Early venous thromboembolism chemoprophylaxis in combat-related penetrating brain injury.
OBJECTIVE Traumatic brain injury (TBI) is independently associated with deep vein thrombosis (DVT) and pulmonary embolism (PE). Given the numerous studies of civilian closed-head injury, the Brain Trauma Foundation recommends venous thromboembolism chemoprophylaxis (VTC) after severe TBI. No studies have specifically examined this practice in penetrating brain injury (PBI). Therefore, the authors examined the safety and effectiveness of early VTC after PBI with respect to worsening intracranial hemorrhage and DVT or PE. METHODS The Kandahar Airfield neurosurgery service managed 908 consults between January 2010 and March 2013. Eighty of these were US active duty members with PBI, 13 of whom were excluded from analysis because they presented with frankly nonsurvivable CNS injury or they died during initial resuscitation. This is a retrospective analysis of the remaining 67 patients. RESULTS Thirty-two patients received early VTC and 35 did not. Mean time to the first dose was 24 hours. Fifty-two patients had blast-related PBI and 15 had gunshot wounds (GSWs) to the head. The incidence of worsened intracranial hemorrhage was 16% after early VTC and 17% when it was not given, with the relative risk approaching 1 (RR = 0.91). The incidence of DVT or PE was 12% after early VTC and 17% when it was not given (RR = 0.73), though this difference was not statistically significant. CONCLUSIONS Early VTC was safe with regard to the progression of intracranial hemorrhage in this cohort of combat-related PBI patients. Data in this study suggest that this intervention may have been effective for the prevention of DVT or PE but not statistically significantly so. More research is needed to clarify the safety and efficacy of this practice.
F. Edward Hébert School of Medicine.
R Michael
RM
Meyer
F. Edward Hébert School of Medicine.
M Benjamin
MB
Larkin
F. Edward Hébert School of Medicine.
Nicholas S
NS
Szuflita
Division of Neurosurgery, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, Maryland.
Chris J
CJ
Neal
Division of Neurosurgery, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, Maryland.|Department of Neurosurgery, Naval Medical Center San Diego, California.
Jeffrey M
JM
Tomlin
Division of Neurosurgery, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, Maryland.|Department of Neurosurgery, Georgetown University, Washington, DC; and.
Rocco A
RA
Armonda
Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, Maryland.
Jeffrey A
JA
Bailey
Division of Neurosurgery, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, Maryland.
Randy S
RS
Bell
D000328:Adult; D000070642:Brain Injuries, Traumatic / Q000453:epidemiology / Q000209:etiology / Q000628:therapy*; D018890:Chemoprevention; D020197:Head Injuries, Penetrating / Q000453:epidemiology / Q000209:etiology / Q000628:therapy*; D006801:Humans; D015994:Incidence; D020300:Intracranial Hemorrhages / Q000453:epidemiology / Q000209:etiology / Q000628:therapy; D008297:Male; D011655:Pulmonary Embolism / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control; D012189:Retrospective Studies; D012306:Risk; D061665:Time-to-Treatment; D054556:Venous Thromboembolism / Q000453:epidemiology / Q000209:etiology* / Q000517:prevention & control*; D020246:Venous Thrombosis / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control; D014857:Warfare; D055815:Young Adult
AIS = Abbreviated Injury Scale; DVT = deep vein thrombosis; GSW = gunshot wound (to the head); ICH = intracranial hemorrhage; ISS = Injury Severity Score; KAF = Kandahar Airfield; PBI = penetrating brain injury; PE = pulmonary embolism; RR = relative risk; TBI = traumatic brain injury; TXA = tranexamic acid; UFH = unfractionated heparin; USAISR = US Army Institute of Surgical Research; VTC = VTE chemoprophylaxis; VTE = venous thromboembolism; aGCS = admission Glasgow Coma Scale; aRR = adjusted relative risk; military neurosurgery; penetrating brain injury; trauma; traumatic brain injury; venous thromboembolism chemoprophylaxis