Evaluation of a disease management plan for prevention and diagnosis of thromboembolic disease in major trauma patients

Abstract

Purpose Evaluate the effectiveness of our program of thromboembolic disease (TED) prophylaxis. Methods 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. Results 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. Conclusions 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%.