Colombia Case Report

Site: Hospital Universitario San Ignacio, Bogotá, Colombia

Case

THe patient is an 85 year-old female presenting after a mechanical fall downstairs two weeks ago. Since the fall, she has constant right-sided rib posterior pain, unrelieved by topical diclofenac. She now suffers from 2 days of progressive shortness of breath with associated dry cough. Her breathing worsens when lying flat. Today, she states that she was seen by an outpatient provider who referred her to the ED for imaging and further work-up.

She denies fevers and abdominal pain, but does report some cloudy urine, for which she recently took a course of antibiotics.

The patient has a past medical history of nonobstructive hypertrophic cardiomyopathy, preserved EF 55%, but notable diastolic dysfunction. She has a Medtronic pacemaker in place and a history of coronary artery disease without myocardial infarction. She takes medication for hyperlipidemia, hypertension, and hypothyroidism. She has not been hospitalized in two years.

She lives with family and has a remote history of tobacco use.

Physical Exam

Vtials

  • BP 136/74       

  • HR 73          

  • RR 28       

  • Afebrile 

  • SpO2 is 74% on room air, improved to 88% on 8L NC, increased to 40% FiO2 Venturi mask 

She is alert and in no distress, has significant tenderness to the right side and posterior ribs. Breath sounds are diminished on the right side. She has no notable spinal tenderness or neuromuscular deficit, but has non-pitting edema in the lower extremities.

ED Course

The patient’s labs demonstrate anemia, Hgb 10.3, with an elevated troponin and BNP.

A CTA chest is performed and shows bilateral central pulmonary emboli with evidence of right heart strain, 10-11th rib fractures with an associated hemothorax and no active contrast extravasation.

A diagnostic/therapeutic thoracentesis is performed with 1L sanguineous drainage. Providers opted not to leave a thoracostomy tube at that time.

A Pulmonary Embolism Severity Index (PESI) score is calculated to be 109 with an Injury Severity Score (ISS) of 16. ED providers discussed with the Pulmonary Embolism Response Team (PERT) regarding further management and given presence of hemothorax, the patient had an IVC filter placed with deferred anticoagulation for 1 week. It is further decided that if she decompensates, she would undergo mechanical thrombectomy. The patient is admitted to the medicine service for monitoring and given prophylactic-dose enoxaparin.

Kaul and Paniagua [CC BY 2.0 (https://creativecommons.org/licenses/by/2.0)]

Kaul and Paniagua [CC BY 2.0 (https://creativecommons.org/licenses/by/2.0)]

James Heilman, MD [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)]

James Heilman, MD [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)]

Discussion

Coagulopathy post-trauma

  • DVT post-trauma is a significant risk. In a 1994 NEJM observational study of trauma patients hospitalized without prophylaxis, 50% (65 of 129) patients with trauma to the face, chest, or abdomen developed DVT. Fracture of the tibia or fibula had a 5x odds ratio (OR) risk, and spinal cord injury 8.5x OR of forming a DVT. [1] 

  • Journal of Trauma 2003 found that obesity and prolonged immobilization (>3 days) were independent predictors of DVT.  Here, patterns of injury and higher ISS scores were not predictors aside from how they impacted prolonged immobility, which in turn was associated with increased risk.[2]

  • The Journal of Surgical Research in 2017 retrospectively identified 5 risk factors that were independent predictors of DVT in their research: [3]

    • >4 transfusions in initial 24 hours

    • GCS <8 for 4+ hours

    • Pelvic fractures

    • Patients undergoing 2+ hour operations

    • Age 40-59 years

  • Clinically detecting signs of VTE (venous thromboembolism) can be difficult as vital sign abnormalities can often be secondary to atelectasis, pulmonary contusion, pain, or other injuries.[4]

  • PE is seen in 2-20% trauma patients.[5]

  • Fatal PE is the 3rd most common cause of death in trauma >24 hours.[5]

VTE prophylaxis in trauma: Mechanical and Pharmaceutical

Mechanical:

  • An example of mechanical prophylaxis is an intermittent pneumatic compression (IPC) device

  • Patients suffering lower extremity trauma may not be able to comply with IPC devices.

