Pulmonary Embolism In Trauma Patients Research Articles

A Nationwide Analysis on the Origins of De Novo Pulmonary Embolism in Trauma Patients: Does the Liver Play a Role?

INTRODUCTION: The trauma literature coined the concept of de novo pulmonary embolism (DNPE) to describe the presence of pulmonary embolism without deep vein thrombosis. Most surmise DNPE stems from localized pulmonary inflammatory changes (Figure). Considering the liver’s proximity to the lungs and its importance in inflammation and coagulation, our team published previous institutional data suggesting liver injury may play a central role in DNPE formation. The purpose of this study was to validate the relationship between liver injury and DNPE using a national trauma database.Figure.: DNPE, de novo pulmonary embolism.METHODS: We identified all blunt trauma patients in the National Trauma Data Bank 2018 dataset. Patients were divided and compared based on whether they suffered liver injury. Our primary outcome was the incidence of DNPE, defined as pulmonary embolism in the absence of deep vein thrombosis. Patients without peripheral duplex studies were excluded. Multivariate regression was used to identify independent risk factors for DNPE formation. RESULTS: In total, we identified 26,592 patients. Compared with non–liver injury patients, liver injury patients had a higher incidence of DNPE (3.4% vs 1.6%; p < 0.05). On multivariate analysis, increased Injury Severity Score (odds ratio [OR] 2.8), Black race (OR 2.1), liver injury (OR 1.9), and multiple bilateral rib fractures (OR 1.6) were independent predictors of DNPE formation. CONCLUSION: This is the first nationwide review to implicate liver injury as a contributing factor in DNPE. Based on our findings, we propose a model for de novo clot formation that involves localized trauma as well as regional thromboembolic and systemic effects of liver injury and polytrauma.

Clinical Characteristics and Risk Factors for Early versus Late Pulmonary Embolism in Trauma Patients: A Retrospective, Observational Study.

BackgroundWe sought to evaluate the clinical characteristics and risk factors for early versus late pulmonary embolism (PE) in trauma patients.MethodsThis 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).ResultsThe 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.ConclusionOne-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.

Increasing Rate of Pulmonary Embolism in Trauma Patients at a Level One Trauma Center: An Opportunity for Quality Improvement?

IntroductionPulmonary embolism (PE) is the most common cause of preventable hospital death in trauma patients, with 100,000 patients dying from PE annually. A steadily increasing PE rate was observed over seven years in the trauma population at a single level one trauma center. Our study seeks to analyze this trend by examining risk factors and searching for targets for improvement. We hypothesized that a change in one or more modifiable risk factors was associated with the increased PE rate. MethodsThis retrospective cohort study considered trauma patients admitted to our trauma center between 2012 and 2018. The change in PE rate over time and correlation with various risk factors were examined using logistic regression. The study population was divided into two cohorts: early (2012-2015), and late (2016-2018). Data were collected from a prospectively maintained trauma database. More detailed information was obtained from individual patient charts for 533 patients worked up for PE. Risk factors were evaluated using both univariate and multivariate analysis.ResultsA total of 14,986 trauma patients were included in the study, of which 132 were diagnosed with PE. The PE rate was 1.11% in the late group compared to 0.67% in the early group (p=.004). We detected no association between the PE rate and preventive measures such as screening for and treating deep venous thrombosis (DVT), placing inferior vena cava (IVC) filters, and patterns of chemical DVT prophylaxis. We did not observe a distal migration of the anatomic distribution of PEs on CT pulmonary angiogram (CTPA). There were nonsignificant trends between PE rate and changes in population demographics and injury patterns, increased frequency of major surgery, and increased tranexamic acid (TXA) use. Of known risk factors for PE, units of packed red blood cells (PRBC) (p=0.041), units of fresh frozen plasma (FFP) (p=.037), and the number of patients receiving transfusion (p=0.043) were all significantly greater in the later period.ConclusionChange in hemostatic resuscitation practices (use of balanced ratios of blood products) is most likely to have contributed to the increased PE rate at our institution. However, PE in trauma is multifactorial, and the increased rate cannot be attributed to any single factor. We did not observe a lapse in preventive measures commonly considered indices of quality of care. Caution is advised against overreliance on PE rate as a measure of quality.

Origins of De Novo Pulmonary Embolism in Trauma Patients: Does the Liver Play a Role?

Origins of De Novo Pulmonary Embolism in Trauma Patients: Does the Liver Play a Role?

