
| | - Mark D Cipolle
- Department of Surgery, Christiana Health Care, Newark, Delaware.,Now with the Department of Surgery Lehigh Valley Health, Allentown, Pennsylvania
| | | | - Bruce A Crookes
- Department of Surgery, Medical University of South Carolina, Charleston
| | - Elliot R Haut
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Andrew J Kerwin
- Now with Department of Surgery, University of Washington, Seattle.,Now with the Department of Surgery, University of Tennessee, Memphis
| | - Laszlo N Kiraly
- Department of Surgery, University of Oregon Health Sciences University, Portland
| | - Lisa M Knowlton
- Department of Surgery, Stanford University, Palo Alto, California
| | - Matthew J Martin
- Department of Surgery, Scripps Mercy Hospital, San Diego, California
| | | | - David J Milia
- Department of Surgery, Medical College of Wisconsin, Milwaukee
| | - Alicia Mohr
- Now with Department of Surgery, University of Washington, Seattle
| | - Ram Nirula
- Department of Surgery, University of Utah, Salt Lake City
| | - Fredrick B Rogers
- Department of Surgery, Lancaster General Hospital, Lancaster, Pennsylvania
| | | | - Sherry L Sixta
- Department of Surgery, Christiana Health Care, Newark, Delaware
| | - David A Spain
- Department of Surgery, Stanford University, Palo Alto, California
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A nested case-control study of risk for pulmonary embolism in the general trauma population using nationwide trauma registry data in Japan. Sci Rep 2021; 11:19192. [PMID: 34584149 PMCID: PMC8478977 DOI: 10.1038/s41598-021-98692-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 09/13/2021] [Indexed: 11/24/2022] Open
Abstract
Post-trauma patients are at great risk of pulmonary embolism (PE), however, data assessing specific risk factors for post-traumatic PE are scarce. This was a nested case–control study using the Japan Trauma Data Bank between 2004 and 2017. We enrolled patients aged ≥ 16 years, Injury Severity Score ≥ 9, and length of hospital stay ≥ 2 days, with PE and without PE, using propensity score matching. We conducted logistic regression analyses to examine risk factors for PE. We included 719 patients with PE and 3595 patients without PE. Of these patients, 1864 [43.2%] were male, and their median Interquartile Range (IQR) age was 73 [55–84] years. The major mechanism of injury was blunt (4282 [99.3%]). Median [IQR] Injury Severity Score (ISS) was 10 [9–18]. In the multivariate analysis, the variables spinal injury [odds ratio (OR), 1.40 (1.03–1.89)]; long bone open fracture in upper extremity and lower extremity [OR, 1.51 (1.06–2.15) and OR, 3.69 (2.89–4.71), respectively]; central vein catheter [OR, 2.17 (1.44–3.27)]; and any surgery [OR, 4.48 (3.46–5.81)] were independently associated with PE. Spinal injury, long bone open fracture in extremities, central vein catheter placement, and any surgery were risk factors for post-traumatic PE. Prompt initiation of prophylaxis is needed for patients with such trauma.
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Kirchner T, Lefering R, Sandkamp R, Eberbach H, Schumm K, Schmal H, Bayer J. Thromboembolic complications among multiple injured patients with pelvic injuries: identifying risk factors for possible patient-tailored prophylaxis. World J Emerg Surg 2021; 16:42. [PMID: 34446032 PMCID: PMC8393450 DOI: 10.1186/s13017-021-00388-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 08/10/2021] [Indexed: 11/15/2022] Open
Abstract
Background Patients with pelvic and/or acetabular fractures are at high risk of developing thromboembolic (TE) complications. In our study we investigate TE complications and the potential negative effects of concomitant pelvic or acetabular injuries in multiple injured patients according to pelvic/acetabular injury severity and fracture classification. Methods The TraumaRegister DGU® was analyzed between 2010 and 2019. Multiple injured patients with pelvic and/or acetabular fractures with ISS ≥ 16 suffering from TE complications were identified. We conducted a univariate and multivariate analysis with TE events as independent variable to examine potential risk factors and contributing factors. Results 10.634 patients met our inclusion criteria. The overall TE incidence was 4.9%. Independent risk factors for the development of TE complications were sepsis, ≥ 10 operative interventions, mass transfusion (≥ 10 PRBCs), age ≥ 65 years and AISAbdomen ≥ 3 (all p < 0.001). No correlation was found for overall injury severity (ISS), moderate traumatic brain injury, additional injury to lower extremities, type B and C pelvic fracture according to Tile/AO/OTA and closed or open acetabular fracture. Conclusions Multiple injured patients suffering from pelvic and/or acetabular fractures are at high risk of developing thromboembolic complications. Independent risk factors for the development of thromboembolic events in our study cohort were age ≥ 65 years, mass transfusion, AISAbdomen ≥ 3, sepsis and ≥ 10 surgery procedures. Among multiple injured patients with acetabular or pelvic injuries the severity of these injuries seems to have no further impact on thromboembolic risk. Our study, however, highlights the major impact of early hemorrhage and septic complications on thromboembolic risk in severely injured trauma patients. This may lead to individualized screening examinations and a patient-tailored thromboprophylaxis in high-risk patients for TE. Furthermore, the number of surgical interventions should be minimized in these patients to reduce thromboembolic risk.
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Affiliation(s)
- Tim Kirchner
- Department of Orthopedics and Trauma Surgery, Medical Center - Albert-Ludwigs-University of Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Rolf Lefering
- IFOM - Institute for Research in Operative Medicine, University Witten/Herdecke, Faculty of Health, Ostmerheimer Str. 200, 51109, Köln, Germany
| | - Richard Sandkamp
- Department of Orthopedics and Trauma Surgery, Medical Center - Albert-Ludwigs-University of Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Helge Eberbach
- Department of Orthopedics and Trauma Surgery, Medical Center - Albert-Ludwigs-University of Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Klaus Schumm
- Department of Orthopedics and Trauma Surgery, Medical Center - Albert-Ludwigs-University of Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Hagen Schmal
- Department of Orthopedics and Trauma Surgery, Medical Center - Albert-Ludwigs-University of Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany.,Department of Orthopedic Surgery, University Hospital Odense, Sdr. Boulevard 29, 5000, Odense C, Denmark
| | - Jörg Bayer
- Department of Orthopedics and Trauma Surgery, Medical Center - Albert-Ludwigs-University of Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany.
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Cao Y, Geng C, Li Y, Zhang Y. In situ Pulmonary Artery Thrombosis: A Previously Overlooked Disease. Front Pharmacol 2021; 12:671589. [PMID: 34305592 PMCID: PMC8296465 DOI: 10.3389/fphar.2021.671589] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 06/28/2021] [Indexed: 12/30/2022] Open
Abstract
Pulmonary thromboembolism (PTE) is the third leading cause of death in cardiovascular diseases. PTE is believed to be caused by thrombi detached from deep veins of lower extremities. The thrombi travel with systemic circulation to the lung and block pulmonary arteries, leading to sudden disruption of hemodynamics and blood gas exchange. However, this concept has recently been challenged by accumulating evidence demonstrating that de novo thrombosis may be formed in pulmonary arteries without deep venous thrombosis. On the other hand, chronic thromboembolic pulmonary hypertension (CTEPH), a subtype of pulmonary hypertension, could have different pathogenesis than traditional PTE. Therefore, this article summarized and compared the risk factors, the common and specific pathogenic mechanisms underlying PTE, in situ pulmonary artery thrombosis, and CTEPH at molecular and cellular levels, and suggested the therapeutic strategies to these diseases, aiming to facilitate understanding of pathogenesis, differential diagnosis, and precision therapeutics of the three pulmonary artery thrombotic diseases.
