Comparing clinical predictors of deep venous thrombosis versus pulmonary embolus after severe injury

A new paradigm for posttraumatic venous thromboembolism?

Scott C. Brakenridge, Steven S. Henley, T. Michael Kashner, Richard M. Golden, Dae Hyun Paik, Herb A. Phelan, Mitchell J. Cohen, Jason L. Sperry, Ernest E. Moore, Joseph P. Minei, Ronald V. Maier, Joseph Cuschieri

Research output: Contribution to journalArticle

28 Citations (Scopus)

Abstract

Background: The traditional paradigm is that deep venous thrombosis (DVT) and pulmonary embolus (PE) are different temporal phases of a single disease process, most often labeled as the composite end point venous thromboembolism (VTE). However, we theorize that after severe blunt injury, DVT and PE may represent independent thrombotic entities rather than different stages of a single pathophysiologic process and therefore exhibit different clinical risk factor profiles. Methods: We examined a large, multicenter prospective cohort of severely injured blunt trauma patients to compare clinical risk factors for DVT and PE, including indicators of injury severity, shock, resuscitation parameters, comorbidities, and VTE prophylaxis. Independent risk factors for each outcome were determined by cross-validated logistic regression modeling using advanced exhaustive model search procedures. Results: The study cohort consisted of 1,822 severely injured blunt trauma patients (median Injury Severity Score [ISS], 33; median base deficit,-9.5). Incidence of DVT and PE were 5.1% and 3.9%, respectively. Only 9 (5.7%) of 73 patients with a PE were also diagnosed with DVT. Independent risk factors associated with DVT include prophylaxis initiation within 48 hours (odds ratio [OR], 0.57; 95% confidence interval [CI], 0.36-0.90) and thoracic Abbreviated Injury Scale (AIS) score of 3 or greater (OR, 1.82; 95% CI, 1.12-2.95), while independent risk factors for PE were serum lactate of greater than 5 (OR, 2.33; 95% CI, 1.43-3.79) and male sex (OR, 2.12; 95% CI, 1.17-3.84). Both DVT and PE exhibited differing risk factor profiles from the classic composite end point of VTE. Conclusion: DVT and PE exhibit differing risk factor profiles following severe injury. Clinical risk factors for diagnosis of DVT after severe blunt trauma include the inability to initiate prompt pharmacologic prophylaxis and severe thoracic injury, which may represent overall injury burden. In contrast, risk factors for PE are male sex and physiologic evidence of severe shock. We hypothesize that postinjury DVT and PE may represent a broad spectrum of pathologic thrombotic processes as opposed to the current conventional wisdom of peripheral thrombosis and subsequent embolus. Level Of Evidence: Prognostic study, level III.

Original languageEnglish (US)
Pages (from-to)1231-1238
Number of pages8
JournalJournal of Trauma and Acute Care Surgery
Volume74
Issue number5
DOIs
StatePublished - May 2013

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Venous Thromboembolism
Embolism
Venous Thrombosis
Lung
Wounds and Injuries
Odds Ratio
Confidence Intervals
Thoracic Injuries
Shock
Abbreviated Injury Scale
Nonpenetrating Wounds
Injury Severity Score
Sex Ratio
Pathologic Processes
Resuscitation
Comorbidity
Lactic Acid
Thrombosis
Cohort Studies
Logistic Models

Keywords

  • deep venous thrombosis
  • injury
  • pulmonary embolus
  • trauma
  • Venous thromboembolism

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine
  • Surgery

Cite this

Comparing clinical predictors of deep venous thrombosis versus pulmonary embolus after severe injury : A new paradigm for posttraumatic venous thromboembolism? / Brakenridge, Scott C.; Henley, Steven S.; Kashner, T. Michael; Golden, Richard M.; Paik, Dae Hyun; Phelan, Herb A.; Cohen, Mitchell J.; Sperry, Jason L.; Moore, Ernest E.; Minei, Joseph P.; Maier, Ronald V.; Cuschieri, Joseph.