Risk scoring models fail to predict pulmonary embolism in trauma patients

BackgroundWe aimed to identify risk factors and risk scoring models to help identify post-traumatic pulmonary embolisms (PE). MethodsWe 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. ResultsOf 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. ConclusionsIn trauma patients with clinically suspected PE, clinical variables and current risk scoring models do not adequately differentiate patients with and without PE.

A Systems-based Approach to Reduce Deep Venous Thrombosis and Pulmonary Embolism in Trauma Patients.

Venous thromboembolism (VTE) in trauma patients carries significant morbidity and mortality. We previously described how titrating enoxaparin dosing by anti-Xa trough levels was associated with a lower VTE rate. We combined this strategy with a higher initial enoxaparin dose for a majority of patients and modified the electronic medical record (EMR) to encourage immediate dosing. We sought to determine if this systems-based approach was associated with a decrease in VTE rate. A retrospective review was conducted of all trauma patients on prophylactic enoxaparin at an academic, Level I Trauma Center from 01/2013 to 05/2014 (PRE) and 06/2015 to 02/2018 (POST). The patients in PRE were prescribed enoxaparin 30mg twice daily without dose adjustments. The patients in POST received 40mg twice daily unless exclusion criteria applied, with doses titrated to maintain anti-Xa trough levels between 0.1 and 0.2IU/mL. There were 478 patients in the PRE and 1306 in the POST. Compared to PRE, POST patients were of similar age and were as likely to present after blunt trauma, although POST patients had lower injury severity scores (10 vs. 9, p < 0.01). The overall VTE rate was lower in POST (6.9% vs. 3.6%, p < 0.01). The adjusted risk of VTE (AOR 0.61, adjusted p = 0.04) was lower in POST and POST was independently protective for VTE (AOR 0.54; p = 0.01). By implementing system changes to improve enoxaparin dosing after trauma, a significant reduction in VTE rate was observed. Wider application of this strategy should be considered.

Clinical Indicators and Risk Scoring Models Fail to Predict Pulmonary Embolism in Trauma Patients

Clinical Indicators and Risk Scoring Models Fail to Predict Pulmonary Embolism in Trauma Patients

Asymptomatic Trauma Patients Screened for Venous Thromboembolism Have a Higher Risk Profile with Lower Rate of Pulmonary Embolism: A Five-Year Single-Institution Experience

Deep vein thrombosis (DVT) is linked to reimbursements and publicly reported metrics. Some hospitals discourage venous duplex ultrasound (VDUS) screening in asymptomatic trauma patients because they often find higher rates of DVT. We aim to evaluate the association between lower extremity (LE) VDUS screening and pulmonary embolism (PE) in trauma patients. Trauma patients admitted to an urban Level-1 trauma center between 2010 and 2015 were retrospectively analyzed. We characterized the association of asymptomatic LE VDUSs with PE, upper extremity DVT, proximal LE DVT, and distal LE DVT by univariate and multivariable logistic regression controlling for confounders. Of the 3959 trauma patients included in our study-after adjusting for covariates related to patient demographics, injury, and procedures-there was a significantly lower likelihood of PE in screened patients (odds ratio (OR) = 0.02, P < 0.001) and a higher rate of distal LE DVT (OR 11.1, P = 0.004). Screening was not associated with higher rates of proximal LE DVT after adjustment for covariates (OR = 1.8, P = 0.193). PE was associated with patient transfer status, pelvis fracture, and spinal procedures in unscreened patients. After adjusting for covariates, we have shown that LE VDUS asymptomatic screening is associated with lower rates of PE in trauma patients and not associated with higher rates of proximal LE DVT. Our detailed institutional review of a large cohort of trauma patients over five years provides support for ongoing asymptomatic screening and better characterizes venous thromboembolism outcomes than similarly sized purely administrative data reviews. As a retrospective cohort study with a large sample size, no loss to follow-up, and a population with low heterogeneity, this study should be considered as level III evidence for care management.

