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Incidence of Asymptomatic Pulmonary Embolism in Moderately to Severely Injured Trauma Patients David J

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Incidence of Asymptomatic Pulmonary Embolism in Moderately to Severely Injured Trauma Patients David J The Journal of TRAUMA௡ Injury, Infection, and Critical Care Incidence of Asymptomatic Pulmonary Embolism in Moderately to Severely Injured Trauma Patients David J. Schultz, MD, Karen J. Brasel, MD, MPH, Lacey Washington, MD, Lawrence R. Goodman, MD, Robert R. Quickel, MD, Randolph J. Lipchik, MD, Todd Clever, BS, and John Weigelt, MD Background: Chest computed tomo- sessed using an anatomic scoring system. patients receiving pharmacologic prophy- graphic (CT) scanning is used frequently Patients not receiving anticoagulation laxis had a PE. to evaluate symptomatic patients for pul- were followed. Conclusion: Asymptomatic PE occur monary embolus (PE). The incidence of Results: Twenty-two of 90 patients in 24% of moderately to severely injured PE diagnosed by helical CT scanning in had a PE. Four had major clot burden, patients. Age, head, chest, and lower ex- asymptomatic patients is unknown. including one patient with a saddle embo- tremity injury are associated with an in- Methods: Asymptomatic trauma pa- lus. Risk factors for asymptomatic PE in- creased risk. Standard thromboembolic tients with an Injury Severity Score > 9 clude age (odds ratio [OR], 1.04), head prophylaxis is not reliably protective. were studied with contrast-enhanced heli- injury (OR, 6.78), chest injury (OR, 4.51), Key Words: Computed tomographic cal CT images of the chest, pelvis, and lower extremity injury (OR, 5.03), and scanning, Pulmonary embolus, Head in- lower extremities. Clot burden was as- transfusion (OR, 3.42). Thirty percent of jury, Chest injury, Transfusion. J Trauma. 2004;56:727–733. hromboembolic complications are common in the uate respiratory symptoms in these patients. Many of these trauma population. Depending on the severity and type scans show atelectasis or pulmonary consolidation, and the Tof injury as well as the method of prophylaxis, the patient’s symptoms resolve with appropriate treatment. How- prevalence of proximal deep venous thrombosis (DVT) and ever, in these symptomatic patients, the scans occasionally pulmonary embolus (PE) can approach 20%.1 Prophylaxis show small pulmonary emboli. This raises a new question: against thromboembolic disease in these patients is aimed are we finding thromboembolic disease that is clinically in- against both DVT and PE, with the assumption that it is significant, or are we finding thromboembolic disease before equally effective against both. Screening the lower extremi- it becomes clinically significant? ties with venous Doppler examinations either once or twice Most prospective studies of PE in injured or postopera- weekly is based on the assumption that the majority of pul- tive patients have been conducted on symptomatic monary emboli develop from venous thrombosis in the pelvis patients.3–6 In patients with deep venous thrombosis or those or lower extremities.2 undergoing major abdominal or orthopedic procedures, the Respiratory complications are also common in injured prevalence of unsuspected or asymptomatic pulmonary em- patients. The pain from chest injury, particularly rib fractures, boli is approximately 25%.7–16 Injured patients can also be at frequently causes splinting and inadequate expansion, leading high risk for DVT and pulmonary emboli, but the prevalence to atelectasis and pneumonia. Enforced recumbency caused of asymptomatic pulmonary emboli remains unknown. The by associated injuries exacerbates this problem. Chest com- purpose of this study was to determine the incidence of PE puted tomography is used with increasing frequency to eval- diagnosed by helical computed tomographic (CT) angiogra- phy in asymptomatic trauma patients and the consequences of withholding anticoagulation in patients with minor clot Received for publication September 24, 2003. burden. Accepted for publication December 31, 2003. Copyright © 2004 by Lippincott Williams & Wilkins, Inc. From the Departments of Surgery (D.J.S., K.J.B., T.C., J.W.) and PATIENTS AND METHODS Radiology (L.W., L.R.G.) and Division of Pulmonary Medicine, Department of Medicine (R.J.L.), Medical College of Wisconsin, Milwaukee, Wisconsin, This prospective cohort study was approved by the and Department of Surgery, Hennepin County Medical Center (R.R.Q.), institutional review boards at the Medical College of Wis- Minneapolis, Minnesota. consin and Froedtert Memorial Lutheran Hospital. Con- Presented at the 62nd Annual Meeting of the American Association for secutive trauma patients with an Injury Severity Score the Surgery of Trauma, September 11–13, 2003, Minneapolis, Minnesota; (ISS) Ն 9 without symptoms suggestive of a pulmonary Second Place, Clinical Investigation, Resident Trauma