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Practice Management Guidelines for Trauma from the Eastern Association for the Surgery of Trauma

Pasquale, Michael MD, FACS; Fabian, Timothy C. MD

The Journal of Trauma: Injury, Infection, and Critical Care: June 1998 - Volume 44 - Issue 6 - p 941-956
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The EAST Ad Hoc Committee on Practice Management Guideline Development.

From the Division of Trauma/Surgical Critical Care (M.P.), Lehigh Valley Hospital, Allentown, Pennsylvania; and the University of Tennessee College of Medicine (T.C.F.), Memphis, Tennessee.

Address for correspondence: Michael Pasquale, MD, FACS, Lehigh Valley Hospital, Chief, Division of Trauma and Surgical Care, Cedar Creat & I-78, P.O. Box 689, Allentown, PA 18105-1556. No reprints available.

Clinical practice guidelines are being used as a means of reducing inappropriate care, controlling geographic variations in practice patterns, and making more effective use of health care resources. Developments at the national health policy level, as well as managed care imperatives, suggest that clinical practice guidelines will play an increasingly prominent role in the practice of medicine. These guidelines can contribute to medicine as an aid in clinical decision making and improving clinical practice [1,2] and as a research tool and an educational resource. We, as trauma surgeons, should participate in such endeavors in an effort to improve trauma care and guide future research.

The Agency for Health Care Policy and Research (AHCPR) has led the way in guideline development methodology and currently has published 20 guidelines addressing a variety of topics. [3] Its initial work has led others to develop an evidence-based approach to care.

Evidence-based guidelines have been published on intravenous analgesia, sedation, sustained neuromuscular blockade in the intensive care unit, and management of severe head injury. [4-6] Clinical computerized bedside protocols have improved outcome in adult respiratory distress syndrome and hypoxia. [7,8] National literature/consensus-based guidelines have also been published for stress ulcer prophylaxis and albumin transfusion and are currently in development for antibiotic use and fever workup in the intensive care unit. [9,10] The role of the Eastern Association for the Surgery of Trauma (EAST) and other national organizations will be to provide a series of national consensus-based guidelines from which institutionally specific clinical management protocols or pathways can be developed (see Figure 1).

Figure 1

Figure 1

A step-by-step process of practice management guideline development, largely adapted from AHCPR recommendations, has been derived [11] to ensure a combination of rigorous methodology and practical feasibility that can be adapted to clinical decision making at any institution (Table 1). Key to guideline development is assessment of the scientific evidence and formulation of recommendations (Table 2).

Table 1

Table 1

Table 2

Table 2

A current limitation on the concept of guideline development is the paucity of prospective, randomized class I data for the development of more secure evidence-based guidelines. It is hoped that through the development of guidelines, a baseline can be created to direct future research and create more class I data.

With these thoughts in mind, a consensus conference of 20 trauma surgeons interested in guideline development was held and initial topics were selected for development. Each member of the conference selected topics that he or she felt were important for development. Four topics were then selected by majority consensus. Each topic was assigned a chairperson, and the chairperson was then responsible for selecting his or her committee members. The individual committees were given latitude on how to approach their topics, but all were expected to conform to the process described above. Once completed, the guidelines were reviewed by the committee chairperson and the chairperson of the guideline committee and returned for revision. The revised guidelines were submitted to the EAST program chairman, the president of EAST, and the board members. The guidelines were presented at the annual meeting of EAST in 1997, and revisions were made based on comments and suggestions from the members. What follows is an abridged version of these guidelines. The unabridged version, which contains a more lengthy discussion of the scientific evidence, data classification, and evidentiary tables, as well as a complete bibliography, is available through the EAST web page (www.east.org) or by written request. Send requests to: EAST Guidelines, c/o Judith Schultz, Trauma Program Development Office, Lehigh Valley Hospital, Cedar Crest & I-78, P.O. Box 689, Allentown, PA 18105-1556.

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Practice Management Guidelines for Screening of Blunt Cardiac Injury

Michael D. Pasquale, MD, Division of Trauma/Surgical Critical Care, Lehigh Valley Hospital, Allentown, Pa; Kimberly K. Nagy, MD, Department of Trauma, Cook County Hospital, Chicago, Ill; John R. Clarke, MD, Department of Surgery, Allegheny University Hospital, Philadelphia, Pa.

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Practice Management Guidelines for Identifying Cervical Spine Injuries after Trauma

Donald W. Marion, MD, Chairman, Department of Neurosurgery, Presbyterian University Hospital, Pittsburgh, Pa; Robert Domeier, MD, Department of Emergency Medicine, St. Joseph Mercy Hospital, Ann Arbor, Mich; C. Michael Dunham, MD, St. Elizabeth Hospital Trauma Center, Youngstown, Ohio; Fred A. Luchette, MD, Division of Trauma/Critical Care, University of Cincinnati College of Medicine, Cincinnati, Ohio; Regis Haid, MD, Department of Neurological Surgery, Emory University School of Medicine, Atlanta, Ga; Scott C. Erwood, MD, Emory Clinic, Atlanta, Ga.

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Practice Management Guidelines for Penetrating Intraperitoneal Colon Injuries

C. Gene Cayten, MD, Institute for Trauma and Emergency Care, New York Medical College, Valhalla, NY; Timothy C. Fabian, MD, University of Tennessee College of Medicine, Memphis, Tenn; Victor F. Garcia, MD, Division of Pediatric Surgery, Children's Hospital Medical Center, Cincinnati, Ohio; Rao R. Ivatury, MD, Department of Surgery, New York Medical College/Lincoln Hospital, Bronx, NY; John A. Morris, Jr., MD, Division of Trauma and Surgical Critical Care, Vanderbilt University, Nashville, Tenn.

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Practice Management Guidelines for Venous Thromboembolism in Trauma Patients

- The Use of Low-Dose Heparin (LDH) for Deep Venous Thrombosis/Pulmonary Embolus (DVT/PE) Prophylaxis

- The Use of Sequential Compression Devices (SCDs) in the Prevention of DVT/PE

- The Role of Low Molecular Weight Heparin in Venous Thromboembolism Prophylaxis in Trauma Patients

- The Role of Arteriovenous Foot Pumps in the Prophylaxis of DVT/PE in the Trauma Patient

- The Role of the Vena Cava Filter in the Prophylaxis and Treatment of PE

- The Role of Treatment of Established DVT/PE with Anticoagulation in the Trauma Patient

- The Role of Ultrasonography in Diagnostic Imaging for DVT in Trauma

- The Role of Impedance Plethysmography (IPG) in Diagnostic Imaging for DVT in Trauma

- The Role of Venography in the Diagnosis of DVT in Trauma Patients

Frederick B. Rogers, MD, Department of Surgery, University of Vermont College of Medicine, Burlington, Vt; Mark D. Cipolle, MD, PhD, Division of Trauma/Surgical Critical Care, Lehigh Valley Hospital, Allentown, Pa; James G. Cushman, MD, Division of Trauma/Surgical Critical Care, Lehigh Valley Hospital, Allentown, Pa; Paul A. Kearney, MD, Department of Surgery, University of Kentucky Chandler Medical Center, Lexington, Ky; Grace S. Rozycki, MD, Department of Surgery, Emory University School of Medicine, Atlanta, Ga; William H. Geerts, MD, Sunnybrook Health Science Center/University of Toronto, Toronto, Ontario, Canada.

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PRACTICE MANAGEMENT GUIDELINES FOR SCREENING OF BLUNT CARDIAC INJURY

I. Statement of the Problem

The reported incidence of blunt cardiac injury (BCI), formerly called myocardial contusion, depends on the modality and criteria used for diagnosis and ranges from 8 to 71% in patients who sustain blunt chest trauma. The true incidence remains unknown because there is no diagnostic gold standard, i.e., the available data are conflicting with respect to how the diagnosis should be made (electrocardiogram (EKG), enzyme analysis, echocardiogram, etc.) The lack of such a standard leads to confusion with respect to making a diagnosis and makes the literature difficult to interpret. Key issues involve identifying a patient population at risk for adverse events from BCI and then appropriately monitoring and treating these patients. Conversely, patients not at risk could potentially be discharged from the hospital with appropriate follow-up.

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II. Process

A MEDLINE search from January 1986 through February 1997 was performed. All English-language citations during this period with the subject words "myocardial contusion," "blunt cardiac injury," and "cardiac trauma" were retrieved. Letters to the editor, isolated case reports, series of patients presenting in cardiac arrest, and articles focusing on emergency room thoracotomy were excluded from the review. This left 56 articles that were primarily well-conducted studies or reviews involving the identification of BCI.

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III. Recommendations

A. Level I

An admission EKG should be performed for all patients in whom there is suspected BCI.

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B. Level II

1. If the admission EKG results are abnormal (arrhythmia, ST changes, ischemia, heart block, unexplained ST), the patient should be admitted for continuous EKG monitoring for 24 to 48 hours. Conversely, if the admission EKG results are normal, the risk of having a BCI that requires treatment is insignificant, and the pursuit of diagnosis should be terminated.

2. If the patient is hemodynamically unstable, an imaging study (echocardiogram) should be obtained. If an optimal transthoracic echocardiogram cannot be performed, then the patient should have a transesophageal echocardiogram.

3. Nuclear medicine studies add little compared with echocardiography and, thus, are not useful if an echocardiogram has been performed.

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C. Level III

1. Elderly patients with known cardiac disease, unstable patients, and those with an abnormal admission EKG can be safely operated on provided that they are appropriately monitored. Consideration should be given to placement of a pulmonary artery catheter in such cases.

2. The presence of a sternal fracture does not predict the presence of BCI and, thus, does not necessarily indicate that monitoring should be performed.

3. Neither creatine phosphokinase with isoenzyme analysis nor measurement of circulating cardiac troponin T are useful in predicting which patients have or will have complications related to BCI.