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Affiliation(s)
- Yunshan Cao
- Department of Cardiology, Gansu Provincial Hospital, Lanzhou, China
| | - Chao Geng
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, China
| | - Yahong Li
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, China
| | - Yan Zhang
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, China
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Ngarmukos S, Kim KI, Wongsak S, Chotanaphuti T, Inaba Y, Chen CF, Liu D. Asia-Pacific venous thromboembolism consensus in knee and hip arthroplasty and hip fracture surgery: Part 1. Diagnosis and risk factors. Knee Surg Relat Res 2021; 33:18. [PMID: 34147134 PMCID: PMC8214263 DOI: 10.1186/s43019-021-00099-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 04/04/2021] [Indexed: 12/11/2022] Open
Affiliation(s)
- Srihatach Ngarmukos
- Department of Orthopaedics, King Chulalongkorn Memorial Hospital and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kang-Il Kim
- Department of Orthopaedic Surgery, Center for Joint Diseases, Kyung Hee University Hospital at Gangdong, 892 Dongnam-ro, Gangdong-gu Seoul, Seoul, 134-727, Korea. .,Department of Orthopaedic Surgery, School of Medicine, Kyung Hee University, Seoul, Korea.
| | - Siwadol Wongsak
- Department of Orthopaedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Thanainit Chotanaphuti
- Department of Orthopaedics, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
| | - Yutaka Inaba
- Department of Orthopaedic Surgery, Yokohama City University Hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan
| | - Cheng-Fong Chen
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Orthopaedics, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - David Liu
- Gold Coast Centre for Bone & Joint Surgery, Gold Coast, Australia
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Schutzman LM, Rigor RR, Lin YLJ, Dang AN, Le PH, Singh HB, Yu B, Wisner PH, Musson CC, Clark IJ, Galante JM, Brown IE. P-selectin antibody treatment after blunt thoracic trauma prevents early pulmonary arterial thrombosis without changes in viscoelastic measurements of coagulation. J Trauma Acute Care Surg 2021; 90:1032-1039. [PMID: 34016926 DOI: 10.1097/ta.0000000000003162] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Previously, in a murine model of blunt thoracic trauma, we provided evidence of primary pulmonary thrombosis associated with increased expression of the cell adhesion molecule, P-selectin. In this study, mice are treated with P-selectin blocking antibody after injury to investigate the clinical viability of this antibody for the prevention of pulmonary thrombosis. In addition, viscoelastic testing is performed to investigate if P-selectin inhibition has a detrimental impact on normal hemostasis. METHODS A murine model of thoracic trauma was used. Mice were divided into sham control and experimental injury groups. Thirty minutes after trauma, mice were treated with the following: P-selectin blocking antibody, isotype control antibody, low-dose heparin, high-dose heparin, or normal saline. At 90 minutes, whole blood was collected for characterization of coagulation by viscoelastic coagulation monitor (VCM Vet; Entegrion, Durham, NC). Mean clotting time, clot formation time, clot kinetics (α angle), and maximum clot firmness were compared between each treatment group. RESULTS Mice that received P-selectin antibody 30 minutes after blunt thoracic trauma had four- to fivefold less (p < 0.001) arterial fibrin accumulation than those that received the isotype control. In both sham and trauma groups, compared with vehicle (normal saline) alone, no statistical difference was noted in any coagulation parameters after injection with P-selectin antibody, isotype control, or low-dose heparin. In addition, blinded histopathological evaluation yielded no difference in hemorrhage scores between injured mice treated with P-selectin blocking antibody and those treated with isotype antibody control. CONCLUSION This study supports the clinical use of P-selectin blocking antibody for the prevention of pulmonary thrombosis by confirming its efficacy when given after a blunt thoracic trauma. In addition, we demonstrated that the administration of P-selectin antibody does not adversely affect systemic coagulation as measured by viscoelastic testing, suggesting that P-selectin antibody can be safely given during the acute posttraumatic period.
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Affiliation(s)
- Linda M Schutzman
- From the Department of Surgery (L.M.S., R.R.R., Y.-L.J.L., A.N.D., P.H.L., H.B.S., B.Y., P.H.W., C.C.M., I.J.C., J.M.G., I.E.B.), University of California Davis School of Medicine; and Division of Trauma, Surgical Critical Care, and Acute Care Surgery, Department of Surgery (J.M.G, I.E.B.), University of California Davis Medical Center, Sacramento, California
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Huang J, Dai X, Zhang X, Li J, Huang M, Liu C, Zhao Z, Xiao L, Liu L, Li N, Kong J, Han X. Retrievable inferior vena cava filter to prevent pulmonary embolism in patients with fractures and deep venous thrombosis of lower extremities: a single-center experience. J Int Med Res 2021; 49:3000605211006591. [PMID: 33845601 PMCID: PMC8047091 DOI: 10.1177/03000605211006591] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective To evaluate the effectiveness of inserting a retrievable inferior vena cava filter (IVCF) to prevent pulmonary embolism (PE) in patients with bone fractures and acute deep venous thrombosis (DVT) before major orthopedic surgery. Methods Clinical data of patients with fractures and acute DVT who underwent IVCF insertion were analyzed. The patients were divided into above-knee DVT (AKDVT), popliteal vein thrombosis (PVT), and below-knee DVT (BKDVT) groups. Results An IVCF was successfully implanted in 964 patients, among whom 929 were followed up (335, 470, and 124 in AKDVT, PVT, and BKDVT groups, respectively). There was no significant difference in the incidence of filter thrombosis among the groups (11.04%, 11.70%, and 8.06%, respectively). No symptomatic PE occurred during follow-up. The mean filter indwelling time was 18.4 ± 4.3 days, and the total filter removal rate was 76.87%. There was no significant difference in the rate of filter implantation, retrieval, complications, or mortality among the groups. Conclusions Retrievable filters can effectively prevent PE before orthopedic surgery in patients with fractures and acute DVT of the lower limbs. AKDVT more readily forms a ≥1-cm thrombus in the IVCF than does BKDVT, and PVT more readily forms a <1-cm thrombus than does AKDVT.
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Affiliation(s)
- Junjie Huang
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, P.R. China.,Department of Vascular Surgery, Tianjin Hospital, Tianjin, P.R. China
| | - Xiangchen Dai
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, P.R. China
| | - Xiujun Zhang
- Department of Vascular Surgery, Tianjin Hospital, Tianjin, P.R. China
| | - Junhai Li
- Department of Vascular Surgery, Tianjin Hospital, Tianjin, P.R. China
| | - Mei Huang
- Department of Vascular Surgery, Tianjin Hospital, Tianjin, P.R. China
| | - Cunfa Liu
- Department of Vascular Surgery, Tianjin Hospital, Tianjin, P.R. China
| | - Ziyuan Zhao
- Department of Vascular Surgery, Tianjin Hospital, Tianjin, P.R. China
| | - Lei Xiao
- Department of Vascular Surgery, Tianjin Hospital, Tianjin, P.R. China
| | - Liguo Liu
- Department of Vascular Surgery, Tianjin Hospital, Tianjin, P.R. China
| | - Nan Li
- Department of Vascular Surgery, Tianjin Hospital, Tianjin, P.R. China
| | - Jingbo Kong
- Department of Vascular Surgery, Tianjin Hospital, Tianjin, P.R. China
| | - Xiaolei Han
- Department of Vascular Surgery, Tianjin Hospital, Tianjin, P.R. China
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Moore EE, Moore HB, Kornblith LZ, Neal MD, Hoffman M, Mutch NJ, Schöchl H, Hunt BJ, Sauaia A. Trauma-induced coagulopathy. Nat Rev Dis Primers 2021; 7:30. [PMID: 33927200 PMCID: PMC9107773 DOI: 10.1038/s41572-021-00264-3] [Citation(s) in RCA: 306] [Impact Index Per Article: 102.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/19/2021] [Indexed: 12/12/2022]
Abstract
Uncontrolled haemorrhage is a major preventable cause of death in patients with traumatic injury. Trauma-induced coagulopathy (TIC) describes abnormal coagulation processes that are attributable to trauma. In the early hours of TIC development, hypocoagulability is typically present, resulting in bleeding, whereas later TIC is characterized by a hypercoagulable state associated with venous thromboembolism and multiple organ failure. Several pathophysiological mechanisms underlie TIC; tissue injury and shock synergistically provoke endothelial, immune system, platelet and clotting activation, which are accentuated by the 'lethal triad' (coagulopathy, hypothermia and acidosis). Traumatic brain injury also has a distinct role in TIC. Haemostatic abnormalities include fibrinogen depletion, inadequate thrombin generation, impaired platelet function and dysregulated fibrinolysis. Laboratory diagnosis is based on coagulation abnormalities detected by conventional or viscoelastic haemostatic assays; however, it does not always match the clinical condition. Management priorities are stopping blood loss and reversing shock by restoring circulating blood volume, to prevent or reduce the risk of worsening TIC. Various blood products can be used in resuscitation; however, there is no international agreement on the optimal composition of transfusion components. Tranexamic acid is used in pre-hospital settings selectively in the USA and more widely in Europe and other locations. Survivors of TIC experience high rates of morbidity, which affects short-term and long-term quality of life and functional outcome.