Early Versus Late Pulmonary Embolism in Trauma Patients: Not All Pulmonary Embolisms are Created Similarly

BackgroundPulmonary embolism (PE) is an uncommon complication occurring in up to 5% of trauma patients. In small previous studies, patients with long-bone fractures were associated with a higher risk of early PE while those with severe head injuries were at higher risk for late PE. Materials and methodsThis was a retrospective analysis at a single level I trauma center from 2010 to 2017. Patients with early PE (≤4 d) were compared to those with late PE (>4 d) using bivariate analysis and multivariable logistic regression analysis. We sought to confirm risk factors for early and late PE, hypothesizing that early PE is associated with long-bone fractures and late PE is associated with above-the-knee deep venous thrombosis (DVT). ResultsFrom 12,833 trauma admissions, 76 patients (0.6%) had a PE. Of these, 33 (43.4%) had an early PE and 43 (54.6%) were diagnosed with late PE. After adjusting for covariates, independent risk factors for late PE included above-the-knee DVT (odds ratio [OR] = 12.01, confidence interval [CI] = 1.34-107.52, P = 0.03), blood transfusion (OR = 8.99, CI = 1.75-46.22, P = 0.009), and craniotomy (OR = 8.82, CI = 1.03-75.97, P = 0.04), while the only independent risk factor for early PE was smoking (OR = 4.56, CI 1.06-19.66, P = 0.04). Severe head injury and long-bone fractures were not risk factors for early or late PE (P > 0.05) ConclusionsThe strongest risk factor for late PE is above-the-knee DVT. Contrary to previous reports, long-bone extremity fractures and severe head injuries are not associated with early or late PE. The only risk factor for early PE was a history of smoking.

Cost-Effectiveness of Early CT in Suspected Pulmonary Embolism in Trauma Patients: A Decision-Analytical Model

Journal of the American College of Surgeons 227(4):p S143, October 2018. | DOI: 10.1016/j.jamcollsurg.2018.07.302

Review article: Do inferior vena cava filters prevent pulmonary embolism in critically ill trauma patients and does the benefit outweigh the risk of insertion? A narrative review article.

Venous thromboembolic disease (VTE) increases the risk of mortality in trauma patients. To decrease the occurrence of VTE, low dose anticoagulants are commonly prescribed. This may be unacceptable in trauma patients who have a high risk of bleeding. Inferior vena cava (IVC) filters can be employed as an alternative strategy to decrease the risk of pulmonary embolism (PE). Insertion of an IVC filter is an invasive procedure that has a range of complications. The benefits of IVC filter insertion must be compared to its risk of complications in each individual patient. A search of the literature since 2005 was conducted on MEDLINE, Evidence-Based Medicine Reviews, Cochrane Central Register of Controlled Trials and Embase. The clinical question posed was does prophylactic IVC filter insertion decrease the risk of PE in trauma patients? The available evidence was low level and unable to definitively answer this question. The majority of articles infer that IVC filter insertion is safe and may decrease the risk of PE. However, there is a need for well-designed randomised controlled trials to be conducted in this area.

Performance Improvement with Current Thromboprophylaxis Strategies Does Not Reduce Pulmonary Embolism in Trauma Patients

Performance Improvement with Current Thromboprophylaxis Strategies Does Not Reduce Pulmonary Embolism in Trauma Patients

The Effectiveness of Prophylactic Inferior Vena Cava Filters in Trauma Patients

Trauma is known to be one of the strongest risk factors for pulmonary embolism (PE). Current guidelines recommend low-molecular-weight heparin therapy for prevention of PE, but trauma places some patients at risk of excess bleeding. Experts are divided on the role of prophylactic inferior vena cava (IVC) filters to prevent PE. To perform a systematic review and meta-analysis examining the comparative effectiveness of prophylactic IVC filters in trauma patients, particularly in preventing PE, fatal PE, and mortality. We searched the following databases for primary studies: MEDLINE, EMBASE, Scopus, CINAHL, International Pharmaceutical Abstracts, clinicaltrial.gov, and the Cochrane Library (all through July 31, 2012). We developed a search strategy using medical subject headings terms and text words of key articles that we identified a priori. We reviewed the references of all included articles, relevant review articles, and related systematic reviews to identify articles the database searches might have missed. We reviewed titles followed by abstracts to identify randomized clinical trials or observational studies with comparison groups reporting on the effectiveness and/or safety of IVC filters for prevention of venous thromboembolism in trauma patients. Two investigators independently reviewed abstracts and abstracted data. For studies amenable to pooling with meta-analysis, we pooled using the random-effects model to analyze the relative risks. We graded the quantity, quality, and consistency of the evidence by adapting an evidence-grading scheme recommended by the Agency for Healthcare Research and Quality. Eight controlled studies compared the effectiveness of no IVC filter vs IVC filter on PE, fatal PE, deep vein thrombosis, and/or mortality in trauma patients. Evidence showed a consistent reduction of PE (relative risk, 0.20 [95% CI, 0.06-0.70]; I(2)=0%) and fatal PE (0.09 [0.01-0.81]; I(2)=0%) with IVC filter placement, without any statistical heterogeneity. We found no significant difference in the incidence of deep vein thrombosis (relative risk, 1.76 [95% CI, 0.50-6.19]; P=.38; I(2)=56.8%) or mortality (0.70 [0.40-1.23]; I(2)=6.7%). The number needed to treat to prevent 1 additional PE with IVC filters is estimated to range from 109 (95% CI, 93-190) to 962 (819-2565), depending on the baseline PE risk. The strength of evidence is low but supports the association of IVC filter placement with a lower incidence of PE and fatal PE in trauma patients. Which patients experience benefit enough to outweigh the harms associated with IVC filter placement remains unclear. Additional well-designed observational or prospective cohort studies may be informative.