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IV. Summary

In general, the diagnosis of BCI should be suspected in patients with an appropriate mechanism of injury or in those who manifest an inappropriately or abnormally poor cardiovascular response to their injury. At present, no single test or combination of tests has proven consistently reliable in detecting cardiac injury. The diagnosis of BCI will be directly proportional to the aggressiveness with which it is sought. The appropriate choice demands achieving a balance between cost-effectiveness of the tests used and the effect of the information acquired on clinical management decisions.

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V. Future Investigations

Future studies should focus on patients who develop complications secondary to BCI. Diagnostic testing should be compared with the less invasive and less expensive tests currently recommended. A cost-benefit analysis should be considered in all future studies.

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VI. References

Class I

1. Frazee RC, Mucha P Jr, Farnell MB, Miller FA Jr. Objective evaluation of blunt cardiac trauma. J Trauma. 1986;26:510-520.

2. Reif J, Justice JL, Olsen WR, Prager RL. Selective monitoring of patients with suspected blunt cardiac injury. Ann Thorac Surg. 1990;50:530-532.

3. Gunnar WP, Martin M, Smith RF, et al. The utility of cardiac evaluation in the hemodynamically stable patient with suspected myocardial contusion. Am Surg. 1991;57:373-377.

4. Karalis DG, Victor MF, Davis GA, et al. The role of echocardiography in blunt chest trauma: a transthoracic and transesophageal echocardiographic study. J Trauma. 1994;36:53-58.

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Class II

1. Kettunen P, Neiminen M. Creatine kinase MB and M-mode echocardiographic changes in cardiac contusion. Ann Clin Res. 1985;17:292-298.

2. Markiewicz W, Best LA, Burstein S, et al. Echocardiographic evaluation after blunt trauma of the chest. Int J Cardiol. 1985;8:269-274.

3. Andersen PT, Moller-Petersen J, Nielsen LK, Molgaard J. Comparisons between CK-B and other clinical indicators of cardiac contusion following multiple trauma. Scand J Thorac Cardiovasc Surg. 1986;20:93-96.

4. Flancbaum L, Wright J, Siegel JH. Emergency surgery in patients with post-traumatic myocardial contusion. J Trauma. 1986;26:795-803.

5. Rosenbaum RC, Johnston GS. Posttraumatic cardiac dysfunction: assessment with radionuclide ventriculography. Radiology. 1986;160:91-94.

6. Waxman K, Soliman MH, Braunstein P, et al. Diagnosis of traumatic cardiac contusion. Arch Surg. 1986;121:689-692.

7. Soliman MH, Waxman K. Value of a conventional approach to the diagnosis of traumatic cardiac contusion after chest injury. Crit Care Med. 1987;15:218-220.

8. Bodin L, Rouby JJ, Viars P. Myocardial contusion in patients with blunt chest trauma as evaluated by thallium 201 myocardial scintigraphy. Chest. 1988;94:72-76.

9. Brunel W, Stoll J, May K, et al. Routine intensive care unit admission is not indicated for suspected myocardial contusion. J Int Care Med. 1988;3:253-257.

10. Fabian TC, Mangiante EC, Patterson CR, Payne LW, Isaacson ML. Myocardial contusion in blunt trauma: clinical characteristics, means of diagnosis, and implications for patient management. J Trauma. 1988;28:50-57.

11. Hiatt JR, Yeatman LA Jr, Child JS. The value of echocardiography in blunt chest trauma. J Trauma. 1988;28:914-922.

12. Keller KD, Shatney CH. Creatine phosphokinase-MB assays in patients with suspected myocardial contusion: diagnostic test or test of diagnosis? J Trauma. 1988;28:58-63.

13. Schamp DJ, Plotnick GD, Croteau D, Rosenbaum RC, Johnston GS, Rodriguez A. Clinical significance of radionuclide angiographically-determined abnormalities following acute blunt chest trauma. Am Heart J. 1988;116:500-504.

14. Baxter BT, Moore EE, Moore FA, McCroskey BL, Ammons LA. A plea for sensible management of myocardial contusion. Am J Surg. 1989;158:557-562.

15. Dubrow TJ, Mihalka J, Eisenhauer DM, et al. Myocardial contusion in the stable patient: what level of care is appropriate? Surgery. 1989;106:267-274.

16. Helling TS, Duke P, Beggs CW, Crouse LJ. A prospective evaluation of 68 patients suffering blunt chest trauma for evidence of cardiac injury. J Trauma. 1989;29:961-966.

17. Miller FB, Shumate CR, Richardson JD. Myocardial contusion: when can the diagnosis be eliminated? Arch Surg. 1989;124:805-808.

18. Ross P Jr, Degutis L, Baker CC. Cardiac contusion: the effect on operative management of the patient with trauma injuries. Arch Surg. 1989;124:506-507.

19. Foil MB, Mackersie RC, Furst SR, et al. The asymptomatic patient with suspected myocardial contusion. Am J Surg. 1990;160:638-643.

20. Healey MA, Brown R, Fleiszer D. Blunt cardiac injury: is this diagnosis necessary? J Trauma. 1990;30:137-146.

21. Holness R, Waxman K. Diagnosis of traumatic cardiac contusion utilizing single photon-emission computed tomography. Crit Care Med. 1990;18:1-3.

22. Norton MJ, Stanford GG, Weigelt JA. Early detection of myocardial contusion and its complications in patients with blunt trauma. Am J Surg. 1990;160:577-582.

23. Wisner DH, Reed WH, Riddick RS. Suspected myocardial contusion: triage and indications for monitoring. Ann Surg. 1990;212:82-86.

24. Fabian TC, Cicala RS, Croce MA, et al. A prospective evaluation of myocardial contusion: correlation of significant arrhythmias and cardiac output with CPK-MB measurements. J Trauma. 1991;31:653-660.

25. Illig KA, Swierzewski MJ, Feliciano DV, Mortor JH. A rational screening and treatment strategy based on the electrocardiogram alone for suspected cardiac contusion. Am J Surg. 1991;162:537-544.

26. McCarthy MC, Pavlina PM, Evans DK, Broadie TA, Park HM, Schauwecker DS. The value of SPECT-thallium scanning in screening for myocardial contusion. Cardiovasc Intervent Radiol. 1991;14:238-240.

27. McLean RF, Devitt JH, Dubbin J, McLellan BA. Incidence of abnormal RNA studies and dysrhythmias in patients with blunt chest trauma. J Trauma. 1991;31:968-970.

28. Brooks SW, Young JC, Cmolik B, et al. The use of transesophageal echocardiography in the evaluation of chest trauma. J Trauma. 1992;32:761-768.

29. Cachecho R, Grindlinger GA, Lee VW. The clinical significance of myocardial contusion. J Trauma. 1992;33:68-73.

30. Godbe D, Waxman K, Wang FW, McDonald R, Braunstein P. Diagnosis of myocardial contusion: quantitative analysis of single photon emission computed tomographic scans. Arch Surg. 1992;127:888-892.

31. Hendel RC, Cohn S, Aurigemma G, et al. Focal myocardial injury following blunt chest trauma: a comparison of indium-111 antimyosin scintigraphy with other noninvasive methods. Am Heart J. 1992;123:1208-1215.

32. McLean RF, Devitt JH, McLellan BA, Dubbin J, Ehrlich LE, Dirkson D. Significance of myocardial contusion following blunt chest trauma. J Trauma. 1992;33:240-243.

33. Paone RF, Peacock JB, Smith DL. Diagnosis of myocardial contusion. South Med J. 1993;86:867-870.

34. Biffl WL, Moore FA, Moore EE, Sauaia A, Read RA, Burch JM. Cardiac enzymes are irrelevant in the patient with suspected myocardial contusion. Am J Surg. 1994;168:523-528.

35. Fildes JJ, Betlej TM, Manglano R, Martin M, Rogers F, Barrett JA. Limiting cardiac evaluation in patients with suspected myocardial contusion. Am Surg. 1995;61:832-835.

36. Adams JE 3rd, Davila-Roman VG, Bessey PQ, Blake DP, Ladenson JH, Jaffe AS. Improved detection of cardiac contusion with cardiac troponin I. Am Heart J. 1996;131:308-312.

37. Dowd MD, Krug S. Pediatric blunt cardiac injury: epidemiology, clinical features, and diagnosis. Pediatric Emergency Medicine Collaborative Research Committee: Working Group on Blunt Cardiac Injury. J Trauma. 1996;40:61-67.

38. Maenza RL, Seaberg D, D'Amico F. A meta-analysis of blunt cardiac trauma: ending myocardial confusion. Am J Emerg Med. 1996;14:237-241.

39. Weiss RL, Brier JA, O'Connor W, Ross S, Brathwaite CM. The usefulness of transesophageal echocardiography in diagnosing cardiac contusions. Chest. 1996;109:73-77.

40. Ferjani M, Droc G, Dreux S, et al. Circulating cardiac troponin T in myocardial contusion. Chest. 1997;111:427-433.

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PRACTICE MANAGEMENT GUIDELINES FOR IDENTIFYING CERVICAL SPINE INSTABILITY AFTER TRAUMA

I. Statement of the Problem

Determination of the stability of the cervical spine is a common problem encountered by those charged with the responsibility for the acute care of trauma patients. Several specific issues are of particular concern for medical, economic, and legal reasons. Who needs cervical spine radiographs? What views of the cervical spine should be obtained? When should flexion/extension radiographs, fluoroscopic radiographs, computed tomographic (CT) scans, or magnetic resonance imaging (MRI) scans be obtained? And how do we demonstrate the absence of significant ligamentous injury in the comatose trauma patient?