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Affiliation(s)
- Ernest E Moore
- Ernest E Moore Shock Trauma Center at Denver Health, Denver, CO, USA.
- Department of Surgery, University of Colorado Denver, Aurora, CO, USA.
| | - Hunter B Moore
- Department of Surgery, University of Colorado Denver, Aurora, CO, USA
| | - Lucy Z Kornblith
- Trauma and Surgical Critical Care, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, CA, USA
| | - Matthew D Neal
- Pittsburgh Trauma Research Center, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Maureane Hoffman
- Duke University School of Medicine, Transfusion Service, Durham VA Medical Center, Durham, NC, USA
| | - Nicola J Mutch
- Aberdeen Cardiovascular & Diabetes Centre, School of Medicine, Medical Sciences and Nutrition, Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK
| | - Herbert Schöchl
- Department of Anesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Salzburg and Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, Vienna, Austria
| | | | - Angela Sauaia
- Department of Surgery, University of Colorado Denver, Aurora, CO, USA
- Colorado School of Public Health, University of Colorado Denver, Aurora, CO, USA
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Buchanan FR, Leede E, Brown LH, Teixeira PG, Aydelotte JD, Cardenas TC, Coopwood TB, Trust MD, Ali S, Brown CVR. Risk scoring models fail to predict pulmonary embolism in trauma patients. Am J Surg 2021; 222:855-860. [PMID: 33608103 DOI: 10.1016/j.amjsurg.2021.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 01/28/2021] [Accepted: 02/07/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND We aimed to identify risk factors and risk scoring models to help identify post-traumatic pulmonary embolisms (PE). METHODS We performed a retrospective review (2014-2019) of all adult trauma patients admitted to our Level I trauma center that received a CT pulmonary angiogram (CTPA) for a suspected PE. A systematic literature search found eleven risk scoring models, all of which were applied to these patients. Scores of patients with and without PE were compared. RESULTS Of the 235 trauma patients that received CTPA, 31 (13%) showed a PE. No risk scoring model had both a sensitivity and specificity above 90%. The Wells Score had the highest area under the curve (0.65). After logistic regression, no risk scoring model variables were independently associated with PE. CONCLUSIONS In trauma patients with clinically suspected PE, clinical variables and current risk scoring models do not adequately differentiate patients with and without PE.
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Affiliation(s)
- Frank R Buchanan
- Department of Surgery and Perioperative Care, Dell Seton Medical Center at the University of Texas, 1500 Red River St, Austin, TX, 78701, USA.
| | - Emily Leede
- Department of Surgery and Perioperative Care, Dell Seton Medical Center at the University of Texas, 1500 Red River St, Austin, TX, 78701, USA.
| | - Lawrence H Brown
- Department of Surgery and Perioperative Care, Dell Seton Medical Center at the University of Texas, 1500 Red River St, Austin, TX, 78701, USA.
| | - Pedro G Teixeira
- Department of Surgery and Perioperative Care, Dell Seton Medical Center at the University of Texas, 1500 Red River St, Austin, TX, 78701, USA.
| | - Jayson D Aydelotte
- Department of Surgery and Perioperative Care, Dell Seton Medical Center at the University of Texas, 1500 Red River St, Austin, TX, 78701, USA.
| | - Tatiana C Cardenas
- Department of Surgery and Perioperative Care, Dell Seton Medical Center at the University of Texas, 1500 Red River St, Austin, TX, 78701, USA.
| | - Thomas B Coopwood
- Department of Surgery and Perioperative Care, Dell Seton Medical Center at the University of Texas, 1500 Red River St, Austin, TX, 78701, USA.
| | - Marc D Trust
- Department of Surgery and Perioperative Care, Dell Seton Medical Center at the University of Texas, 1500 Red River St, Austin, TX, 78701, USA.
| | - Sadia Ali
- Department of Surgery and Perioperative Care, Dell Seton Medical Center at the University of Texas, 1500 Red River St, Austin, TX, 78701, USA.
| | - Carlos V R Brown
- Department of Surgery and Perioperative Care, Dell Seton Medical Center at the University of Texas, 1500 Red River St, Austin, TX, 78701, USA.
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Qu SW, Cong YX, Wang PF, Fei C, Li Z, Yang K, Shang K, Ke C, Huang H, Zhuang Y, Zhang BF, Zhang K. Deep Vein Thrombosis in the Uninjured Lower Extremity: A Retrospective Study of 1454 Patients With Lower Extremity Fractures. Clin Appl Thromb Hemost 2021; 27:1076029620986862. [PMID: 33426903 PMCID: PMC7802023 DOI: 10.1177/1076029620986862] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The purpose of this study was to identify patients at higher risk of deep venous thrombosis (DVT) in the uninjured lower extremity both preoperatively and postoperatively in patients with lower extremity fractures. We collected the clinical data of patients with lower extremities fractures who presented at Xi’an Honghui Hospital between 1 July, 2015 and 31 October, 2017. Doppler ultrasonography was used to diagnose the DVT. Patients were examined pre- and postoperatively. The patients were divided into thrombosis group and no thrombosis group according to the preoperative and postoperative ultrasonography results. The thrombosis group was defined as patients with DVT in the uninjured lower extremity and the no thrombosis group was defined as patients without DVT in the uninjured lower extremity. This study enrolled 1454 patients who met the inclusion criteria. The incidence of preoperative DVT in the uninjured lower extremity was 9.63% whereas the postoperative incidence was 20.29%. Age (OR = 0.965, 95 CI%: 0.954-0.977; P ≤ 0.001) and female (OR = 0.667, 95% CI: 0.451-0.986, P = 0.042) were independent risk factors for preoperative DVT in the uninjured lower extremity. Blood loss (OR = 0.997, 95 CI%: 0.995-1.000; P = 0.020), D-dimer level at admission (OR = 0.941, 95 CI%: 0.887-0.999; P = 0.045), and postoperative day 5 D-dimer level (OR = 0.889, 95 CI%: 0.819-0.965; P = 0.005), were independent risk factors for postoperative DVT in the uninjured lower extremity. For the patients with lower extremity fractures, age and female were associated with the preoperative DVT in the uninjured lower extremity. Blood loss, D-dimer at admission and postoperative day 5 D-dimer were associated with the postoperative DVT in the uninjured lower extremity.