Papers Competition, 2003. embolus or deep venous thrombosis were studied on Address for reprints: Karen J. Brasel, MD, MPH, Department of Sur- postinjury days 3 to 7. This time interval was chosen gery, Medical College of Wisconsin, 9200 West Wisconsin, Milwaukee, WI because it is the interval during which initial screening for 53226; email: [email protected]. asymptomatic deep venous thrombosis in high-risk trauma DOI: 10.1097/01.TA.0000119687.23542.EC patients is recommended.3 In addition to documented Volume 56 • Number 4 727 The Journal of TRAUMA௡ Injury, Infection, and Critical Care thromboembolic disease or symptoms suggestive of a deep venous thrombosis or pulmonary emboli, patients were excluded for the following reasons: mechanical ventila- tion, renal failure, iodine allergy, pregnancy, and age younger than 18 years. Patients on mechanical ventilation were excluded because of the difficulty in determining whether these patients were truly asymptomatic. After obtaining informed consent, 120 mL of nonionic contrast was injected and the patient was scanned from lung apex to diaphragm on a 16-slice multidetector helical CT scanner using 1.25-mm axial images and a 0.7-second rota- tion time (GE Lightspeed 16, Milwaukee, WI). After 3.5 minutes, 5-mm axial images every 2 cm from the iliac crest to the knees were obtained to evaluate the iliac, common femoral, and popliteal veins. Scans were initially interpreted by the on-call radiologist to screen for large pulmonary em- boli or deep venous thrombosis potentially requiring urgent treatment. The primary service was notified immediately about all scans with significant positive findings. All scans Fig. 1. Segmental pulmonary embolus seen in the white circle as the were then read by one of two experienced faculty chest segmental pulmonary artery branches into subsegmental arteries. radiologists. Emboli were scored using a modification of the Miller scoring system.17 This anatomic scoring system ranges RESULTS from 0.25 to 20 and is based on the pulmonary artery and its Ninety-four consecutive patients were enrolled. Eighty- segments. Each main pulmonary artery with clot receives a six eligible patients refused consent during the same period. score of 10, each segmental artery a score of 1, and each Three patients were excluded because their ISS was less than involved subsegmental artery a score of 0.25. Patients were 9 on final review, and one patient was excluded because of classified according to clot burden as follows: 0.25 to 2.0, poor scan quality (a result of morbid obesity). Of the 90 minimal burden; and 2.25 to 4.0, moderate burden. Clot evaluable patients, 22 patients (24%) were diagnosed with Burden Greater than 4.25: Major Burden; Glot burden greater PE. Eighteen patients had minor clot burden and four had than 4.25, major burden. major clot burden. Three quarters of the patients with minor Patients with suspected DVT underwent duplex exami- clot burden had subsegmental emboli (single or multiple) nation to confirm the presence of DVT. Treatment recom- only (Fig. 1). One of the patients with major clot burden had mendations based on clot burden were given, but ultimate a saddle embolus (Fig. 2). The four patients with major clot treatment and/or plans for further follow-up in patients with either deep venous thrombosis or pulmonary emboli was determined by the primary service. Recommendations in- cluded no treatment for minimal clot burden without coexis- tent DVT, and treatment of any patient with moderate or major clot burden or minor clot burden with a coexistent DVT. DVT was scored as absent, acute, or chronic. Age, gender, injury mechanism, organ injury, Abbrevi- ated Injury Scale score, ISS, need for blood transfusion, use of sequential compression devices, and use of prophylactic anticoagulation were analyzed for association with pulmo- nary embolism. Outcomes of hospital and intensive care unit length of stay were compared. All patients were phoned 3 months after discharge and questioned about complications, respiratory symptoms, lower extremity symptoms, and bleeding problems using a symp- tom checklist. Mailed questionnaires and chart review were used to ascertain follow-up when phone contact was not possible. Statistical analysis was performed using Student’s t Fig. 2. Saddle pulmonary embolus seen in the left and right main test, Fisher’s exact test, and multivariate regression. pulmonary arteries circled in black. 728 April 2004 Asymptomatic Pulmonary Embolism embolus received low-molecular-weight heparin as prophy- Table 1 Demographic Data laxis, as did another patient with major clot burden; two other PE Present PE Absent patients with major clot burden and the patient with the No. 22 68 coexistent DVT had only mechanical prophylaxis. Age (yr) 40.7 31.7 None of the 17 patients with minor clot burden were ISS 20.1 15.5 anticoagulated, and none had signs or symptoms
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