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II. Process

A. Identification of References

A computerized search of the National Library of Medicine was undertaken using Grateful Med software. All English-language citations from the last 20 years with "cervical spine" in the title and the subject words "radiography," "cervical vertebrae," or "trauma" were retrieved. Of the 961 citations retrieved, 160 dealt with the determination of cervical spine stability in the first few hours after trauma, and these articles were selected for further review. Ninety-eight were either general reviews, letters to the editor, or were considered of such poor quality as to not warrant inclusion in this document. This left 62 articles that were primarily original studies of large groups of patients or smaller, well-conducted studies addressing specific questions relevant to this practice guideline.

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B. Quality of the References

The quality-assessment instrument applied to the references was developed for this project. There have been no such instruments developed previously for use with articles that do not deal with therapies, and clearance of the cervical spine is a question of diagnosis rather than therapy. Five factors were considered essential to high-quality articles regarding the diagnosis of cervical spine injury: (1) a study population greater than 100 patients; (2) a well-defined population at risk; (3) a prospective study; (4) a description of the specialty or specialties of the physicians charged with interpreting the radiographic studies; and (5) a specific description of the studies obtained.

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III. Recommendations

A. Level I

There is insufficient evidence to support a level I recommendation for this practice management guideline.

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B. Level II

1. Trauma patients who are alert, awake, have no mental status changes, no neck pain, no distracting pain, and no neurologic deficits may be considered to have a stable cervical spine and need no radiologic studies of their cervical spine.

2. All other trauma patients should have the following three cervical spine radiographs: lateral view revealing the base of the occiput to the upper border of the first thoracic vertebra; anteroposterior view revealing the spinous processes of the second cervical through the first thoracic vertebra; and an open mouth odontoid view revealing the lateral masses of the first cervical vertebra and the entire odontoid process. Axial CT scans with sagittal reconstruction should be obtained for any questionable level of injury, or through the lower cervical spine if this area cannot be visualized on plain radiographs. All life-threatening hemodynamic and pulmonary problems should be addressed before a prolonged cervical spine evaluation is undertaken. Before removing cervical spine immobilization devices, all radiographs should be read by an experienced trauma surgeon, emergency medicine physician, neurosurgeon, orthopedic spine surgeon, radiologist, or other physician with expertise in interpreting these studies.

3. If the cervical spine radiographic results are normal but the patient complains of significant neck pain, cervical spine radiographs with the patient actively positioning the neck in extreme flexion and extension should be obtained.

4. If the patient has a neurologic deficit that may be referable to a cervical spine injury, an immediate surgical subspecialty consultation and MRI scan of the cervical spine should be obtained.

5. Trauma patients who have an altered level of consciousness attributable to a traumatic brain injury or other causes that are considered likely to leave the patient unable to complain of neck pain or neurologic deficits for 24 or more hours after injury may be considered to have a stable cervical spine if adequate three-view plain radiographs (CT supplementation as necessary) and thin-cut axial CT images through C1 and C2 are read as normal by an experienced physician.

6. If the patient has abnormalities of the cervical spine discovered on any of the radiographic or MRI images as recommended above, the surgical subspecialists responsible for spinal trauma should be consulted.

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IV. Summary

Because of the lack of class I data, no level I recommendations can be made for this topic. There have been numerous prospective and retrospective cohort studies of large numbers of trauma patients that provide some insight into the incidence of cervical spine injuries after blunt trauma (2-6%), the indications for cervical spine radiographs, and the types of radiographs most likely to detect cervical spine injuries. Virtually all of the publications fail to clearly define the criteria used to decide who gets cervical spine radiographs and who does not. No researchers have carefully conducted long-term follow-up on all of their trauma patients to identify all cases of cervical spine injury missed in the acute setting. The true incidence of cervical spine injury is thus not known.

It is clear from the literature that no imaging modality is accurate 100% of the time. Most studies have found that a three-view spine series (anteroposterior, lateral, and open mouth odontoid view), supplemented by thin-cut axial CT images with sagittal reconstruction through suspicious areas or inadequately visualized areas, provides a false-negative rate of less than 0.1% if the studies are technically adequate and properly interpreted. CT scans alone, MRI scans, and flexion/extension radiographs have all been shown to miss injuries and have not been shown to be more accurate than the guidelines mentioned above.

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V. Future Investigations

Future studies should prospectively evaluate and identify those imaging studies that should be used to make an acute determination of cervical spine injury and stability.

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VI. References

Class II

1. Jacobs LM, Schwartz R. Prospective analysis of acute cervical spine injury: a methodology to predict injury. Ann Emerg Med. 1986;15:44-49.

2. Ross SE, Schwab CW, David ET, Delong WG, Born CT. Clearing the cervical spine: initial radiologic evaluation. J Trauma. 1987;27:1055-1060.

3. Neifeld GL, Keene JG, Hevesy G, Leikin J, Proust A, Thisted RA. Cervical injury in head trauma. J Emerg Med. 1988;6:203-207.

4. Roberge RJ, Wears RC, Kelly M, et al. Selective application of cervical spine radiography in alert victims of blunt trauma: a prospective study. J Trauma. 1988;28:784-788.

5. Freemyer B, Knopp R, Piche J, Wales L, Williams J. Comparison of five-view and three-view cervical spine series in the evaluation of patients with cervical trauma. Ann Emerg Med. 1989;18:818-821.

6. Kreipke DL, Gillespie KR, McCarthy MC, Mail JT, Lappas JC, Broadie TA. Reliability of indications for cervical spine films in trauma patients. J Trauma. 1989;29:1438-1439.

7. Schleehauf K, Ross SE, Civil ID, Schwab CW. Computed tomography in the initial evaluation of the cervical spine. Ann Emerg Med. 1989;18:815-817.

8. Kirshenbaum KJ, Nadimpalli SR, Fantus R, Cavallino RP. Unsuspected upper cervical spine fractures associated with significant head trauma: role of CT. J Emerg Med. 1990;8:183-198.

9. Hoffman JR, Schriger DL, Mower W, Luo JS, Zucker M. Low-risk criteria for cervical-spine radiography in blunt trauma: a prospective study. Ann Emerg Med. 1992;21:1454-1460.

10. Davis JW, Parks SN, Detlefs CL, Williams GG, Williams JL, Smith RW. Clearing the cervical spine in obtunded patients: the use of dynamic fluoroscopy. J Trauma. 1995;39:435-438.

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PRACTICE MANAGEMENT GUIDELINES FOR PENETRATING INTRAPERITONEAL COLON INJURIES

I. Statement of the Problem

Management of penetrating colon wounds has been evolving during the last three decades. Before that time, most colon wounds in the civilian population were managed by exteriorization of the wound or proximal colostomy because of the fear of a high rate of breakdown. In the past 20 years, there has been a trend toward increased use of primary repair. Advantages of primary repair are the avoidance of colostomy, with the subsequent reduction in the morbidity of the colostomy itself and the cost associated with colostomy care and the subsequent hospitalization for closure. Potential drawbacks of primary repair are the morbidity and mortality associated with failure of repair. If there is no difference in morbidity between the approaches, primary repair would be preferred. In recent years, there have been several prospective studies that support primary repair over colostomy; however, there is continued confusion regarding when primary repair is appropriate.

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II. Process

A computerized search of the National Library of Medicine was undertaken using Knowledge Server software. English-language citations during the period 1979 through 1996 using the words "colon injury" and "colon trauma" were identified from the database of journal articles. Of the 113 articles identified, those dealing with either prospective or retrospective series of injuries were selected. The following groups of articles were excluded from analysis: (1) literature review articles; (2) wartime experiences; and (3) articles from institutions that were duplicative. This left 42 articles that were institutional studies of groups of patients who sustained penetrating abdominal trauma with intraperitoneal colon injury and in which the method of surgical management was evaluated. Another group of articles reported on colostomy closure after penetrating injury. The articles were reviewed by a group of five trauma surgeons who collaborated to produce this practice management guideline.

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III. Recommendations

A. Level I

There are sufficient class I and class II data to support a standard of primary repair for nondestructive (involvement of <50% of the bowel wall without devascularization) colon wounds in the absence of peritonitis.

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B. Level II

1. Patients with penetrating intraperitoneal colon wounds that are destructive (involvement of >50% of the bowel wall or devascularization of a bowel segment) can undergo resection and primary anastomosis if they:

- are hemodynamically stable without evidence of shock (sustained preoperative or intraoperative hypotension as defined by systolic blood pressure < 90 mm Hg);

- have no significant underlying disease;

- have minimal associated injuries (Penetrating Abdominal Trauma Index < 25, Injury Severity Score (ISS) < 25, Flint grade < 11);

- have no peritonitis.

2. Patients with shock, underlying disease, significant associated injuries, or peritonitis should have destructive colon wounds managed by resection and colostomy.

3. Colostomies performed after colon and rectal trauma can be closed within 2 weeks if contrast enema is performed to confirm distal colon healing. This recommendation pertains to patients who do not have nonhealing bowel injury, unresolved wound sepsis, or are unstable.

4. A barium enema should not be performed to rule out colon cancer or polyps before colostomy closure for trauma in patients who otherwise have no indications for being at risk for colon cancer or polyps.

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IV. Summary

The decreased morbidity associated with avoidance of colostomy, the disability associated with the interval from creation to closure of the colostomy, and the charges associated with colostomy and the closure of the colostomy all support a standard for primary repair of nondestructive penetrating colon wounds. For destructive penetrating colon wounds, the data would support resection and anastomosis for stable patients without significant associated injuries. Patients with serious associated injuries or significant underlying disease have better results with resection and colostomy.

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V. Future Investigations

Future studies should be conducted in a prospective, randomized fashion and concentrate on the role of colostomy and the timing of closure for destructive colon injuries.

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VI. References

Class I

1. Stone HH, Fabian TC. Management of perforating colon trauma: randomization between primary closure and exteriorization. Ann Surg. 1979;190:430-436.