In: Journal of Trauma and Acute Care Surgery, Vol. 74, No. 5, 05.2013, p. 1231-1238.

Research output: Contribution to journalArticle

Brakenridge, Scott C. ; Henley, Steven S. ; Kashner, T. Michael ; Golden, Richard M. ; Paik, Dae Hyun ; Phelan, Herb A. ; Cohen, Mitchell J. ; Sperry, Jason L. ; Moore, Ernest E. ; Minei, Joseph P. ; Maier, Ronald V. ; Cuschieri, Joseph. / Comparing clinical predictors of deep venous thrombosis versus pulmonary embolus after severe injury : A new paradigm for posttraumatic venous thromboembolism?. In: Journal of Trauma and Acute Care Surgery. 2013 ; Vol. 74, No. 5. pp. 1231-1238.
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abstract = "Background: The traditional paradigm is that deep venous thrombosis (DVT) and pulmonary embolus (PE) are different temporal phases of a single disease process, most often labeled as the composite end point venous thromboembolism (VTE). However, we theorize that after severe blunt injury, DVT and PE may represent independent thrombotic entities rather than different stages of a single pathophysiologic process and therefore exhibit different clinical risk factor profiles. Methods: We examined a large, multicenter prospective cohort of severely injured blunt trauma patients to compare clinical risk factors for DVT and PE, including indicators of injury severity, shock, resuscitation parameters, comorbidities, and VTE prophylaxis. Independent risk factors for each outcome were determined by cross-validated logistic regression modeling using advanced exhaustive model search procedures. Results: The study cohort consisted of 1,822 severely injured blunt trauma patients (median Injury Severity Score [ISS], 33; median base deficit,-9.5). Incidence of DVT and PE were 5.1{\%} and 3.9{\%}, respectively. Only 9 (5.7{\%}) of 73 patients with a PE were also diagnosed with DVT. Independent risk factors associated with DVT include prophylaxis initiation within 48 hours (odds ratio [OR], 0.57; 95{\%} confidence interval [CI], 0.36-0.90) and thoracic Abbreviated Injury Scale (AIS) score of 3 or greater (OR, 1.82; 95{\%} CI, 1.12-2.95), while independent risk factors for PE were serum lactate of greater than 5 (OR, 2.33; 95{\%} CI, 1.43-3.79) and male sex (OR, 2.12; 95{\%} CI, 1.17-3.84). Both DVT and PE exhibited differing risk factor profiles from the classic composite end point of VTE. Conclusion: DVT and PE exhibit differing risk factor profiles following severe injury. Clinical risk factors for diagnosis of DVT after severe blunt trauma include the inability to initiate prompt pharmacologic prophylaxis and severe thoracic injury, which may represent overall injury burden. In contrast, risk factors for PE are male sex and physiologic evidence of severe shock. We hypothesize that postinjury DVT and PE may represent a broad spectrum of pathologic thrombotic processes as opposed to the current conventional wisdom of peripheral thrombosis and subsequent embolus. Level Of Evidence: Prognostic study, level III.",
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T1 - Comparing clinical predictors of deep venous thrombosis versus pulmonary embolus after severe injury

T2 - A new paradigm for posttraumatic venous thromboembolism?

AU - Brakenridge, Scott C.

AU - Henley, Steven S.

AU - Kashner, T. Michael

AU - Golden, Richard M.

AU - Paik, Dae Hyun

AU - Phelan, Herb A.

AU - Cohen, Mitchell J.

AU - Sperry, Jason L.

AU - Moore, Ernest E.

AU - Minei, Joseph P.

AU - Maier, Ronald V.

