title: Evaluation of a disease management plan for prevention and diagnosis of thromboembolic disease in major trauma patients.
abstract: Evaluate the effectiveness of our program of thromboembolic disease (TED) prophylaxis.Multisystem trauma patients with closed head injury, spinal cord injury, and/or long bone/pelvic fractures severe enough to require inpatient rehabilitation are at high risk for TED: deep venous thrombosis (DVT) and pulmonary embolism (PE). A retrospective analysis of 262 such trauma patients, from September 1995 through July 1997, was performed to evaluate the effectiveness of our program of TED prophylaxis. Mechanical compression devices (CDs) and/or anticoagulation treatment were the primary methods of prophylaxis. If clinical suspicion of TED was present, duplex ultrasound (DU) was used. Otherwise, patients were screened once by DU before transfer to a rehabilitation facility.There was 99% compliance with prophylaxis use. One hundred one patients died of injuries less than 48 hours after admission. Forty-four patients died in the hospital more than 48 hours after admission; 4 (9%) had TED manifest as DVTs (3 patients; 66% at the level of the popliteal or above) and PE (1 patient; 2%). One hundred seventeen patients survived and were transferred to rehabilitation facilities. Fourteen of these (12%) had TED manifest as DVTs (13 patients; 71% at the level of the popliteal or above) before transfer and PE (1 patient; 1%). Three patients developed DVTs without PEs during 2-month follow-up in rehabilitation. Of the 14 patients who developed TED, 7 had prophylaxis with CDs alone and 5 had CDs plus heparin, aspirin, or caval filter (CD+), an incidence of 11%. Increased injury severity score and increased length of stay were associated with development of TED (p < 0.05). Forty-two percent of patients with TED were suspected on the basis of clinical examination and confirmed by DU; 9 of 105 (8.5%) were found exclusively by the single DU screening of clinically negative lower extremities.The compliance rate for TED prophylaxis in these severely injured trauma patients was high. An 11% incidence of TED was found in this population; 4 of 160 patients (2.5%) died with or from TED. Compression devices alone or CD+ offered equal prophylaxis. Single DU screening of clinically negative lower extremities demonstrated an 8.6% incidence of TED; clinical suspicion of TED as an indication for DU screening increased positive findings to 42%.
authors.affiliation: University of Missouri-Columbia Health Sciences Center, Columbia, Missouri, USA
authors.initials: ME
authors.lastname: Keller
authors.initials: MH
authors.lastname: Metzler
authors.initials: JO
authors.lastname: Phillips
authors.initials: RE
authors.lastname: Huckfeldt
authors.initials: DP
authors.lastname: Spadone