2. Chappuis CW, Frey DJ, Dietzen CD, Panetta TP, Buechter KJ, Cohn I Jr. Management of penetrating colon injuries: a prospective randomized trial. Ann Surg. 1991;213:492-498.

3. Falcone RE, Wanamaker SR, Santanello SA, Carey LC. Colorectal trauma: primary repair or anastomosis with intracolonic bypass vs. ostomy. Dis Colon Rectum. 1992;35:957-963.

4. Sasaki LS, Allaben RD, Golwala R, Mittal VK. Primary repair of colon injuries: a prospective randomized study. J Trauma. 1995;39:895-901.

5. Velmahos GC, Degiannis E, Wells M, Souter I, Saadia R. Early closure of colostomies in trauma patients: a prospective randomized trial. Surgery. 1995;118:815-820.

6. Gonzalez RP, Merlotti GJ, Holevar MR. Colostomy in penetrating colon injury: is it necessary? J Trauma. 1996;41:271-275.

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Class II

1. George SM Jr, Fabian TC, Voeller GR, Kudsk KA, Mangiante EC, Britt LG. Primary repair of colon wounds: a prospective trial in nonselected patients. Ann Surg. 1989;209:728-734.

2. Baker LW, Thomson SR, Chadwick SJ. Colon wound management and prograde colonic lavage in large bowel trauma. Br J Surg. 1990;77:872-876.

3. Demetriades D, Charalambides D, Pantanowitz D. Gunshot wounds of the colon: role of primary repair. Ann R Coll Surg Engl. 1992;74:381-384.

4. Ivatury RR, Gaudino J, Nallathambi MN, Simon RJ, Kazigo ZJ, Stahl WM. Definitive treatment of colon injuries: a prospective study. Am Surg. 1993;59:43-49.

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PRACTICE MANAGEMENT GUIDELINES FOR VENOUS THROMBOEMBOLISM IN TRAUMA PATIENTS

The Use of Low-Dose Heparin (LDH) for Deep Venous Thrombosis/Pulmonary Embolus (DVT/PE) Prophylaxis

I. Statement of the Problem

The fact that DVT and PE occur after trauma is incontrovertible. The optimal mode of prophylaxis has yet to be determined. LDH (5,000 U subcutaneously two or three times daily) represents one pharmacologic treatment modality used for prophylaxis against DVT and PE. A meta-analysis of 29 trials in more than 8,000 surgical patients demonstrated that LDH significantly decreased the incidence of DVT from 25.2% in patients with no prophylaxis to 8.7% in treated patients (p < 0.001). Similarly, PE was halved by LDH treatment (0.5% in treated patients compared with 1.2% in controls; p < 0.001). In double-blind trials, the incidence of major hemorrhage was higher in treated patients (1.8%) than in controls (0.8%), but this was not significant. Minor bleeding complications, such as wound hematomas, were more frequent in LDH-treated patients (6.3%) than in controls (4.1%; p < 0.001).

Unfractionated LDH has not been shown to be particularly effective in preventing venous thromboembolism (VTE) in trauma patients. Two recent prospective trials demonstrated that LDH was not better in preventing DVT than no prophylaxis in patients with an ISS > 9. Sample sizes in these studies were small, and hence, a type II statistical error cannot be excluded. The results of LDH in trauma, with regard to PE, are even more vague. We are aware of only two studies using a combined modality of LDH and mechanical prophylaxis.

Defining the trauma patient who is at high risk for VTE is subjective, and this definition has been variable in the literature. The following injury patterns appear to differentiate high-risk patients for VTE: severe closed head injury (Glasgow Coma Scale score < 8); pelvis plus long-bone fractures; multiple long-bone fractures; and spinal cord injury. A group of trauma surgeons has developed a risk-factor assessment tool for VTE, and preliminary evidence supports it as a valid indicator of the development of VTE (Greenfield, EAST 1998). The various risk factors are weighted (Table 3); scores of <3 represent low risk, scores of 3 to 5 represent moderate risk, and scores of >5 represent high risk.

Table 3

Table 3

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II. Process

A MEDLINE review from 1966 to the present revealed several hundred articles related to the use of LDH in medical and general surgical patients. Only the eight articles related to the use of LDH in trauma patients were used for the following recommendations.

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III. Recommendations

A. Level I

LDH has little, if any, benefit as a sole agent for prophylaxis in the trauma patient at high risk for VTE.

B. Level II

For patients in whom bleeding could exacerbate their injuries (such as those with intracranial hemorrhage, incomplete spinal cord injuries, intraocular injuries, severe pelvic or lower-extremity injuries with traumatic hemorrhage, and intra-abdominal solid-organ injuries being managed nonoperatively), the safety of LDH has not been established, and an individual decision should be made when considering anticoagulant prophylaxis.

C. Level III

There may be a role for the use of LDH in combination with sequential compression devices in trauma patients at high risk for VTE, although there are few data in trauma patients to support such a combination.

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IV. Summary

The overall effectiveness of LDH for prophylaxis of VTE in trauma patients remains unclear. Most studies show no effect of LDH on VTE. Most studies on the use of LDH in trauma patients suffer from severe methodologic errors, poor study design, and small sample size, suggesting the possibility of a type II statistical error.

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V. Future Investigations

There are enough accumulated data to warrant not using LDH in a trial in high-risk trauma patients. Future studies should focus on the potential benefit of LDH in low-risk trauma patients.

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VI. References

Class I

1. Clagett GP, Reisch JS. Prevention of venous thromboembolism in general surgical patients: results of meta-analysis. Ann Surg. 1988;208:227-240.

2. Geerts WH, Jay RM, Code KI, et al. A comparison of low-dose heparin with low-molecular-weight heparin as prophylaxis against venous thromboembolism after major trauma. N Engl J Med. 1996;335:701-707.

Class II

1. Knudson MM, Lewis FR, Clinton A, Atkinson K, Megerman J. Prevention of venous thromboembolism in trauma patients. J Trauma. 1994;37:480-487.

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The Use of Sequential Compression Devices (SCDs) in the Prevention of DVT/PE

I. Statement of the Problem

Attacking the long-recognized risk factor of stasis, SCDs have been shown to increase mean and peak femoral venous blood velocities on the lower extremity. Additionally, SCDs have been shown to have a direct effect on the fibrinolytic pathway, acting to shorten the euglobulin lysis time, increase levels of coagulation cascade inhibitor molecules, and affecting the balance of plasminogen activation. In a number of prospective, randomized studies, SCDs have been shown to reduce the incidence of both DVT and PE. Reports suggest that SCDs should be worn with thromboembolism-deterrent stockings; however, this practice has not been widely studied and is not standard. Complications of SCDs have been noted in case reports and have been associated with improper positioning of the lower extremity during surgery, which should be avoided.

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II. Process

A MEDLINE search from 1986 to the present produced a large number of articles on this topic. Those articles pertinent to trauma-related thromboembolism prevention were reviewed. Twenty-three of these articles were evaluated to formulate the following guidelines.

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III. Recommendations

A. Level I

There are insufficient data to support level I recommendations on this topic.

B. Level II

Trauma patients at high risk for DVT, such as patients with head injuries, spinal cord injuries, or pelvis or hip fractures, should receive SCDs for prophylaxis against DVT.

C. Level III

1. For patients in whom the lower extremity is inaccessible for the placement of SCDs at the calf level, foot pumps may act as an effective alternative to lower the rate of DVT formation.

2. Patients who have surgery in the lithotomy position or evidence of significant weight loss should have precautions taken in positioning to prevent the occasional complications of peroneal nerve compression.

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IV. Summary

The use of SCDs worn on the lower extremity in patients at high risk for DVT and to reduce the rate of DVT is widely accepted; however, clinical studies demonstrating their effectiveness in trauma patients are few. Although the exact mechanism of action of SCDs is not known, their effect is believed to be based on a combination of factors addressing stasis and hypercoagulability. Until these mechanisms are better studied and understood, answers to specific questions regarding the appropriate use of SCDs are forthcoming.

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V. Future Investigations

More studies need to be done specifically related to the use of SCDs in trauma patients at risk for VTE. Questions regarding the efficacy of using the device on one lower extremity versus two, and whether an arm versus a leg provides equal protection, need to be addressed. There are a number of commercial vendors of compression devices, and whether one vendor is superior needs to be determined. Finally, the role of multimodality therapy (mechanical and pharmacologic) to provide any additional protection from VTE needs to be ascertained.

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VI. References

Class II

1. Inada K, Koike S, Shirai N, Matsumoto K, Hirose M. Effects of intermittent pneumatic leg compression for prevention of postoperative deep venous thrombosis with special reference to fibrinolytic activity. Am J Surg. 1988;155:602-605.

2. Woolson ST, Watt JM. Intermittent pneumatic compression to prevent proximal deep venous thrombosis during and after total hip replacement: a prospective, randomized study of compression alone, compression and aspirin, and compression and low-dose warfarin. J Bone Joint Surg Am. 1991;73:507-512.

3. Keith SL, McLaughlin DJ, Anderson FA Jr, et al. Do graduated compression stockings and pneumatic boots have an additive effect on the peak velocity of venous blood flow? Arch Surg. 1992;127:727-730.

4. Knudson MM, Collins JA, Goodman SB, McCrory DW. Thromboembolism following multiple trauma. J Trauma. 1992;32:2-11.

5. Knudson MM, Lewis FR, Clinton A, Atkinson K, Megerman J. Prevention of venous thromboembolism in trauma patients. J Trauma. 1994;37:480-487.

6. Christen Y, Reymond MA, Vogel JJ, Klopfenstein CE, Morel P, Bounameaux H. Hemodynamic effects of intermittent pneumatic compression of the lower limbs during laparoscopic cholecystectomy. Am J Surg. 1995;170:395-398.