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Affiliation(s)
- Shuang-Wei Qu
- Department of Orthopedic Trauma, Honghui Hospital, 12480Xi'an Jiaotong University, Beilin District, Xi'an, Shaanxi Province, People's Republic of China
| | - Yu-Xuan Cong
- Department of Orthopedic Trauma, Honghui Hospital, 12480Xi'an Jiaotong University, Beilin District, Xi'an, Shaanxi Province, People's Republic of China
| | - Peng-Fei Wang
- Department of Orthopedic Trauma, Honghui Hospital, 12480Xi'an Jiaotong University, Beilin District, Xi'an, Shaanxi Province, People's Republic of China
| | - Chen Fei
- Department of Orthopedic Trauma, Honghui Hospital, 12480Xi'an Jiaotong University, Beilin District, Xi'an, Shaanxi Province, People's Republic of China
| | - Zhi Li
- Department of Orthopedic Trauma, Honghui Hospital, 12480Xi'an Jiaotong University, Beilin District, Xi'an, Shaanxi Province, People's Republic of China
| | - Kun Yang
- Department of Orthopedic Trauma, Honghui Hospital, 12480Xi'an Jiaotong University, Beilin District, Xi'an, Shaanxi Province, People's Republic of China
| | - Kun Shang
- Department of Orthopedic Trauma, Honghui Hospital, 12480Xi'an Jiaotong University, Beilin District, Xi'an, Shaanxi Province, People's Republic of China
| | - Chao Ke
- Department of Orthopedic Trauma, Honghui Hospital, 12480Xi'an Jiaotong University, Beilin District, Xi'an, Shaanxi Province, People's Republic of China
| | - Hai Huang
- Department of Orthopedic Trauma, Honghui Hospital, 12480Xi'an Jiaotong University, Beilin District, Xi'an, Shaanxi Province, People's Republic of China
| | - Yan Zhuang
- Department of Orthopedic Trauma, Honghui Hospital, 12480Xi'an Jiaotong University, Beilin District, Xi'an, Shaanxi Province, People's Republic of China
| | - Bin-Fei Zhang
- Department of Orthopedic Trauma, Honghui Hospital, 12480Xi'an Jiaotong University, Beilin District, Xi'an, Shaanxi Province, People's Republic of China
| | - Kun Zhang
- Department of Orthopedic Trauma, Honghui Hospital, 12480Xi'an Jiaotong University, Beilin District, Xi'an, Shaanxi Province, People's Republic of China
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40
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Knudson MM. A Perfect Storm: 2019 Scudder Oration on Trauma. J Am Coll Surg 2020; 230:269-282. [PMID: 31794833 DOI: 10.1016/j.jamcollsurg.2019.11.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 11/20/2019] [Indexed: 11/25/2022]
Affiliation(s)
- M Margaret Knudson
- Department of Surgery, University of California, San Francisco, CA and the American College of Surgeons, Chicago, IL.
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41
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Glover TE, Sumpter JE, Ercole A, Newcombe VFJ, Lavinio A, Carrothers AD, Menon DK, O'Leary R. Pulmonary embolism following complex trauma: UK MTC observational study. Emerg Med J 2020; 36:608-612. [PMID: 31551302 DOI: 10.1136/emermed-2018-208372] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 07/17/2019] [Accepted: 08/05/2019] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To describe the incidence of pulmonary embolism (PE) in a critically ill UK major trauma centre (MTC) patient cohort. METHODS A retrospective, multidataset descriptive study of all trauma patients requiring admission to level 2 or 3 care in the East of England MTC from 1 November 2014 to 1 May 2017. Data describing demographics, the nature and extent of injuries, process of care, timing of PE prophylaxis, tranexamic acid (TXA) administration and CT scanner type were extracted from the Trauma Audit and Research Network database and hospital electronic records. PE presentation was categorised as immediate (diagnosed on initial trauma scan), early (within 72 hours of admission but not present initially) and late (diagnosed after 72 hours). RESULTS Of the 2746 trauma patients, 1039 were identified as being admitted to level 2 or 3 care. Forty-eight patients (4.6%) were diagnosed with PE during admission with 14 immediate PEs (1.3%). Of 32.1% patients given TXA, 6.3% developed PE compared with 3.8% without TXA (p=0.08). CONCLUSION This is the largest study of the incidence of PE in UK MTC patients and describes the greatest number of immediate PEs in a civilian complex trauma population to date. Immediate PEs are a rare phenomenon whose clinical importance remains unclear. Tranexamic acid was not significantly associated with an increase in PE in this population following its introduction into the UK trauma care system.
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Affiliation(s)
- Thomas E Glover
- Neurosciences and Trauma Critical Care Unit, Cambridge University Hospitals, Cambridge, UK
| | - Joanna E Sumpter
- Neurosciences and Trauma Critical Care Unit, Cambridge University Hospitals, Cambridge, UK
| | - Ari Ercole
- Neurosciences and Trauma Critical Care Unit, Cambridge University Hospitals, Cambridge, UK.,University Division of Anaesthesia, Department of Medicine, University of Cambridge, UK
| | - Virginia F J Newcombe
- Neurosciences and Trauma Critical Care Unit, Cambridge University Hospitals, Cambridge, UK.,University Division of Anaesthesia, Department of Medicine, University of Cambridge, UK
| | - Andrea Lavinio
- Neurosciences and Trauma Critical Care Unit, Cambridge University Hospitals, Cambridge, UK
| | - Andrew D Carrothers
- Orthopaedic Trauma Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - David K Menon
- Neurosciences and Trauma Critical Care Unit, Cambridge University Hospitals, Cambridge, UK.,University Division of Anaesthesia, Department of Medicine, University of Cambridge, UK
| | - Ronan O'Leary
- Neurosciences and Trauma Critical Care Unit, Cambridge University Hospitals, Cambridge, UK
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Walker PF, Schobel S, Caruso JD, Rodriguez CJ, Bradley MJ, Elster EA, Oh JS. Trauma Embolic Scoring System in military trauma: a sensitive predictor of venous thromboembolism. Trauma Surg Acute Care Open 2019; 4:e000367. [PMID: 31897437 PMCID: PMC6924724 DOI: 10.1136/tsaco-2019-000367] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 11/02/2019] [Accepted: 11/19/2019] [Indexed: 01/20/2023] Open
Abstract
Introduction Clinical decision support tools capable of predicting which patients are at highest risk for venous thromboembolism (VTE) can assist in guiding surveillance and prophylaxis decisions. The Trauma Embolic Scoring System (TESS) has been shown to model VTE risk in civilian trauma patients. No such support tools have yet been described in combat casualties, who have a high incidence of VTE. The purpose of this study was to evaluate the utility of TESS in predicting VTE in military trauma patients. Methods A retrospective cohort study of 549 combat casualties from October 2010 to November 2012 admitted to a military treatment facility in the USA was performed. TESS scores were calculated through data obtained from the Department of Defense Trauma Registry and chart reviews. Univariate analysis and multivariate logistic regression were performed to evaluate risk factors for VTE. Receiver operating characteristic (ROC) curve analysis of TESS in military trauma patients was also performed. Results The incidence of VTE was 21.7% (119/549). The median TESS for patients without VTE was 8 (IQR 4–9), and the median TESS for those with VTE was 10 (IQR 9–11). On multivariate analysis, Injury Severity Score (ISS) (OR 1.03, p=0.007), ventilator days (OR 1.05, p=0.02), and administration of tranexamic acid (TXA) (OR 1.89, p=0.03) were found to be independent risk factors for development of VTE. On ROC analysis, an optimal high-risk cut-off value for TESS was ≥7 with a sensitivity of 0.92 and a specificity of 0.53 (area under the curve 0.76, 95% CI 0.72 to 0.80, p<0.0001). Conclusions When used to predict VTE in military trauma, TESS shows moderate discrimination and is well calibrated. An optimal high-risk cut-off value of ≥7 demonstrates high sensitivity in predicting VTE. In addition to ISS and ventilator days, TXA administration is an independent risk factor for VTE development. Level of evidence Level III.
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Affiliation(s)
- Patrick F Walker
- Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Seth Schobel
- Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Joseph D Caruso
- Surgery, Landstuhl Regional Medical Center, Landstuhl, Germany
| | | | - Matthew J Bradley
- Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Eric A Elster
- Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - John S Oh
- Surgery, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
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43
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Engels PT, Thomas H, Coates A, Bakry H, Alali A, AlGhambdi A, Al-Jabri A, Bugshan A. Venous thromboembolism prophylaxis and the impact of a thrombosis service at a Canadian level 1 trauma centre. Can J Surg 2019; 62:475-481. [PMID: 31782645 DOI: 10.1503/cjs.012918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Background Venous thromboembolism (VTE) is a common and serious complication seen in patients with trauma. Guidelines recommend the routine use of pharmacologic prophylaxis; however, compliance rates vary widely. The aim of this study was to describe the clinical practice related to VTE prophylaxis in the first 24 hours after injury at our level 1 Canadian trauma centre and the impact of a thrombosis consultation service. Methods We performed a retrospective review of the health records of adult patients with trauma admitted between Jan. 1, 2012, and June 30, 2013. The rate of VTE was ascertained. The use of an initial prophylactic regimen, potential contraindications to prophylaxis and involvement of the thrombosis service were determined. Results A total of 633 patients were included, 459 men and 174 women with a mean age of 47.4 years. The mean Injury Severity Score was 15.8. The overall VTE rate was 2.8%. A total of 514 patients (81.2%) received VTE prophylaxis, mechanical in 302 (47.7%) and pharmacologic in 231 (36.5%) (19 patients received both types). The thrombosis service was involved in the care of 164 patients (25.9%). Patients seen by the thrombosis service were more likely to receive VTE prophylaxis than those not seen by the service (145 [88.4%] v. 369 [78.7%], p < 0.01). Conclusion Compliance with VTE prophylaxis administration was suboptimal, and opportunities for improvement exist. The involvement of a thrombosis consultation service appears to improve compliance with VTE prophylaxis, and augmented use of this service may improve clinical outcomes.