  • A meta-analysis out of Medellín, Colombia, demonstrated reduced DVT in mechanical prophylaxis compared to no prophylaxis, but noted no change in rates of PE or mortality. [6]

 Pharmaceutical:

  • 1996 NEJM study demonstrated improved prophylaxis using low molecular weight heparin (enoxaparin) compared to unfractionated heparin (heparin) in trauma patients [5]

  • Two retrospective studies in the 2017 Journal of Trauma Acute Care Surgery again demonstrated LMWH is associated with a lower rate of PE in trauma patients compared to twice-daily heparin. [7,8]

  • However, 3-times daily heparin has been shown to be noninferior to LMWH.[9,10]

  • Notably, this may be of significant consideration to lower-resource environments where cost savings can be crucial.

Combination:

  • 2008 meta-analysis concluded that the dual use of mechanical and pharmaceutical prophylaxis is superior to pharmaceutical alone in high-risk patients. [11]

Vena Cava Filters:

  • Can be placed in the IVC, less commonly the SVC for upper extremity DVTs

  • Two types: permanent and retrievable

  • Indicated for patients who have failed, have complications from, or contraindications to anticoagulation

  • Recurrent PE in patients with a filter is estimated 2-4% [12]

  • Filters have not been shown to add any additional benefit to patients that can be anticoagulated. [13]

  • Filters have associated complications, which include higher rates of lower extremity or filter thrombosis, venous stasis ulcers, misplacement or migration, and venous perforation.

  • Retrospective study has linked filters with higher 30- day mortality in those with contraindications to anticoagulation. This may be due to the population in which they are placed. [14]

  •  Controversially, retrospective study of filters has been associated with lower mortality specifically in patients who cannot be anticoagulated secondary to active bleeding. [15]

  • Currently the FDA advises close follow-up and retrieval in patients with filters placed for transiently increased PE risks, ideally between 24-59 days post-placement. [16]  

  • In general, prophylactic filters are not recommended, but may be beneficial in the select high-risk trauma patient. Further randomized trials are needed. [4]

 Conclusions

  • Trauma patients are at an increased risk of thrombosis.

  • Combined mechanical and pharmaceutic prophylaxis is best, but one or the other is better than none.

  • In choosing pharmaceutical prophylaxis, LMWH is superior to twice-daily heparin, but was shown to be equivocal to 3x-daily dosing.

  • Unfractionated heparin may be superior when decreased renal function or cost is of significant consideration.

  • IVC filters can carry a burden of complications

  • In the select high-risk patient, where other forms of prophylaxis are contraindicated, filters may be beneficial. This may specifically apply to patients with active bleeding.

  • Filters should be removed as soon as they are no longer needed if they are retrievable. 

Faculty Reviewers: Drs. Kyle Dennison Martin and Melanie Lippmann

References:

  1. Geerts, W. H., Code, K. I., Jay, R. M., Chen, E., & Szalai, J. P. (1994, December 15). A prospective study of venous thromboembolism after major trauma. Retrieved May 24, 2019, from https://www.ncbi.nlm.nih.gov/pubmed?term=7969340

  2. Meissner, M. H., Chandler, W. L., & Elliott, J. S. (2003, February). Venous thromboembolism in trauma: A local manifestation of systemic hypercoagulability? Retrieved May 24, 2019, from https://www.ncbi.nlm.nih.gov/pubmed?term=12579044

  3. Meizoso, J. P., Karcutskie, 4. T., Ray, J. J., Ruiz, X., Ginzburg, E., Namias, N., . . . Proctor, K. G. (2017, January). A simplified stratification system for venous thromboembolism risk in severely injured trauma patients. Retrieved May 24, 2019, from https://www.ncbi.nlm.nih.gov/pubmed?term=27979470

  4. Benjamin, E. (n.d.). Thromboembolism and prevention in the severely injured trauma patient. Retrieved May 24, 2019, from https://www.uptodate.com/contents/thromboembolism-and-prevention-in-the-severely-injured-trauma-patient?search=IVC filter&topicRef=8212&source=see_link

  5. Geerts, W. H., Jay, R. M., Code, K. I., Chen, E., Szalai, J. P., Saibil, E., & Hamilton, P. (1996, September 5). A Comparison of Low-Dose Heparin with Low-Molecular-Weight Heparin as Prophylaxis against Venous Thromboembolism after Major Trauma | NEJM. Retrieved May 24, 2019, from https://www.nejm.org/doi/10.1056/NEJM199609053351003?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub=www.ncbi.nlm.nih.gov