7. Fisher CG, Blachut PA, Salvian AJ, Meek RN, O'Brien PJ. Effectiveness of pneumatic leg compression devices for the prevention of thromboembolic disease in orthopaedic trauma patients: a prospective, randomized study of compression alone versus no prophylaxis. J Orthop Trauma. 1995;9:1-7.

8. Jacobs DG, Piotrowski JJ, Hoppensteadt DA, Salvator AE, Fareed J. Hemodynamic and fibrinolytic consequences of intermittent pneumatic compression: preliminary results. J Trauma. 1996;40:710-717.

9. Ramos R, Salem BI, De Pawlikowski MP, Coordes C, Eisenberg S. The efficacy of pneumatic compression stockings in the prevention of pulmonary embolism after cardiac surgery. Chest. 1996;109:82-85.

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The Role of Low Molecular Weight Heparin in Venous Thromboembolism Prophylaxis in Trauma Patients

I. Statement of the Problem

The use of low molecular weight heparin (LMWH) has gained popularity for reducing the risk of VTE during the last 20 years. Specifically, in trauma patients with an ISS > 9, LMWH was shown to be more efficacious than unfractionated heparin (UH) in preventing DVT (venography). The LMWH group, however, had more bleeding, but this was not statistically significant. In another large study of trauma patients, LMWH was found to have similar efficacy to SCDs in preventing DVT (duplex ultrasonography); however, the overall DVT incidence for all groups was only 2%. The orthopedic literature contains several studies noting that LMWH outperforms UH for VTE prophylaxis and is more efficacious than oral anticoagulants in knee-replacement surgery. The general surgery literature is more variable, but two studies show clear efficacy of LMWH over UH for VTE prophylaxis. Except for two recent studies examining 1-month prophylaxis in hip-replacement surgery, the duration of prophylaxis was generally 7 to 14 days while patients were hospitalized.

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II. Process

MEDLINE searches and a review of the literature revealed hundreds of articles examining the use of LMWH in VTE prophylaxis. Sixty class I and class II references were found suitable for analysis.

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III. Recommendations

A. Level I

There are insufficient data to make level I recommendations for general use of LMWH as VTE prophylaxis in trauma patients.

B. Level II

LMWH should be used for VTE prophylaxis in trauma patients with the following injury patterns: (1) pelvic fractures requiring operative fixation or prolonged bed rest (>5 days); (2) complex lower-extremity fractures (defined as open fractures or multiple fractures in one extremity) requiring operative fixation or prolonged bed rest (>5 days); and (3) spinal cord injury with complete or incomplete motor paralysis.

C. Level III

1. Trauma patients with an ISS > 9, who can receive anticoagulants, should receive LMWH as their primary mode of VTE prophylaxis.

2. The use of LMWH or oral anticoagulants for several weeks after injury should be considered in patients who remain at high risk for VTE (i.e., elderly pelvic fracture patients, spinal cord injury patients, and patients who require prolonged bed rest (>5 days), and prolonged hospitalization or rehabilitation).

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IV. Summary

There is a wealth of class I data supporting the use of LMWH as VTE prophylaxis in orthopedic surgery. This literature is derived primarily from total hip-replacement and knee-replacement patients. Overall, LMWH appears to be equivalent or superior to UH for prophylaxis in general surgery patients. There are now class I data concluding that LMWH is superior to UH for prophylaxis in moderate-risk to high-risk trauma patients. Most data in many different types of patients confirm improved efficacy of LMWH with the same or even less bleeding risk compared with prophylaxis with UF. LMWH should be the standard form of VTE prophylaxis in trauma patients with complex pelvic and lower-extremity injuries as well as in those with spinal cord injuries. Class I data indicate that LMWH should be strongly considered for use in all high-risk trauma patients when their bleeding risk is acceptable.

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V. Future Investigations

There are many unresolved issues concerning VTE prophylaxis of trauma patients that need to be studied in a multicenter fashion. There are two multicenter trials being formulated at this time, both of which will address the use of LMWH in trauma patients and answer the question of synergy between anticoagulation and sequential compression. When these studies are completed, the class I data will more clearly define the role of LMWH for VTE prophylaxis in trauma patients. Until prospectively validated risk-assessment tools are available, we urge that each institution adopt local guidelines for VTE risk and establish guidelines among the trauma, orthopedic, and neurologic surgeons for bleeding risk after trauma.

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VI. References

Class I

1. Planes A, Vochelle N, Ferru J, et al. Enoxaparine low molecular weight heparin: its use in the prevention of deep venous thrombosis following total hip replacement. Haemostasis. 1986;16:152-158.

2. Turpie AGG, Levine MN, Hirsh J, et al. A randomized controlled trial of a low-molecular-weight heparin (enoxaparin) to prevent deep-vein thrombosis in patients undergoing elective hip surgery. N Engl J Med. 1986;315:925-929.

3. Planes A, Vochelle N, Mansat C. Prevention of deep vein thrombosis after total hip replacement by enoxaparine: once daily injection of 40 mg versus two daily injections of 20 mg. Thromb Haemost. 1987;58:117. Abstract.

4. Eriksson BI, Zachrisson BE, Teger-Nilsson AC, Risberg B. Thrombosis prophylaxis with low molecular weight heparin in total hip replacement. Br J Surg. 1988;75:1053-1057.

5. The European Fraxiparin Study (EFS) Group. Comparison of a low molecular weight heparin and unfractionated heparin for the prevention of deep vein thrombosis in patients undergoing abdominal surgery. Br J Surg. 1988;75:1058-1063.

6. Planes A, Vochelle N, Mazas F, et al. Prevention of postoperative venous thrombosis: a randomized trial comparing unfractionated heparin with low molecular weight heparin in patients undergoing total hip replacement. Thromb Haemost. 1988;60:407-410.

7. Samama M, Bernard P, Bonnardot JP, Combe-Tamzali S, Lanson Y, Tissot E. Low molecular weight heparin compared with unfractionated heparin in prevention of postoperative thrombosis. Br J Surg. 1988;75:128-131.

8. Ockelford PA, Patterson J, Johns AS. A double-blind randomized placebo controlled trial of thromboprophylaxis in major elective general surgery using once daily injections of a low molecular weight heparin fragment (Fragmin). Thromb Haemost. 1989;62:1046-1049.

9. Barsotti J, Gruel Y, Rosset P, et al. Comparative double-blind study of two dosage regimens of low-molecular weight heparin in elderly patients with a fracture of the neck of the femur. J Orthop Trauma. 1990;4:371-375.

10. Bergqvist D, Burmark US, Frisell J, et al. Thromboprophylactic effect of low molecular weight heparin started in the evening before elective general abdominal surgery: a comparison with low-dose heparin. Semin Thromb Hemost. 1990;16(suppl):19-24.

11. Green D, Lee MY, Lim AC, et al. Prevention of thromboembolism after spinal cord injury using low-molecular-weight heparin. Ann Intern Med. 1990;113:571-574.

12. Eriksson BI, Kalebo P, Anthymyr BA, Wadenvik H, Tengborn L, Risberg B. Prevention of deep-vein thrombosis and pulmonary embolism after total hip replacement: comparison of low-molecular-weight heparin and unfractionated heparin. J Bone Joint Surg Am. 1991;73:484-493.

13. Levine MN, Hirsh J, Gent M, et al. Prevention of deep vein thrombosis after elective hip surgery: a randomized trial comparing low molecular weight heparin with standard unfractionated heparin. Ann Intern Med. 1991;114:545-551.

14. Planes A, Vochelle N, Fagola M, et al. Efficacy and safety of a perioperative enoxaparin regimen in total hip replacement under various anesthesias. Am J Surg. 1991;161:525-531.

15. Torholm C, Broeng L, Jorgensen PS, et al. Thromboprophylaxis by low-molecular-weight heparin in elective hip surgery: a placebo controlled study. J Bone Joint Surg Br. 1991;73:434-438.

16. Jorgensen PS, Knudsen JB, Broeng L, et al. The thromboprophylactic effect of a low-molecular-weight heparin (Fragmin) in hip fracture surgery: a placebo-controlled study. Clin Orthop. 1992;278:95-100.

17. Leclerc JR, Geerts WH, Desjardins L, et al. Prevention of deep vein thrombosis after major knee surgery: a randomized, double-blind trial comparing a low molecular weight heparin fragment (enoxaparin) to placebo. Thromb Haemost. 1992;67:417-423.

18. Bounameaux H, Huber O, Khabiri E, Schneider PA, Didier D, Rohner A. Unexpectedly high rate of phlebographic deep venous thrombosis following elective general abdominal surgery among patients given prophylaxis with low-molecular-weight heparin. Arch Surg. 1993;128:326-328.

19. Gallus A, Cade J, Ockelford P, et al. Orgaran (Org 10172) or heparin for preventing venous thrombosis after elective surgery for malignant disease? A double-blind, randomised, multicentre comparison. Thromb Haemost. 1993;70:562-567.

20. Hull R, Raskob G, Pineo G, et al. A comparison of subcutaneous low-molecular-weight heparin with warfarin sodium for prophylaxis against deep-vein thrombosis after hip or knee implantation. N Engl J Med. 1993;329:1370-1376.

21. Kakkar VV, Cohen AT, Edmonson RA, et al. Low molecular weight versus standard heparin for prevention of venous thromboembolism after major abdominal surgery. Lancet. 1993;341:259-265.

22. Fauno P, Suomalainen O, Rehnberg V, et al. Prophylaxis for the prevention of venous thromboembolism after total knee arthroplasty: a comparison between unfractionated and low-molecular-weight heparin. J Bone Joint Surg Am. 1994;76:1814-1818.