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Affiliation(s)
- Paul T. Engels
- From the Department of Surgery, McMaster University, Hamilton, Ont
| | - Heather Thomas
- From the Department of Surgery, McMaster University, Hamilton, Ont
| | - Angela Coates
- From the Department of Surgery, McMaster University, Hamilton, Ont
| | - Husham Bakry
- From the Department of Surgery, McMaster University, Hamilton, Ont
| | - Abdulaziz Alali
- From the Department of Surgery, McMaster University, Hamilton, Ont
| | - Ahmad AlGhambdi
- From the Department of Surgery, McMaster University, Hamilton, Ont
| | - Ahmed Al-Jabri
- From the Department of Surgery, McMaster University, Hamilton, Ont
| | - Ahmed Bugshan
- From the Department of Surgery, McMaster University, Hamilton, Ont
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Kingdon LK, Miller EM, Savage SA. The Utility of Rivaroxaban as Primary Venous Thromboprophylaxis in an Adult Trauma Population. J Surg Res 2019; 244:509-515. [DOI: 10.1016/j.jss.2019.06.079] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 05/17/2019] [Accepted: 06/19/2019] [Indexed: 11/28/2022]
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45
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Johnston LR, Rodriguez CJ, Elster EA, Bradley MJ. Evaluation of Military Use of Tranexamic Acid and Associated Thromboembolic Events. JAMA Surg 2019; 153:169-175. [PMID: 29071337 DOI: 10.1001/jamasurg.2017.3821] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Importance Since publication of the CRASH-2 and MATTERs studies, the US military has included tranexamic acid (TXA) in clinical practice guidelines. While TXA was shown to decrease mortality in trauma patients requiring massive transfusion, improper administration and increased risk of venous thromboembolism remain a concern. Objective To determine the appropriateness of TXA administration by US military medical personnel based on current Joint Trauma System clinical practice guidelines and to determine if TXA administration is associated with venous thromboembolism. Design, Setting, and Participants This cohort study of US military casualties in US military combat support hospitals in Afghanistan and a single US-based tertiary military treatment facility within the continental United States was conducted from 2011 to 2015, with follow-up through initial hospitalization and readmissions. Exposures Data collected for all patients included demographic information as well as Injury Severity Score; receipt of blood products, TXA, and/or a massive transfusion; and admission hemodynamics. Main Outcomes and Measures Variance from guidelines in TXA administration and venous thromboembolism. Tranexamic acid overuse was defined as a hemodynamically stable patient receiving TXA but not a massive transfusion, underuse was defined as a patient receiving a massive transfusion but not TXA, and TXA administration was considered delayed when given more than 3 hours after injury. Results Of the 455 identified patients, 443 (97.4%) were male, and the mean (SD) age was 25.3 (4.8) years. A total of 173 patients (38.0%) received a massive transfusion, and 139 (30.5%) received TXA in theater. Overuse occurred in 18 of 282 patients (6.4%) and underuse in 46 of 173 (26.6%) receiving massive transfusions, and delayed administration was found in 6 of 145 patients (4.3%) receiving TXA. Overuse increased at 3.3% per quarter (95% CI, 4.0-9.9; P < .001; R2 = 0.340) and underuse decreased at -4.4% per quarter (95% CI, -4.5 to -3.6; P < .001; R2 = 0.410). Tranexamic acid administration was an independent risk factor for venous thromboembolism (odds ratio, 2.58; 95% CI, 1.20-5.56; P = .02). Conclusions and Relevance Military medical personnel decreased missed opportunities to appropriately use TXA but also increased overuse. In addition, TXA administration was an independent risk factor for venous thromboembolism. A reevaluation of the use of TXA in combat casualties should be undertaken.
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Affiliation(s)
- Luke R Johnston
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Carlos J Rodriguez
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Eric A Elster
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland.,Surgical Critical Care Initiative, Bethesda, Maryland
| | - Matthew J Bradley
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland.,Surgical Critical Care Initiative, Bethesda, Maryland.,Department of Regenerative Medicine, Naval Medical Research Center, Silver Spring, Maryland
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Tachino J, Yamamoto K, Shimizu K, Shintani A, Kimura A, Ogura H, Shimazu T. Quick risk assessment profile (qRAP) is a prediction model for post-traumatic venous thromboembolism. Injury 2019; 50:1540-1544. [PMID: 31248583 DOI: 10.1016/j.injury.2019.06.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 06/11/2019] [Accepted: 06/21/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The Risk Assessment Profile (RAP) score is used as a tool of risk prediction in post-traumatic venous thromboembolism (VTE), but this scoring system is complicated to use in clinical settings due to its many variables. The objective of this study was to validate the utility of the RAP model and to develop a simpler risk prediction model for post-traumatic VTE. METHODS We conducted an observational study at two emergency and critical care centres in Japan between 2013 and 2016. Consecutive adult trauma patients who survived for 24 h or more after admission to the hospital were enroled. One prediction model (quick RAP model) was created with 6 variables based on clinical utility, experience, and thrombogenic mechanism from 17 variables in the conventional RAP model. We calculated diagnostic performance with 95% confidence interval (95% CI) by exact method. RESULTS We identified and analysed 859 patients. Twenty-six patients (3.0%) had VTE (17 with deep venous thrombosis alone, 2 with pulmonary embolism alone, and 7 with both). In the external validation, the RAP model had a sensitivity of 100% (95% CI, 86.8-100%) and specificity of 37.9% (95% CI, 34.6-41.3%). In contrast, the qRAP model had a sensitivity of 96.2% (95% CI, 80.4-99.9%) and specificity of 56.2% (95% CI, 52.7-59.6%). In the internal validation, receiver-operating characteristic curve analysis showed that the two models had similar area under the curve values that were not significantly different (0.832 and 0.800, respectively; RAP vs qRAP, p = 0.477). CONCLUSIONS We developed a practical, modified predictive model for VTE, the qRAP model, which appeared only slightly less accurate than the conventional RAP model and had the advantage of being simpler to use to predict VTE. In our dataset, the conventional RAP model was also evaluated as useful for the prediction of post-traumatic VTE.
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Affiliation(s)
- Jotaro Tachino
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Japan.
| | - Kouji Yamamoto
- Department of Medical Statistics, Osaka City University, Graduate School of Medicine, Japan
| | - Kentaro Shimizu
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Japan
| | - Ayumi Shintani
- Department of Medical Statistics, Osaka City University, Graduate School of Medicine, Japan
| | - Akio Kimura
- Department of Emergency Medicine and Critical Care, Center Hospital of the National Center for Global Health and Medicine, Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Japan
| | - Takeshi Shimazu
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Japan
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47
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Dynamic coagulability after injury: Is delaying venous thromboembolism chemoprophylaxis worth the wait? J Trauma Acute Care Surg 2019; 85:907-914. [PMID: 30124623 DOI: 10.1097/ta.0000000000002048] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Severely injured patients often progress from early hypocoagulable to normal and eventually hypercoagulable states, developing increased risk for venous thromboembolism (VTE). Prophylactic anticoagulation can decrease this risk, but its initiation is frequently delayed for extended periods due to concerns for bleeding. To facilitate timely introduction of VTE chemoprophylaxis, we characterized the transition from hypo- to hypercoagulability and hypothesized that trauma-induced coagulopathy resolves within 24 hours after injury. METHODS Serial blood samples were collected prospectively from critically injured patients for 120 hours after arrival at an urban Level I trauma center. Extrinsic thromboelastometry maximum clot firmness was used to classify patients as hypocoagulable (HYPO, <49 mm), normocoagulable (NORM, 49-71 mm), or hypercoagulable (HYPER, >71 mm) at each time point. Changes in coagulability over hospital course, VTE occurrence, and timing of prophylaxis initiation were analyzed. RESULTS 898 patients (median Injury Severity Score, 13; mortality, 12%; VTE, 8%) were enrolled. Upon arrival, 3% were HYPO (90% NORM, 7% HYPER), which increased to 9% at 6 hours before down-trending. Ninety-seven percent were NORM by 24 hours, and 53% were HYPER at 120 hours. Median maximum clot firmness began in the NORM range, up-trended gradually, and entered the HYPER range at 120 hours. Patients with traumatic brain injury (TBI) followed a similar course and were not more HYPO at any time point than those without TBI. Failure to initiate prophylaxis by 72 hours was predicted by TBI and associated with VTE development (27% vs 16%, p < 0.05). CONCLUSIONS Regardless of injury pattern, trauma-induced coagulopathy largely resolves within 24 hours, after which hypercoagulability becomes increasingly more prevalent. Deferring initiation of chemoprophylaxis, which is often biased toward patients with intracranial injuries, is associated with VTE development. LEVEL OF EVIDENCE Prognostic study, level III; Therapeutic, level IV.
