Venous Thromboembolism after Traumatic Brain Injury

Abstract

No standard exists for venous thromboembolism (VTE) prophylaxis after traumatic brain injury (TBI). Caregivers agree that there is an early time point after injury in which the chances of spontaneous injury progression are high and the risks of prophylactic anticoagulation are excessive, and that these injuries eventually stabilize to the point that anticoagulation may be safely started. Translating this consensus into an application that can inform bedside decision making has not occurred. National groups have promulgated guidelines in the United States suggesting that anticoagulants be used when the risk of renewed intracranial hemorrhage has ceased with no guidance beyond this vague recommendation. This is largely due to the relative paucity of literature about pharmacologic prophylaxis, which has in turn been due to fears of propagation of intracranial hemorrhage. Although interest in this field has increased of late, many studies are limited by the simple dichotomization of TBI patients as having the presence or absence of intracranial blood. Although methodologically easier, this approach does not account for the heterogeneity of TBI and, consequently, the spectrum of time to stabilization. To address this, our group has created an algorithm which stratifies patients by risk for spontaneous progression and tailors a unique VTE prophylaxis regimen to each arm.

Very early initiation of chemical venous thromboembolism prophylaxis after blunt solid organ injury is safe

“…Although the use of chemical VTE prophylaxis in patients with head injuries appears to be safe, adoption is slow and prospective trials are lacking. 16,17 Limitations Limitations of our study are related to the retrospective nature and lack of controlled protocol for chemical VTE initiation at our centre. While patients were similar in age, sex and injury scores, there was a significant differ ence in the percentage of highgrade splenic injuries, which could be a confounding factor and may highlight a reluctance to initiate chemical VTE prophylaxis in this particular subset of patients, leading to a selection bias that was unlikely to be overcome by using a larger sample size.…”

Venous thromboembolic events in critically ill traumatic brain injury patients

“…Traumatic brain injury (TBI) patients treated in the intensive care unit (ICU) appear at high risk for venous thromboembolism (VTE), such as deep venous thrombosis (DVT) of the legs and pulmonary embolism (PE) [1][2][3]. Moreover, the occurrence of massive PE is a known cause of late death in trauma patients, and the risk is increased in patients with DVT [4,5].…”

The Parkland Protocol's Modified Berne-Norwood Criteria Predict Two Tiers of Risk for Traumatic Brain Injury Progression

“…4,5 In 2012, we published a study of 245 patients with at least two CT scans of the head who had been classified and followed per this original iteration of the Parkland Protocol between February 2010 and March 2011. 3 In that study, we found that spontaneous progression of hemorrhage occurred in 25% of subjects in the low-risk arm (n = 136), 43% of moderate-risk subjects (n = 42), and 64% of high-risk subjects (n = 67).…”

“…In recognition of this spectrum of risk, we have constructed and promulgated a theoretical treatment algorithm for VTE prophylaxis after TBI, which we are calling the ''Parkland Protocol.'' 4,5 Based on a modification of injury patterns initially put forth by Berne and Norwood, 6-8 our original protocol and its subsequent iterations classify TBI patients as low, moderate, or high risk for spontaneous progression of their intracranial hemorrhage (ICH) pattern and tailor a VTE prophylaxis regimen to each arm (Fig. 1).…”