23. Menzin J, Richner R, Huse D, Colditz GA, Oster G. Prevention of deep-vein thrombosis following total hip replacement surgery with enoxaparin versus unfractionated heparin: a pharmacoeconomic evaluation. Ann Pharmacother. 1994;28:271-275.

24. RD Heparin Arthroplasty Group. RD heparin compared with warfarin for prevention of venous thromboembolic disease following total hip or knee arthroplasty. J Bone Joint Surg Am. 1994;76:1174-1185.

25. Spiro TE, Fitzgerald RH, Trowbridge AA, et al. Enoxaparin a low molecular weight heparin and warfarin for the prevention of venous thromboembolic disease after elective knee replacement surgery. Blood. 1994;84:26a. Abstract.

26. Spiro TE, Johnson GJ, Christie MJ, et al. Efficacy and safety of enoxaparin to prevent deep venous thrombosis after hip replacement surgery. Ann Intern Med. 1994;121:81-89.

27. Bergqvist D, Burmark US, Flordal PA, et al. Low molecular weight heparin started before surgery as prophylaxis against deep vein thrombosis: 2500 versus 5000 XaI units in 2070 patients. Br J Surg. 1995;82:496-501.

28. Colwell CW Jr, Spiro TE, Trowbridge AA, Stephens JW, Gardiner GA Jr, Ritter MA. Efficacy and safety of enoxaparin versus unfractionated heparin for prevention of deep venous thrombosis after elective knee arthroplasty. Clin Orthop. 1995;321:19-27.

29. Hamulyak K, Lensing AW, van der Meer J, Smid WM, van Ooy A, Hoek JA. Subcutaneous low-molecular weight heparin or oral anticoagulants for the prevention of deepvein thrombosis in elective hip and knee replacement? Fraxiparine Oral Anticoagulant Study Group. Thromb Haemost. 1995;74:1428-1431.

30. Heit J. Efficacy and safety of ardeparin compared to warfarin for prevention of venous thromboembolism following total knee replacement: a double-blind dose ranging. Thromb Haemost. 1995;73:978. Abstract.

31. Warwick D, Bannister GC, Glew D, et al. Perioperative low-molecular-weight heparin: is it effective and safe? J Bone Joint Surg Br. 1995;77:715-719.

32. Wiig JN, Solhaug JH, Bilberg T, et al. Prophylaxis of venographically diagnosed deep vein thrombosis in gastrointestinal surgery: multicentre trials 20 mg and 40 mg enoxaparin versus dextran. Eur J Surg. 1995;161:663-668.

33. Bergqvist D, Benoni G, Bjorgell O, et al. Low-molecular-weight heparin (enoxaparin) as prophylaxis against venous thromboembolism after total hip replacement. N Engl J Med. 1996;335:696-700.

34. Bergqvist D, Flordal PA, Friberg B, et al. Thromboprophylaxis with a low molecular weight heparin (tinzaparin) in emergency abdominal surgery: a double-blind multicenter trial. Vasa. 1996;25:156-160.

35. Geerts WH, Jay RM, Code KI, et al. A comparison of low-dose heparin with low-molecular-weight heparin as prophylaxis against venous thromboembolism after major trauma. N Engl J Med. 1996;335:701-707.

36. Leclerc JR, Geerts WH, Desjardins L, et al. Prevention of venous thromboembolism after knee arthroplasty: a randomized, double-blind trial comparing enoxaparin with warfarin. Ann Intern Med. 1996;124:619-626.

37. Levine MN, Gent M, Hirsh J, et al. Ardeparin (low-molecular-weight heparin) vs graduated compression stockings for the prevention of venous thromboembolism: a randomized trial in patients undergoing knee surgery. Arch Intern Med. 1996;156:851-856.

38. Planes A, Vochelle N, Darmon JY, Fagola M, Bellaud M, Huet Y. Risk of deep-venous thrombosis after hospital discharge in patients having undergone total hip replacement: double-blind randomised comparison of enoxaparin versus placebo. Lancet. 1996;348:224-228.

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The Role of Arteriovenous Foot Pumps in the Prophylaxis of DVT/PE in the Trauma Patient

I. Statement of the Problem

Gardner and Fox, in 1983, discovered a venous pump on the sole of the foot that consists of a plexus of veins that fills by gravity and empties upon weight bearing, thus increasing femoral blood flow without muscular assistance. A mechanical device, the A-V foot pump, has been developed to mimic this effect of weight bearing. The major advantage of this system is that it only requires access to the foot, which enables it to be used in patients with Jones dressings, casts, or externally fixed limbs, who previously were unsuitable for SCDs. One study has shown that the pulsatile action of the A-V foot pump increased venous blood flow velocity in the popliteal vein by 250%.

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II. Process

With the recent clinical introduction of the A-V foot pump, there is a paucity of relevant literature related to this subject. A MEDLINE review dating back to 1980 revealed 12 articles on A-V foot pumps. There were only four articles specifically related to the use of A-V foot pumps in the trauma patient.

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III. Recommendations

A. Level I

There are insufficient data to suggest level I recommendations for this topic.

B. Level II

There are insufficient data to suggest level II recommendations for this topic.

C. Level III

A-V foot pumps may be used as a substitute for SCDs in those high-risk trauma patients who cannot wear SCDs because of external fixators or casts.

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IV. Summary

Small clinical series in elective orthopedic patients support the use of A-V foot pumps to prevent DVT. Only one clinical series in trauma patients compares A-V foot pumps with other standard techniques of DVT prophylaxis. The results from this series are not definitive in terms of the benefits of A-V foot pumps in preventing DVT. There is a theoretical advantage, however, to the use of A-V foot pumps in high-risk trauma patients who have a contraindication to heparin because of their injuries and who cannot have SCDs placed on the lower extremity because of external fixators or large bulky dressings.

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V. Future Investigations

More prospective, randomized studies are needed comparing A-V foot pumps with standard prophylactic measures in trauma patients at high risk for the development of DVT.

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VI. References

Class I

1. Santori FS, Vitullo A, Stopponi M, Santori N, Ghera S. Prophylaxis against deep-vein thrombosis in total hip replacement: comparison of heparin and foot impulse pump. J Bone Joint Surg Br. 1994;76:579-583.

2. Westrich GH, Sculco TP. Prophylaxis against deep venous thrombosis after total knee arthroplasty: pneumatic plantar compression and aspirin compared with aspirin alone. J Bone Joint Surg Am. 1996;78:826-834.

Class II

1. Fordyce MJ, Ling RS. A venous foot pump reduces thrombosis after total hip replacement. J Bone Joint Surg Br. 1992;74:45-49.

2. Stranks GJ, Mackenzie NA, Grover ML, Fail T. The A-V Impulse System reduces deep-vein thrombosis and swelling after hemiarthroplasty for hip fracture. J Bone Joint Surg Br. 1992;74:775-778.

3. Wilson NV, Das SK, Kakkar VV, et al. Thrombo-embolic prophylaxis in total knee replacement: evaluation of the A-V impulse system. J Bone Joint Surg Br. 1992;74:50-52.

4. Bradley JC, Krugener GH, Jager HJ. The effectiveness of intermittent plantar venous compression in prevention of deep venous thrombosis after total hip arthroplasty. J Arthroplasty. 1993;8:57-61.

5. Knudson MM, Morabito D, Paiement GD, Shackleford S. Use of low molecular weight heparin in preventing thromboembolism in trauma patients. J Trauma. 1996;41:446-459.

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The Role of the Vena Cava Filter in the Prophylaxis and Treatment of PE

I. Statement of the Problem

Vena caval interruption is a form of PE prophylaxis that is being used more frequently in trauma patients with ongoing bleeding or those with recent brain, spinal cord, or ocular injury who will not tolerate even minor amounts of bleeding. Furthermore, patients with multiple injuries often have extremity injuries that preclude the use of SCDs. The decision to place a "prophylactic" vena cava filter in a trauma patient requires a fundamental understanding of the risk/benefit ratio. The data included in this review indicate that the risk/benefit ratio is favorable in a high-risk trauma patient. The problem, therefore, becomes defining the "high-risk" patient and the short-term and long-term complication rates of vena caval interruption.

The literature is somewhat difficult to interpret because each group of authors differs in their definition of a prophylactic vena cava filter. This review is designed to examine the data available for the use of vena cava filters for "extended" indications in the trauma patient, i.e., filter placement early after injury, before the patient has clinical or radiographic evidence of a DVT or PE.

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II. Process

A MEDLINE search from 1980 to 1996 showed five articles when "vena cava filter" was cross-referenced with "trauma." An additional personal review of the literature revealed seven other articles and two abstracts that addressed extended indications of vena cava filter placement in trauma patients. Also, there were four articles that specifically addressed complications and long-term follow-up with vena cava filters that are included in this review.

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III. Recommendations

A. Level I

There is a large body of evidence not reviewed in this section to support insertion of a vena cava filter for standard indications in trauma patients. These indications include:

- recurrent PE despite full anticoagulation;

- proximal DVT and contraindications to full anticoagulation;

- proximal DVT and major bleeding while on full anticoagulation;

- progression of iliofemoral clot despite anticoagulation (rare).

B. Level II

Extended indications for prophylactic vena cava filter placement in a patient with established DVT or PE include:

- large free-floating thrombus in the iliac vein or the inferior vena cava;

- after massive PE in which recurrent emboli may prove fatal;

- during or after surgical embolectomy.

C. Level III

Insertion of a prophylactic vena caval filter should be considered in patients without a DVT/PE if they (1) cannot receive anticoagulation because of increased bleeding risk and (2) have one or more of the following injury patterns:

- severe closed head injury (Glasgow Coma Scale score < 8);

- incomplete spinal cord injury with paraplegia or quadriplegia;

- complex pelvic fractures with associated long-bone fractures;

- multiple long-bone fractures.