AU - Cuschieri, Joseph

PY - 2013/5

Y1 - 2013/5

N2 - Background: The traditional paradigm is that deep venous thrombosis (DVT) and pulmonary embolus (PE) are different temporal phases of a single disease process, most often labeled as the composite end point venous thromboembolism (VTE). However, we theorize that after severe blunt injury, DVT and PE may represent independent thrombotic entities rather than different stages of a single pathophysiologic process and therefore exhibit different clinical risk factor profiles. Methods: We examined a large, multicenter prospective cohort of severely injured blunt trauma patients to compare clinical risk factors for DVT and PE, including indicators of injury severity, shock, resuscitation parameters, comorbidities, and VTE prophylaxis. Independent risk factors for each outcome were determined by cross-validated logistic regression modeling using advanced exhaustive model search procedures. Results: The study cohort consisted of 1,822 severely injured blunt trauma patients (median Injury Severity Score [ISS], 33; median base deficit,-9.5). Incidence of DVT and PE were 5.1% and 3.9%, respectively. Only 9 (5.7%) of 73 patients with a PE were also diagnosed with DVT. Independent risk factors associated with DVT include prophylaxis initiation within 48 hours (odds ratio [OR], 0.57; 95% confidence interval [CI], 0.36-0.90) and thoracic Abbreviated Injury Scale (AIS) score of 3 or greater (OR, 1.82; 95% CI, 1.12-2.95), while independent risk factors for PE were serum lactate of greater than 5 (OR, 2.33; 95% CI, 1.43-3.79) and male sex (OR, 2.12; 95% CI, 1.17-3.84). Both DVT and PE exhibited differing risk factor profiles from the classic composite end point of VTE. Conclusion: DVT and PE exhibit differing risk factor profiles following severe injury. Clinical risk factors for diagnosis of DVT after severe blunt trauma include the inability to initiate prompt pharmacologic prophylaxis and severe thoracic injury, which may represent overall injury burden. In contrast, risk factors for PE are male sex and physiologic evidence of severe shock. We hypothesize that postinjury DVT and PE may represent a broad spectrum of pathologic thrombotic processes as opposed to the current conventional wisdom of peripheral thrombosis and subsequent embolus. Level Of Evidence: Prognostic study, level III.

AB - Background: The traditional paradigm is that deep venous thrombosis (DVT) and pulmonary embolus (PE) are different temporal phases of a single disease process, most often labeled as the composite end point venous thromboembolism (VTE). However, we theorize that after severe blunt injury, DVT and PE may represent independent thrombotic entities rather than different stages of a single pathophysiologic process and therefore exhibit different clinical risk factor profiles. Methods: We examined a large, multicenter prospective cohort of severely injured blunt trauma patients to compare clinical risk factors for DVT and PE, including indicators of injury severity, shock, resuscitation parameters, comorbidities, and VTE prophylaxis. Independent risk factors for each outcome were determined by cross-validated logistic regression modeling using advanced exhaustive model search procedures. Results: The study cohort consisted of 1,822 severely injured blunt trauma patients (median Injury Severity Score [ISS], 33; median base deficit,-9.5). Incidence of DVT and PE were 5.1% and 3.9%, respectively. Only 9 (5.7%) of 73 patients with a PE were also diagnosed with DVT. Independent risk factors associated with DVT include prophylaxis initiation within 48 hours (odds ratio [OR], 0.57; 95% confidence interval [CI], 0.36-0.90) and thoracic Abbreviated Injury Scale (AIS) score of 3 or greater (OR, 1.82; 95% CI, 1.12-2.95), while independent risk factors for PE were serum lactate of greater than 5 (OR, 2.33; 95% CI, 1.43-3.79) and male sex (OR, 2.12; 95% CI, 1.17-3.84). Both DVT and PE exhibited differing risk factor profiles from the classic composite end point of VTE. Conclusion: DVT and PE exhibit differing risk factor profiles following severe injury. Clinical risk factors for diagnosis of DVT after severe blunt trauma include the inability to initiate prompt pharmacologic prophylaxis and severe thoracic injury, which may represent overall injury burden. In contrast, risk factors for PE are male sex and physiologic evidence of severe shock. We hypothesize that postinjury DVT and PE may represent a broad spectrum of pathologic thrombotic processes as opposed to the current conventional wisdom of peripheral thrombosis and subsequent embolus. Level Of Evidence: Prognostic study, level III.

KW - deep venous thrombosis

KW - injury

KW - pulmonary embolus

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KW - Venous thromboembolism

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