Risk of pulmonary embolism in trauma patients: Not all created equal

Patients with traumatic brain injury (TBI) are assumed to be at an increased risk for pulmonary embolism (PE). Delay in the initiation of chemoprophylaxis and prophylactic placement of inferior vena cava filters have been advocated by some because of concerns for increased intracranial hemorrhage in the presence of prophylactic anticoagulation. We hypothesized that patients with isolated TBI would not be at increased risk for the development of PE compared with the general trauma population. Patients from the National Trauma Data Bank from the year 2008 were analyzed. Patient demographics, Injury Severity Score, and the prevalence of deep-vein thrombosis and PE were extracted. Studied injuries were assigned to six categories: thorax, abdominal solid organs, pelvic fracture, lower extremity fracture, spine fracture, and TBI. Of a total of 627,775 injured patients, 2,182 (0.35%) had a documented PE. The prevalence of PE in patients with isolated TBI, lower extremity, pelvic fracture, liver and/or spleen, thorax, spine, multiple injuries, and none of the studied injuries were 0.25%, 0.36%, 0.35%, 0.37%, 0.52%, 0.37%, 1.1%, and 0.12%, respectively. Using an age-, sex- and race-adjusted multivariable logistic regression model and controlling for interaction between inferior vena cava filters and injury types, we found that isolated TBI was not associated with PE. Isolated TBI does not appear to be associated with an increased incidence of PE compared with other injuries. Patients with isolated TBI may not require early aggressive prophylaxis as is the standard for other high-risk groups.

Early pulmonary embolism after injury: A different clinical entity?

BackgroundWe sought to characterize pulmonary embolism (PE) occurring early after injury. We hypothesized that early PE may represent a different clinical entity than those occurring later in the post-injury period. MethodsAll trauma patients diagnosed with PE from 2005 to 2010 were examined. PEs diagnosed within 72h of admission were compared against those occurring later. Results19 out of 54 PEs were diagnosed early. Early PE patients had a higher rate of lower extremity fractures, a lower mean injury severity score, and a lower average length of stay. Early PE patients had a shorter average time to start of chemical prophylaxis, were less likely to have had a femoral line, and less likely to have operative intervention under general anaesthesia. ConclusionsEarly PE after trauma may occur with different underlying pathophysiology than previously thought. Further study is indicated as this has implications concerning the prevention of PE in trauma patients.

Role of Prophylactic Vena Cava Filters for the Prevention of Pulmonary Embolism in Trauma Patients

Role of Prophylactic Vena Cava Filters for the Prevention of Pulmonary Embolism in Trauma Patients

Admission rapid thrombelastography predicts development of pulmonary embolism in trauma patients

Injury leads to dramatic disturbances in coagulation with increased risk of bleeding followed by a hypercoagulable state. A comprehensive assessment of these coagulation abnormalities can be measured and described by thrombelastography. The purpose of this study was to identify whether admission rapid-thrombelastography (r-TEG) could identify patients at risk of developing pulmonary embolism (PE) during their hospital stay. Patients admitted between September 2009 to February 2011 who met criteria for our highest-level trauma activation and were transported directly from the scene were included in the study. PE defined as clinically suspected and computed tomography angiography confirmed PE. We evaluated r-TEG values with particular attention to the maximal amplitude (mA) parameter that is indicative of overall clot strength. Demographics, vital signs, injury severity, and r-TEG values were then evaluated. In addition to r-TEG values, gender and injury severity score (ISS) were chosen a priori for developing a multiple logistic regression model predicting development of PE. r-TEG was obtained on 2,070 consecutive trauma activations. Of these, 2.5% (53) developed PE, 97.5% (2,017) did not develop PE. Patients in the PE group were older (median age, 41 vs. 33 years, p = 0.012) and more likely to be white (69% vs. 54%, p = 0.036). None of the patients in the PE group sustained penetrating injury (0% vs. 25% in the no-PE group, p < 0.001). The PE group also had admission higher mA values (66 vs. 63, p = 0.050) and higher ISS (median, 31 vs. 19, p = 0.002). When controlling for gender, race, age, and ISS, elevated mA at admission was an independent predictor of PE with an odds ratio of 3.5 for mA > 65 and 5.8 for mA > 72. Admission r-TEG mA values can identify patients with an increased risk of in-hospital PE. Further studies are needed to determine whether alternative anticoagulation strategies should be used for these high-risk patients. Prognostic study, level III.