Patients at high risk for bleeding complications for 5 to 10 days after injury would include those with intracranial hemorrhage, ocular injury with associated hemorrhage, solid intra-abdominal organ injury (i.e., liver, spleen, kidney), or pelvic or retroperitoneal hematoma requiring transfusion. Other risk factors for bleeding include cirrhosis, active peptic ulcer disease, end-stage renal disease, and coagulopathy attributable to injury, medication, or congenital or hereditary conditions.

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IV. Summary

There is virtually no class I literature to support insertion of a vena cava filter in a trauma patient without an established DVT or PE. There is starting to accumulate a fair amount of class II and III data that may support its use in high-risk trauma patients without a documented occurrence of a DVT or PE. At this time, we recommend consideration of inferior vena cava filter insertion in patients without a documented DVT or PE who meet high-risk criteria and cannot be anticoagulated.

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V. Future Investigations

There is an obvious need for class I randomized, prospective, controlled data to either support or refute the use of vena caval interruption in trauma patients. Such studies need to enroll only high-risk patients with a sufficiently high PE rate to attempt to prove filter efficacy and improve outcome in the patients who receive a truly prophylactic vena cava filter. The pilot portion of such a study has been completed, and the large multicenter trial should involve many investigators from trauma associations. Other important unresolved issues include whether vena cava filters significantly reduce the incidence of clinically important PE in patients who receive "optimal" prophylaxis, and if so, can a group of patients be identified who have a high failure rate with optimal prophylaxis? The short-term and long-term complications of vena cava filter insertion used as primary prophylaxis in trauma patients need to be identified. Finally, the cost-effectiveness of vena cava filter insertion needs to be determined.

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VI. References

Class I

1. Greenfield LJ, Proctor MC, Rodriguez JL, Luchette FA, Cipolle MD, Cho J. Posttrauma thromboembolism prophylaxis. J Trauma. 1997;42:100-103.

Class II

1. Carabasi RA 3d, Moritz MJ, Jarrell BE. Complications encountered with the use of the Greenfield filter. Am J Surg. 1987;154:163-168.

2. Webb LX, Rush PT, Fuller SB, Meredith JW. Greenfield filter prophylaxis of pulmonary embolism in patients undergoing surgery for acetabular fracture. J Orthop Trauma. 1992;6:139-145.

3. Rogers FB, Shackford SR, Wilson J, Ricci MA, Morris CS. Prophylactic vena cava filter insertion in severely injured trauma patients: indications and preliminary results. J Trauma. 1993;35:637-642.

4. Leach TA, Pastena JA, Swan KG, Tikellis JI, Blackwood JM, Odorn JW. Surgical prophylaxis for pulmonary embolism. Am Surg. 1994;60:292-295.

5. Rosenthal D, McKinsey JF, Levy AM, Lamis PA, Clark MD. Use of the Greenfield filter in patients with major trauma. Cardiovasc Surg. 1994;2:52-55.

6. Wilson JT, Rogers FB, Wald SL, Shackford SR, Ricci MA. Prophylactic vena cava filter insertion in patients with traumatic spinal cord injury: preliminary results. Neurosurgery. 1994;35:234-239.

7. Rogers FB, Shackford SR, Ricci MA, Wilson JT, Parsons S. Routine prophylactic vena cava filter insertion in severely injured trauma patients decreases the incidence of pulmonary embolism. J Am Coll Surg. 1995;180:641-647.

8. Patton JH Jr, Fabian TC, Croce MA, Minard G, Pritchard FE, Kudsk KA. Prophylactic Greenfield filters: acute complications and long-term follow up. J Trauma. 1996;41:231-237.

9. Rodriguez JL, Lopez JM, Proctor MC, et al. Early placement of prophylactic vena caval filters in injured patients at high risk for pulmonary embolism. J Trauma. 1996;40:797-804.

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The Role of the Treatment of Established DVT/PE with Anticoagulation in the Trauma Patient

I. Statement of the Problem

In a patient with a diagnosed DVT, the goals of therapy are to prevent progression of the thrombosis and subsequent PE. Objective evidence to support the treatment of DVT with intravenous heparin comes from a prospective randomized trial by Hull and coworkers in which the efficacy of intravenous heparin was compared with that of subcutaneous heparin in the initial treatment of established DVT. Recurrent VTE occurred in 19.3% of those treated with subcutaneous heparin and in 5.2% of those treated with intravenous heparin (p < 0.024). In another prospective, controlled trial of anticoagulant therapy for PE, there were no deaths attributable to PE in the group receiving heparin anticoagulation compared with a mortality rate of 26% in those who did not receive heparin. This landmark study could never be repeated today for ethical reasons.

The data supporting anticoagulation for established VTE are incontrovertible. The dosage, timing, duration, and route of anticoagulant therapy may be subject to some circumspection.

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II. Process

A MEDLINE search from 1966 to the present revealed several thousand articles related to anticoagulant treatment for DVT/PE. Ten of these were felt to be of significant quality on which to base the following recommendations.

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III. Recommendations

A. Level I

For a documented DVT or PE in a patient with a contraindication to or complication of anticoagulation, vena caval interruption with a mechanical device is warranted.

B. Level II

1. For a documented first episode of DVT/PE and no contraindication to receiving anticoagulation, at least 6 months of anticoagulation therapy is warranted.

2. Patients with congenital deficiency of antithrombin III, protein C, or protein S, or those who, because of the nature of their injuries (such as those with spinal cord injury and permanent neurologic deficit), are at permanent high risk for DVT/PE or recurrent VTE, should receive anticoagulant therapy indefinitely. An alternative to anticoagulant therapy in these patients is vena caval interruption with a mechanical device.

C. Level III

Low molecular weight heparin administered subcutaneously may be substituted for unfractionated intravenous heparin as the initial anticoagulant treatment for established DVT.

The treatment of asymptomatic calf DVT is controversial, and according to the literature, the rates of proximal extension of calf DVT vary from 0 to 30%. Patients with symptomatic calf DVT seem to be at higher risk of extension and should be treated for 3 to 6 months with anticoagulation. Asymptomatic calf DVT are particularly prevalent in trauma and joint-replacement patients (20-40%), even with prophylaxis. The current evidence (Hyers et al.) indicates that patients with asymptomatic calf DVT should either undergo 3 months of anticoagulation or be followed with serial duplex ultrasonography for 10 to 14 days to identify proximal extension of the thrombus.

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IV. Summary

Anticoagulation is a well-established treatment for DVT/PE. Current evidence suggests that a 3- to 6-month period provides adequate treatment for a first episode of DVT/PE in a patient without a clotting abnormality. Those in whom the risk of recurrent VTE extends beyond 6 months may have anticoagulation extended indefinitely. In addition, those patients whose injuries preclude the use of anticoagulants because bleeding would exacerbate their injuries should have consideration given to placement of a vena cava filter. Recent evidence also supports initial treatment of VTE with LMWH.

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V. Future Investigations

Future studies should target the timing and duration of intravenous and oral anticoagulant therapies. In addition, studies comparing initial therapy with intravenous heparin and subcutaneous heparin should be carried out.

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V. References

Class I

1. Barritt DW, Jordan SC. Anticoagulant drugs in the treatment of pulmonary embolism: a controlled trial. Lancet. 1960;1:1309-1312.

2. Hull R, Hirsh J, Jay R, et al. Different intensities of oral anticoagulant therapy in the treatment of proximal-vein thrombosis. N Engl J Med. 1982;307:1676-1681.

3. Hull RD, Raskob GE, Hirsh J, et al. Continuous intravenous heparin compared with intermittent subcutaneous heparin in the initial treatment of proximal-vein thrombosis. N Engl J Med. 1986;315:1109-1114.

4. Schulman S, Rhedin AS, Lindmarker P, et al. A comparison of six weeks with six months of oral anticoagulant therapy after a first episode of venous thromboembolism. N Engl J Med. 1995;332:1661-1665.

5. Koopman MM, Prandoni P, Piovella F, et al. Treatment of venous thrombosis with intravenous unfractionated heparin administered in the hospital as compared with subcutaneous low-molecular-weight heparin administered at home. N Engl J Med. 1996;334:682-687.

6. Levine M, Gent M, Hirsh J, et al. A comparison of low-molecular-weight heparin administered primarily at home with unfractionated heparin administered in the hospital for proximal deep-vein thrombosis. N Engl J Med. 1996;334:677-681.

Class II

1. Wessler S, Gitel SN. Warfarin: from bedside to bench. N Engl J Med. 1984;311:645-652.

2. Hyers TM, Hull RD, Weg JG. Antithrombotic therapy for venous thromboembolic disease. Chest. 1995;108:335S-351S.

3. Brathwaite CE, Mure AJ, O'Malley KF, Spence RK, Ross SE. Complications of anticoagulation for pulmonary embolism in low risk trauma patients. Chest. 1993;104:718-720.

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The Role of Ultrasonography in Diagnostic Imaging for DVT in Trauma

I. Statement of the Problem

Early identification of DVT in trauma patients would allow for treatment to be initiated, thus decreasing the frequency of complications. Ultrasonographic scanning has several advantages as a diagnostic tool in detecting DVT: it is noninvasive, requires to contrast medium, can be performed at the bedside, and is able to detect nonocclusive thrombus. Two types of ultrasonography will be discussed. Doppler ultrasonography involves a hand-held probe placed over the skin of the vein being studied. Duplex ultrasonography uses real time B-mode sonography, which produces a two-dimensional image using high-frequency sound waves and Doppler ultrasonography. It is important for the reader to distinguish between these two technologies in the accuracy of ultrasonography to detect DVT. Furthermore, in the critical review of ultrasonographic technology to detect DVT, a dichotomy exists in the sensitivity of ultrasonography to detect DVT in symptomatic versus asymptomatic patients.