  6. Barrera, L. M., Perel, P., Ker, K., Cirocchi, R., Farinella, E., & Morales, C. H. (2013, March 28). Thromboprophylaxis for trauma patients. Retrieved May 24, 2019, from https://www.ncbi.nlm.nih.gov/pubmed?term=23543562

  7. Byrne, J. P., Geerts, W., Mason, S. A., Gomez, D., Hoeft, C., Murphy, R., . . . Nathens, A. B. (2017, February). Effectiveness of low-molecular-weight heparin versus unfractionated heparin to prevent pulmonary embolism following major trauma: A propensity-matched analysis. Retrieved May 24, 2019, from https://www.ncbi.nlm.nih.gov/pubmed?term=27906870

  8. Jacobs, B. N., Cain-Nielsen, A. H., Jakubus, J. L., Mikhail, J. N., Fath, J. J., Regenbogen, S. E., & Hemmila, M. R. (2017, July). Unfractionated heparin versus low-molecular-weight heparin for venous thromboembolism prophylaxis in trauma. Retrieved May 24, 2019, from https://www.ncbi.nlm.nih.gov/pubmed?term=28426561

  9. Arnold, J. D., Dart, B. W., Barker, D. E., Maxwell, R. A., Burkholder, H. C., Mejia, V. A., . . . Longley, J. M. (2010, June). Gold Medal Forum Winner. Unfractionated heparin three times a day versus enoxaparin in the prevention of deep vein thrombosis in trauma patients. Retrieved May 24, 2019, from https://www.ncbi.nlm.nih.gov/pubmed?term=20583509

  10. Olson, E. J., Bandle, J., Calvo, R. Y., Shackford, S. R., Dunne, C. E., Van, J. M., . . . Sise, C. B. (2015, December). Heparin versus enoxaparin for prevention of venous thromboembolism after trauma: A randomized noninferiority trial. Retrieved May 24, 2019, from https://www.ncbi.nlm.nih.gov/pubmed?term=26317819

  11. Kakkos, S. K., Caprini, J. A., Geroulakos, G., Nicolaides, A. N., Stansby, G. P., & Reddy, D. J. (2008, October 08). Combined intermittent pneumatic leg compression and pharmacological prophylaxis for prevention of venous thromboembolism in high-risk patients. Retrieved May 24, 2019, from https://www.ncbi.nlm.nih.gov/pubmed?term=18843686

  12. Fedullo, P. F., & Roberts, A. (2019, May 16). Placement of vena cava filters and their complications. Retrieved May 24, 2019, from https://www.uptodate.com/contents/placement-of-vena-cava-filters-and-their-complications?search=IVC filter&source=search_result&selectedTitle=1~57&usage_type=default&display_rank=1#H22564719

  13. Decousus, H., Leizorovicz, A., Parent, F., Page, Y., Tardy, B., Girard, P., . . . Simonneau, G. (1998, February 12). A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis. Prévention du Risque d'Embolie Pulmonaire par Interruption Cave Study Group. Retrieved May 24, 2019, from https://www.ncbi.nlm.nih.gov/pubmed?term=9459643

  14. Turner, T. E. (2018, July 13). Inferior Vena Cava Filter Placement and 30-Day Mortality. Retrieved May 24, 2019, from https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2687385

  15. White, R., Brunson, A., Romano, P., Li, Z., & Wun, T. (2016, May 24). Outcomes After Vena Cava Filter Use in Noncancer Patients With Acute Venous Thromboembolism. Retrieved May 24, 2019, from https://www.ahajournals.org/doi/full/10.1161/CIRCULATIONAHA.115.020338?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub=pubmed

  16. Morales, J. P., Li, X., Irony, T. Z., Ibrahim, N. G., Moynahan, M., & Cavanaugh, K. J. (2013, October). Decision analysis of retrievable inferior vena cava filters in patients without pulmonary embolism. Retrieved May 24, 2019, from https://www.ncbi.nlm.nih.gov/pubmed/26992759

Ashley GrayGlobal EMComment