Incidence of PE in Trauma Patients on the Rise

Before 1997, the reported incidence of pulmonary embolism (PE) after trauma ranged from 0.4% to 18%, but more-recent data suggest that the incidence is

An Economic Evaluation of Venous Thromboembolism Prophylaxis Strategies in Critically Ill Trauma Patients at Risk of Bleeding

Critically ill trauma patients with severe injuries are at high risk for venous thromboembolism (VTE) and bleeding simultaneously. Currently, the optimal VTE prophylaxis strategy is unknown for trauma patients with a contraindication to pharmacological prophylaxis because of a risk of bleeding. Using decision analysis, we estimated the cost effectiveness of three VTE prophylaxis strategies-pneumatic compression devices (PCDs) and expectant management alone, serial Doppler ultrasound (SDU) screening, and prophylactic insertion of a vena cava filter (VCF) -- in trauma patients admitted to an intensive care unit (ICU) with severe injuries who were believed to have a contraindication to pharmacological prophylaxis for up to two weeks because of a risk of major bleeding. Data on the probability of deep vein thrombosis (DVT) and pulmonary embolism (PE), and on the effectiveness of the prophylactic strategies, were taken from observational and randomized controlled studies. The probabilities of in-hospital death, ICU and hospital discharge rates, and resource use were taken from a population-based cohort of trauma patients with severe injuries (injury severity scores >12) admitted to the ICU of a regional trauma centre. The incidence of DVT at 12 weeks was similar for the PCD (14.9%) and SDU (15.0%) strategies, but higher for the VCF (25.7%) strategy. Conversely, the incidence of PE at 12 weeks was highest in the PCD strategy (2.9%), followed by the SDU (1.5%) and VCF (0.3%) strategies. Expected mortality and quality-adjusted life years were nearly identical for all three management strategies. Expected health care costs at 12 weeks were Can$55,831 for the PCD strategy, Can$55,334 for the SDU screening strategy, and Can$57,377 for the VCF strategy, with similar trends noted over a lifetime analysis. The attributable mortality due to PE in trauma patients with severe injuries is low relative to other causes of mortality. Prophylactic placement of VCF in patients at high risk of VTE who cannot receive pharmacological prophylaxis is expensive and associated with an increased risk of DVT. Compared to the other strategies, SDU screening was associated with better clinical outcomes and lower costs.

The Increasing Use of Vena Cava Filters in Adult Trauma Victims: Data From the American College of Surgeons National Trauma Data Bank

Vena cava filters (VCFs) have been advocated for prophylaxis of pulmonary embolism in trauma patients at high risk for venous thrombosis in whom anticoagulation is contraindicated or not feasible. We sought to determine the frequency of VCF insertion and patterns of use in trauma patients using a large database. Retrospective analysis of data from the National Trauma Data Bank of the American College of Surgeons on patients over the age of 17 years from 1991 to 2002. We examined the annual frequency of VCF placement, the demographics and injury severity of patients receiving them, and the characteristics of the hospitals at which they were being placed. Of 614,349 patients, 6,282 received a VCF (1%); 86% were placed prophylactically (without an associated discharge diagnosis of either pulmonary embolism or venous thrombosis). Filter use increased significantly from 0.3% of patients in 1994 to 1.2% in 2002 (p < 0.001). There was substantial variation in clinical practice with regard to placement of VCF according to injury type and its perceived risk of venous thromboembolism. VCFs were placed significantly more frequently at hospitals verified as Level I trauma centers. VCF insertion has increased significantly during the past 10 years in trauma patients reported to the National Trauma Data Bank. The lack of an evidence-based guideline for their use has resulted in a wide variation in practice. Such variation in practice indicates the need for a consensus conference or a multicenter prospective clinical trial to determine their role in trauma patients.