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II. Process

A MEDLINE search from 1966 to the present revealed several thousand articles related to the ultrasonographic diagnosis of DVT. Several of the more seminal articles and review articles related to the ultrasonographic diagnosis of DVT in the nontrauma patient are included to provide a perspective on the current state of the technology. A total of 16 articles related to the ultrasonographic diagnosis of DVT in the trauma patient are discussed in this review.

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III. Recommendations

A. Level I

Duplex ultrasonography can be used to assess symptomatic trauma patients with suspected DVT without confirmatory venography.

B. Level II

There are insufficient data to suggest level II recommendations for this topic.

C. Level III

1. Hand-held Doppler ultrasonographic devices can be used to assess symptomatic trauma patients with suspected DVT, but confirmatory venography is recommended in patients who screen positive for DVT with Doppler ultrasonography.

2. Serial duplex ultrasonographic imaging of high-risk asymptomatic trauma patients to screen for DVT may be cost-effective and decrease the incidence of PE. The use of ultrasonography in screening asymptomatic patients, however, is burdened by a low sensitivity compared with venography.

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IV. Summary

Numerous studies in the nontrauma literature attest to the overall accuracy of both Doppler and duplex ultrasonography in the detection of DVT in the symptomatic patient. The overall accuracy of screening ultrasonography in the asymptomatic patient is less clear. Many reports on the use of screening ultrasonography (either Doppler or duplex) lack corroboration of accuracy with contrast venography. Of concern is that many of these studies report on PEs in the presence of negative screening ultrasonographic examinations, leading one to speculate on the ability of duplex ultrasonography to detect clinically significant DVT.

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V. Future Investigations

A prospective study with an adequate sample size and appropriate power calculation, possibly multi-institutional (with standardization of ultrasonographic techniques), should be undertaken to determine the accuracy (i.e., sensitivity and specificity as well as positive and negative predictive values) of screening duplex ultrasonography compared with standard venography in trauma patients. It is not cost-effective to serially screen all trauma patients for DVT; therefore, the high-risk trauma patient who is prone to develop DVT likewise needs to be identified.

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VI. References

Class I

1. Comerota AJ, Katz ML, Hashemi HA. Venous duplex imaging for the diagnosis of acute deep venous thrombosis. Haemost. 1993;23:61-71.

2. Agnelli G, Radicchia S, Nenci GG. Diagnosis of deep vein thrombosis in asymptomatic high-risk patients. Haemostasis. 1995;25:40-48.

3. Wheeler HB, Anderson FA Jr. Diagnostic methods for deep vein thrombosis. Haemostasis. 1995;25:6-26.

Class II

1. Myllynen P, Kammonen M, Rokkanen P, Bostman O, Lalla M, Maasonen E. Deep venous thrombosis and pulmonary embolism in patients with acute spinal cord injury: a comparison with nonparalyzed patients immobilized due to spinal fractures. J Trauma. 1985;25:541-543.

2. Dorfman GS, Froehlich JA, Cronan JJ, Urbanek PJ, Herndon JH. Lower-extremity venous thrombosis in patients with acute hip fractures: determination of anatomic location and time of onset with compression sonography. AJR Am J Roentgenol. 1990;154:851-855.

3. Knudson MM, Collins JA, Goodman SB, McCrory DW. Thromboembolism following multiple trauma. J Trauma. 1992;32:2-11.

4. Knudson MM, Lewis FR, Clinton A, Atkinson K, Megerman J. Prevention of venous thromboembolism in trauma patients. J Trauma. 1994;37:480-487.

5. Jongbloets LM, Lensing AW, Koopman MM, Buller HR, ten Cate JW. Limitations of compression ultrasound for the detection of symptomless postoperative deep vein thrombosis. Lancet. 1994;343:1142-1144.

6. Meythaler JM, DeVivo MJ, Hayne JB. Cost-effectiveness of routine screening for proximal deep venous thrombosis in acquired brain injury patients admitted to rehabilitation. Arch Phys Med Rehabil. 1996;77:1-5.

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The Role of Impedance Plethysmography (IPG) in Diagnostic Imaging for DVT in Trauma

I. Statement of the Problem

IPG is a noninvasive technique based on the principle that volume changes of the leg lead to changes in electrical resistance (impedance). Temporary venous occlusion is produced by an inflatable thigh cuff, and the venous volume response in the calf is measured during inflation of the cuff and for a few seconds after its release. Normally, there is a progressive increase in blood volume of the calf after inflation of the thigh cuff, followed by a rapid runoff when the cuff is released. IPG can be falsely normal if thrombi are nonocclusive or if proximal DVT is associated with well-developed collaterals. In addition, an elevated central venous pressure or venous compression by mass or hematoma can produce a false-positive result. When a DVT is present, the runoff is notably impaired. In a critical review of IPG's effectiveness in detecting DVT, a clear demarcation exists between symptomatic patients and asymptomatic high-risk patients who are screened for DVT.

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II. Process

IPG was first introduced by Wheeler in 1970. A MEDLINE search since that time revealed 4,319 articles related to IPG and only 4 articles specifically related to trauma patients.

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III. Recommendations

A. Level I

There are insufficient data to suggest a standard for this topic.

B. Level II

There are insufficient data to suggest a guideline for this topic.

C. Level III

1. IPG testing may be used in symptomatic patients to detect DVT. For those patients in whom the clinical suspicion for DVT is high and who test negative for DVT on IPG, confirmatory ultrasonography or venography is recommended.

2. The reported low sensitivity of IPG makes it unsuitable for screening of asymptomatic high-risk trauma patients.

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IV. Summary

Most studies demonstrate that IPG has a high sensitivity and specificity in the detection of proximal DVT in symptomatic patients. Its low sensitivity in detecting DVT in asymptomatic patients precludes its use as a surveillance technique in trauma patients at high risk for DVT. There are few studies that specifically address the role of IPG in the trauma patient.

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V. Future Investigations

With improved reported accuracy of duplex ultrasonography over IPG, we believe that future investigational efforts would be better directed at the role of duplex ultrasonography in screening for DVT in the trauma patient.

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VI. References

Class I

1. Wheeler HB, Hirsh J, Wells P, Anderson FA Jr. Diagnostic tests for deep vein thrombosis: clinical usefulness depends on probability of disease. Arch Intern Med. 1994;154:1921-1928.

Class II

1. Cruickshank MK, Levine MN, Hirsh J, et al. An evaluation of impedance plethysmography and125 I-fibrinogen leg scanning in patients following hip surgery. Thromb Haemost. 1989;62:830-834.

2. Huisman MV, Buller HR, ten Cate JW, Heijermans HS, van der Laan J, van Maanen DJ. Management of clinically suspected acute venous thrombosis in outpatients with serial impedance plethysmography in a community hospital setting. Arch Intern Med. 1989;149:511-513.

3. Geerts WH, Code KI, Jay RM, Chen E, Szalai JP. A prospective study of venous thromboembolism after major trauma. N Engl J Med. 1994;331:1601-1606.

4. Ginsberg JS, Wells PS, Hirsh J, et al. Reevaluation of the sensitivity of impedance plethysmography for the detection of proximal deep vein thrombosis. Arch Intern Med. 1994;154:1930-1933.

5. Hull RD, Feldstein W, Stein PD, Pineo GF. Cost-effectiveness of pulmonary embolism diagnosis. Arch Intern Med. 1996;156:68-72.

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The Role of Venography in the Diagnosis of DVT in Trauma Patients

I. Statement of the Problem

Venography is the diagnostic modality with which all other invasive or noninvasive diagnostic modalities for DVT are compared. It is often referred to as the "gold standard" for the detection of DVT in trauma patients.

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II. Process

A MEDLINE search from 1966 to the present identified 3,520 articles related to venography in the diagnosis of DVT. Only eight articles were specifically related to the use of venography to detect DVT in the trauma patient. These articles, as well as some seminal review articles, were reviewed.

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III. Recommendations

A. Level I

There are insufficient data to support a level I recommendation on this topic.

B. Level II

1. Ascending venography should be used as a confirmatory study in those trauma patients who have equivocal impedance plethysmographic or ultrasonographic results for DVT.

2. Ascending venography should not be used to screen asymptomatic trauma patients at high risk for DVT. There may be a role for ascending venography in research studies on the incidence of DVT in trauma patients.

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IV. Summary

Although venography traditionally has been the diagnostic modality for DVT with which all other diagnostic modalities have been compared, logistical problems and complications associated with the procedure make it less appealing than other noninvasive diagnostic measures. Nevertheless, it still has a role in confirming DVT in trauma patients when diagnostic studies are equivocal, or possibly as an outcome measure in clinical trials of thromboprophylaxis efficacy.

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V. Future Investigations

A study comparing venography with other noninvasive imaging modalities for DVT such as duplex ultrasonography should be performed.

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VI. References

Class II

1. Freeark RJ, Boswick J, Fardin R. Posttraumatic venous thrombosis. Arch Surg. 1967;95:567-575.

2. Bettmann MA, Robbins A, Braun SD, Wetzner S, Dunnick NR, Finkelstein J. Contrast venography of the leg: diagnostic efficacy, tolerance, and complication rates with ionic and nonionic contrast media. Radiology. 1987;165:113-116.

3. Yelnik A, Dizien O, Bussel B, Schouman-Claeys E, Frija G, Pannier S. Systematic lower limb phlebography in acute spinal cord injury in 147 patients. Paraplegia. 1991;29:253-260.

4. Geerts WH, Code KI, Jay RM, Chen E, Szalai JP. A prospective study of venous thromboembolism after major trauma. N Engl J Med. 1994;331:1601-1606.

5. Burke B, Sostman HD, Carroll BA, Witty LA. The diagnostic approach to deep venous thrombosis: which technique? Clin Chest Med. 1995;16:253-268.

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