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48
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Wang P, Kandemir U, Zhang B, Wang B, Li J, Zhuang Y, Wang H, Zhang H, Liu P, Zhang K. Incidence and Risk Factors of Deep Vein Thrombosis in Patients With Pelvic and Acetabular Fractures. Clin Appl Thromb Hemost 2019; 25:1076029619845066. [PMID: 31014089 PMCID: PMC6714909 DOI: 10.1177/1076029619845066] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This study aimed to investigate the incidence and risk factors for deep vein thrombosis (DVT) in patients with pelvic and acetabular fractures. Patients with pelvic or acetabular fractures were included. Demographic data, fracture classification, time to surgery, and d-dimer levels at admission and one day after surgical intervention were recorded. Duplex ultrasonography was performed in the lower extremities for DVT evaluation. All patients received mechanical and chemical thromboprophylaxis. One hundred ten patients with a mean age of 44.2 ± 13.8 years were included. There were 48 patients with pelvic fractures and 62 patients with acetabular fractures. Thirty-two (29.09%) patients sustained DVT; 21 (19.09%) patients exhibited proximal thrombosis, and 3 patients suffered pulmonary embolism. The incidence of DVT in patients with acetabular fractures was significantly higher than that of patients with pelvic fractures (χ2 = 4.42, P = .04). The incidence of proximal DVT was significantly higher in patients with complex acetabular fractures than in patients with simple acetabular fractures (χ2 = 6.65, P = .01). Multivariate analysis showed that age older than 60 years, associated injuries, and the time to surgery longer than 2 weeks were independent risk factors (P < .05). Despite mechanical and chemical thromboprophylaxis, the risk of DVT in patients with pelvic and acetabular fractures is still very high, and most of the thromboses were localized proximally. The risk of DVT is higher in patients older than 60 years, in those with associated injuries, and when the time from injury to operation is more than 2 weeks.
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Affiliation(s)
- Pengfei Wang
- 1 Department of Orthopedics and Traumatology, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Utku Kandemir
- 2 Department of Orthopaedic Surgery, University of California, San Francisco, CA, USA
| | - Binfei Zhang
- 1 Department of Orthopedics and Traumatology, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Baohui Wang
- 1 Department of Orthopedics and Traumatology, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Jiahao Li
- 3 Shaanxi University of Traditional Chinese Medicine, Xian Yang, China
| | - Yan Zhuang
- 1 Department of Orthopedics and Traumatology, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Hu Wang
- 1 Department of Orthopedics and Traumatology, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Hong Zhang
- 4 Department of Radiology, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Ping Liu
- 1 Department of Orthopedics and Traumatology, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Kun Zhang
- 1 Department of Orthopedics and Traumatology, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
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Shenoy R, Cunningham KW, Ross SW, Christmas AB, Thomas BW, Avery MJ, Lessne ML, Prasad T, Sing RF. “Death Knell” for Prophylactic Vena Cava Filters? A 20-Year Experience with a Venous Thromboembolism Guideline. Am Surg 2019. [DOI: 10.1177/000313481908500829] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The role of prophylactic vena cava filters (pVCFs) in trauma patients remains controversial. After 20 years of data collection and experience, we reviewed our venous thromboembolism guideline for the efficacy of pVCFs in preventing pulmonary embolism (PE). A retrospective cohort study was performed using our Level I trauma center registry from January 1997 thru December 2016. This population was then divided by the presence of pVCFs. Univariate analysis was performed comparing the incidence of PEs, deep vein thrombosis, and mortality between those with and without a pVCF. There were 35,658 patients identified, of whom 2 per cent (n = 847) received pVCFs. The PE rate was 0.4 per cent in both groups. The deep vein thrombosis rate for pVCFs was 3.9 per cent compared with 0.6 per cent in the no-VCF group ( P < 0.0001). Given that there was no difference in the rates of PEs between the cohorts, the subset of patients with a PE were analyzed by their risk factors. Only ventilator days > 3 were associated with a higher risk in the no-pVCF group (0.2 vs 1.5%, P = 0.033). pVCFs did not confer benefit reducing PE rate. In addition, despite their intended purpose, pVCFs cannot eliminate PEs in high-risk trauma patients, suggesting a lack of utility for prophylaxis in this population.
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Affiliation(s)
- Rathna Shenoy
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina and
| | - Kyle W. Cunningham
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina and
| | - Samuel Wade Ross
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina and
| | - A. Britton Christmas
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina and
| | - Bradley W. Thomas
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina and
| | - Michael J. Avery
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina and
| | - Mark L. Lessne
- Vascular and Interventional Specialists of Charlotte Radiology, Charlotte, North Carolina
| | - Tanushree Prasad
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina and
| | - Ronald F. Sing
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina and
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50
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Ho KM, Rao S, Honeybul S, Zellweger R, Wibrow B, Lipman J, Holley A, Kop A, Geelhoed E, Corcoran T, Misur P, Edibam C, Baker RI, Chamberlain J, Forsdyke C, Rogers FB. A Multicenter Trial of Vena Cava Filters in Severely Injured Patients. N Engl J Med 2019; 381:328-337. [PMID: 31259488 DOI: 10.1056/nejmoa1806515] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Whether early placement of an inferior vena cava filter reduces the risk of pulmonary embolism or death in severely injured patients who have a contraindication to prophylactic anticoagulation is not known. METHODS In this multicenter, randomized, controlled trial, we assigned 240 severely injured patients (Injury Severity Score >15 [scores range from 0 to 75, with higher scores indicating more severe injury]) who had a contraindication to anticoagulant agents to have a vena cava filter placed within the first 72 hours after admission for the injury or to have no filter placed. The primary end point was a composite of symptomatic pulmonary embolism or death from any cause at 90 days after enrollment; a secondary end point was symptomatic pulmonary embolism between day 8 and day 90 in the subgroup of patients who survived at least 7 days and did not receive prophylactic anticoagulation within 7 days after injury. All patients underwent ultrasonography of the legs at 2 weeks; patients also underwent mandatory computed tomographic pulmonary angiography when prespecified criteria were met. RESULTS The median age of the patients was 39 years, and the median Injury Severity Score was 27. Early placement of a vena cava filter did not result in a significantly lower incidence of symptomatic pulmonary embolism or death than no placement of a filter (13.9% in the vena cava filter group and 14.4% in the control group; hazard ratio, 0.99; 95% confidence interval [CI], 0.51 to 1.94; P = 0.98). Among the 46 patients in the vena cava filter group and the 34 patients in the control group who did not receive prophylactic anticoagulation within 7 days after injury, pulmonary embolism developed in none of those in the vena cava filter group and in 5 (14.7%) in the control group, including 1 patient who died (relative risk of pulmonary embolism, 0; 95% CI, 0.00 to 0.55). An entrapped thrombus was found in the filter in 6 patients. CONCLUSIONS Early prophylactic placement of a vena cava filter after major trauma did not result in a lower incidence of symptomatic pulmonary embolism or death at 90 days than no placement of a filter. (Funded by the Medical Research Foundation of Royal Perth Hospital and others; Australian New Zealand Clinical Trials Registry number, ACTRN12614000963628.).
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Affiliation(s)
- Kwok M Ho
- From the Departments of Intensive Care Medicine (K.M.H., J.C.), Neurosurgery (S.H.), and Radiology (P.M.), the State Trauma Unit (S.R., R.Z., C.F.), and the Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics (A.K.), Royal Perth Hospital, the Schools of Population and Global Health (K.M.H.), Allied Health (E.G.), and Medicine and Pharmacology (B.W., T.C.), University of Western Australia, and the School of Veterinary and Life Sciences (K.M.H.) and the Western Australian Centre for Thrombosis and Haemostasis (R.I.B.), Murdoch University, Perth, WA, the Departments of Neurosurgery (S.H.) and Intensive Care Medicine (B.W.), Sir Charles Gairdner Hospital, Nedlands, WA, Critical Care Services, Royal Brisbane and Women's Hospital and University of Queensland, Brisbane (J.L., A.H.), and the Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, WA (C.E.) - all in Australia; and Trauma Services, Lancaster General Hospital, University of Pennsylvania, Lancaster (F.B.R.)
| | - Sudhakar Rao
- From the Departments of Intensive Care Medicine (K.M.H., J.C.), Neurosurgery (S.H.), and Radiology (P.M.), the State Trauma Unit (S.R., R.Z., C.F.), and the Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics (A.K.), Royal Perth Hospital, the Schools of Population and Global Health (K.M.H.), Allied Health (E.G.), and Medicine and Pharmacology (B.W., T.C.), University of Western Australia, and the School of Veterinary and Life Sciences (K.M.H.) and the Western Australian Centre for Thrombosis and Haemostasis (R.I.B.), Murdoch University, Perth, WA, the Departments of Neurosurgery (S.H.) and Intensive Care Medicine (B.W.), Sir Charles Gairdner Hospital, Nedlands, WA, Critical Care Services, Royal Brisbane and Women's Hospital and University of Queensland, Brisbane (J.L., A.H.), and the Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, WA (C.E.) - all in Australia; and Trauma Services, Lancaster General Hospital, University of Pennsylvania, Lancaster (F.B.R.)
| | - Stephen Honeybul
- From the Departments of Intensive Care Medicine (K.M.H., J.C.), Neurosurgery (S.H.), and Radiology (P.M.), the State Trauma Unit (S.R., R.Z., C.F.), and the Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics (A.K.), Royal Perth Hospital, the Schools of Population and Global Health (K.M.H.), Allied Health (E.G.), and Medicine and Pharmacology (B.W., T.C.), University of Western Australia, and the School of Veterinary and Life Sciences (K.M.H.) and the Western Australian Centre for Thrombosis and Haemostasis (R.I.B.), Murdoch University, Perth, WA, the Departments of Neurosurgery (S.H.) and Intensive Care Medicine (B.W.), Sir Charles Gairdner Hospital, Nedlands, WA, Critical Care Services, Royal Brisbane and Women's Hospital and University of Queensland, Brisbane (J.L., A.H.), and the Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, WA (C.E.) - all in Australia; and Trauma Services, Lancaster General Hospital, University of Pennsylvania, Lancaster (F.B.R.)
| | - Rene Zellweger
- From the Departments of Intensive Care Medicine (K.M.H., J.C.), Neurosurgery (S.H.), and Radiology (P.M.), the State Trauma Unit (S.R., R.Z., C.F.), and the Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics (A.K.), Royal Perth Hospital, the Schools of Population and Global Health (K.M.H.), Allied Health (E.G.), and Medicine and Pharmacology (B.W., T.C.), University of Western Australia, and the School of Veterinary and Life Sciences (K.M.H.) and the Western Australian Centre for Thrombosis and Haemostasis (R.I.B.), Murdoch University, Perth, WA, the Departments of Neurosurgery (S.H.) and Intensive Care Medicine (B.W.), Sir Charles Gairdner Hospital, Nedlands, WA, Critical Care Services, Royal Brisbane and Women's Hospital and University of Queensland, Brisbane (J.L., A.H.), and the Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, WA (C.E.) - all in Australia; and Trauma Services, Lancaster General Hospital, University of Pennsylvania, Lancaster (F.B.R.)
| | - Bradley Wibrow
- From the Departments of Intensive Care Medicine (K.M.H., J.C.), Neurosurgery (S.H.), and Radiology (P.M.), the State Trauma Unit (S.R., R.Z., C.F.), and the Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics (A.K.), Royal Perth Hospital, the Schools of Population and Global Health (K.M.H.), Allied Health (E.G.), and Medicine and Pharmacology (B.W., T.C.), University of Western Australia, and the School of Veterinary and Life Sciences (K.M.H.) and the Western Australian Centre for Thrombosis and Haemostasis (R.I.B.), Murdoch University, Perth, WA, the Departments of Neurosurgery (S.H.) and Intensive Care Medicine (B.W.), Sir Charles Gairdner Hospital, Nedlands, WA, Critical Care Services, Royal Brisbane and Women's Hospital and University of Queensland, Brisbane (J.L., A.H.), and the Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, WA (C.E.) - all in Australia; and Trauma Services, Lancaster General Hospital, University of Pennsylvania, Lancaster (F.B.R.)
| | - Jeffrey Lipman
- From the Departments of Intensive Care Medicine (K.M.H., J.C.), Neurosurgery (S.H.), and Radiology (P.M.), the State Trauma Unit (S.R., R.Z., C.F.), and the Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics (A.K.), Royal Perth Hospital, the Schools of Population and Global Health (K.M.H.), Allied Health (E.G.), and Medicine and Pharmacology (B.W., T.C.), University of Western Australia, and the School of Veterinary and Life Sciences (K.M.H.) and the Western Australian Centre for Thrombosis and Haemostasis (R.I.B.), Murdoch University, Perth, WA, the Departments of Neurosurgery (S.H.) and Intensive Care Medicine (B.W.), Sir Charles Gairdner Hospital, Nedlands, WA, Critical Care Services, Royal Brisbane and Women's Hospital and University of Queensland, Brisbane (J.L., A.H.), and the Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, WA (C.E.) - all in Australia; and Trauma Services, Lancaster General Hospital, University of Pennsylvania, Lancaster (F.B.R.)
| | - Anthony Holley
- From the Departments of Intensive Care Medicine (K.M.H., J.C.), Neurosurgery (S.H.), and Radiology (P.M.), the State Trauma Unit (S.R., R.Z., C.F.), and the Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics (A.K.), Royal Perth Hospital, the Schools of Population and Global Health (K.M.H.), Allied Health (E.G.), and Medicine and Pharmacology (B.W., T.C.), University of Western Australia, and the School of Veterinary and Life Sciences (K.M.H.) and the Western Australian Centre for Thrombosis and Haemostasis (R.I.B.), Murdoch University, Perth, WA, the Departments of Neurosurgery (S.H.) and Intensive Care Medicine (B.W.), Sir Charles Gairdner Hospital, Nedlands, WA, Critical Care Services, Royal Brisbane and Women's Hospital and University of Queensland, Brisbane (J.L., A.H.), and the Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, WA (C.E.) - all in Australia; and Trauma Services, Lancaster General Hospital, University of Pennsylvania, Lancaster (F.B.R.)
| | - Alan Kop
- From the Departments of Intensive Care Medicine (K.M.H., J.C.), Neurosurgery (S.H.), and Radiology (P.M.), the State Trauma Unit (S.R., R.Z., C.F.), and the Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics (A.K.), Royal Perth Hospital, the Schools of Population and Global Health (K.M.H.), Allied Health (E.G.), and Medicine and Pharmacology (B.W., T.C.), University of Western Australia, and the School of Veterinary and Life Sciences (K.M.H.) and the Western Australian Centre for Thrombosis and Haemostasis (R.I.B.), Murdoch University, Perth, WA, the Departments of Neurosurgery (S.H.) and Intensive Care Medicine (B.W.), Sir Charles Gairdner Hospital, Nedlands, WA, Critical Care Services, Royal Brisbane and Women's Hospital and University of Queensland, Brisbane (J.L., A.H.), and the Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, WA (C.E.) - all in Australia; and Trauma Services, Lancaster General Hospital, University of Pennsylvania, Lancaster (F.B.R.)
| | - Elizabeth Geelhoed
- From the Departments of Intensive Care Medicine (K.M.H., J.C.), Neurosurgery (S.H.), and Radiology (P.M.), the State Trauma Unit (S.R., R.Z., C.F.), and the Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics (A.K.), Royal Perth Hospital, the Schools of Population and Global Health (K.M.H.), Allied Health (E.G.), and Medicine and Pharmacology (B.W., T.C.), University of Western Australia, and the School of Veterinary and Life Sciences (K.M.H.) and the Western Australian Centre for Thrombosis and Haemostasis (R.I.B.), Murdoch University, Perth, WA, the Departments of Neurosurgery (S.H.) and Intensive Care Medicine (B.W.), Sir Charles Gairdner Hospital, Nedlands, WA, Critical Care Services, Royal Brisbane and Women's Hospital and University of Queensland, Brisbane (J.L., A.H.), and the Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, WA (C.E.) - all in Australia; and Trauma Services, Lancaster General Hospital, University of Pennsylvania, Lancaster (F.B.R.)
| | - Tomas Corcoran
- From the Departments of Intensive Care Medicine (K.M.H., J.C.), Neurosurgery (S.H.), and Radiology (P.M.), the State Trauma Unit (S.R., R.Z., C.F.), and the Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics (A.K.), Royal Perth Hospital, the Schools of Population and Global Health (K.M.H.), Allied Health (E.G.), and Medicine and Pharmacology (B.W., T.C.), University of Western Australia, and the School of Veterinary and Life Sciences (K.M.H.) and the Western Australian Centre for Thrombosis and Haemostasis (R.I.B.), Murdoch University, Perth, WA, the Departments of Neurosurgery (S.H.) and Intensive Care Medicine (B.W.), Sir Charles Gairdner Hospital, Nedlands, WA, Critical Care Services, Royal Brisbane and Women's Hospital and University of Queensland, Brisbane (J.L., A.H.), and the Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, WA (C.E.) - all in Australia; and Trauma Services, Lancaster General Hospital, University of Pennsylvania, Lancaster (F.B.R.)
| | - Philip Misur
- From the Departments of Intensive Care Medicine (K.M.H., J.C.), Neurosurgery (S.H.), and Radiology (P.M.), the State Trauma Unit (S.R., R.Z., C.F.), and the Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics (A.K.), Royal Perth Hospital, the Schools of Population and Global Health (K.M.H.), Allied Health (E.G.), and Medicine and Pharmacology (B.W., T.C.), University of Western Australia, and the School of Veterinary and Life Sciences (K.M.H.) and the Western Australian Centre for Thrombosis and Haemostasis (R.I.B.), Murdoch University, Perth, WA, the Departments of Neurosurgery (S.H.) and Intensive Care Medicine (B.W.), Sir Charles Gairdner Hospital, Nedlands, WA, Critical Care Services, Royal Brisbane and Women's Hospital and University of Queensland, Brisbane (J.L., A.H.), and the Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, WA (C.E.) - all in Australia; and Trauma Services, Lancaster General Hospital, University of Pennsylvania, Lancaster (F.B.R.)
| | - Cyrus Edibam
- From the Departments of Intensive Care Medicine (K.M.H., J.C.), Neurosurgery (S.H.), and Radiology (P.M.), the State Trauma Unit (S.R., R.Z., C.F.), and the Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics (A.K.), Royal Perth Hospital, the Schools of Population and Global Health (K.M.H.), Allied Health (E.G.), and Medicine and Pharmacology (B.W., T.C.), University of Western Australia, and the School of Veterinary and Life Sciences (K.M.H.) and the Western Australian Centre for Thrombosis and Haemostasis (R.I.B.), Murdoch University, Perth, WA, the Departments of Neurosurgery (S.H.) and Intensive Care Medicine (B.W.), Sir Charles Gairdner Hospital, Nedlands, WA, Critical Care Services, Royal Brisbane and Women's Hospital and University of Queensland, Brisbane (J.L., A.H.), and the Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, WA (C.E.) - all in Australia; and Trauma Services, Lancaster General Hospital, University of Pennsylvania, Lancaster (F.B.R.)
| | - Ross I Baker
- From the Departments of Intensive Care Medicine (K.M.H., J.C.), Neurosurgery (S.H.), and Radiology (P.M.), the State Trauma Unit (S.R., R.Z., C.F.), and the Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics (A.K.), Royal Perth Hospital, the Schools of Population and Global Health (K.M.H.), Allied Health (E.G.), and Medicine and Pharmacology (B.W., T.C.), University of Western Australia, and the School of Veterinary and Life Sciences (K.M.H.) and the Western Australian Centre for Thrombosis and Haemostasis (R.I.B.), Murdoch University, Perth, WA, the Departments of Neurosurgery (S.H.) and Intensive Care Medicine (B.W.), Sir Charles Gairdner Hospital, Nedlands, WA, Critical Care Services, Royal Brisbane and Women's Hospital and University of Queensland, Brisbane (J.L., A.H.), and the Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, WA (C.E.) - all in Australia; and Trauma Services, Lancaster General Hospital, University of Pennsylvania, Lancaster (F.B.R.)
| | - Jenny Chamberlain
- From the Departments of Intensive Care Medicine (K.M.H., J.C.), Neurosurgery (S.H.), and Radiology (P.M.), the State Trauma Unit (S.R., R.Z., C.F.), and the Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics (A.K.), Royal Perth Hospital, the Schools of Population and Global Health (K.M.H.), Allied Health (E.G.), and Medicine and Pharmacology (B.W., T.C.), University of Western Australia, and the School of Veterinary and Life Sciences (K.M.H.) and the Western Australian Centre for Thrombosis and Haemostasis (R.I.B.), Murdoch University, Perth, WA, the Departments of Neurosurgery (S.H.) and Intensive Care Medicine (B.W.), Sir Charles Gairdner Hospital, Nedlands, WA, Critical Care Services, Royal Brisbane and Women's Hospital and University of Queensland, Brisbane (J.L., A.H.), and the Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, WA (C.E.) - all in Australia; and Trauma Services, Lancaster General Hospital, University of Pennsylvania, Lancaster (F.B.R.)
| | - Claire Forsdyke
- From the Departments of Intensive Care Medicine (K.M.H., J.C.), Neurosurgery (S.H.), and Radiology (P.M.), the State Trauma Unit (S.R., R.Z., C.F.), and the Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics (A.K.), Royal Perth Hospital, the Schools of Population and Global Health (K.M.H.), Allied Health (E.G.), and Medicine and Pharmacology (B.W., T.C.), University of Western Australia, and the School of Veterinary and Life Sciences (K.M.H.) and the Western Australian Centre for Thrombosis and Haemostasis (R.I.B.), Murdoch University, Perth, WA, the Departments of Neurosurgery (S.H.) and Intensive Care Medicine (B.W.), Sir Charles Gairdner Hospital, Nedlands, WA, Critical Care Services, Royal Brisbane and Women's Hospital and University of Queensland, Brisbane (J.L., A.H.), and the Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, WA (C.E.) - all in Australia; and Trauma Services, Lancaster General Hospital, University of Pennsylvania, Lancaster (F.B.R.)
| | - Frederick B Rogers
- From the Departments of Intensive Care Medicine (K.M.H., J.C.), Neurosurgery (S.H.), and Radiology (P.M.), the State Trauma Unit (S.R., R.Z., C.F.), and the Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics (A.K.), Royal Perth Hospital, the Schools of Population and Global Health (K.M.H.), Allied Health (E.G.), and Medicine and Pharmacology (B.W., T.C.), University of Western Australia, and the School of Veterinary and Life Sciences (K.M.H.) and the Western Australian Centre for Thrombosis and Haemostasis (R.I.B.), Murdoch University, Perth, WA, the Departments of Neurosurgery (S.H.) and Intensive Care Medicine (B.W.), Sir Charles Gairdner Hospital, Nedlands, WA, Critical Care Services, Royal Brisbane and Women's Hospital and University of Queensland, Brisbane (J.L., A.H.), and the Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, WA (C.E.) - all in Australia; and Trauma Services, Lancaster General Hospital, University of Pennsylvania, Lancaster (F.B.R.)
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