Association of Mechanism of Injury with Risk for Venous Thromboembolism After Trauma

Research

JAMA Surgery | Original Investigation | ASSOCIATION OF VA SURGEONS Association of Mechanism of Injury With Risk for Venous Thromboembolism After Trauma

Charles A. Karcutskie, MD, MA; Jonathan P. Meizoso, MD; Juliet J. Ray, MD; Davis Horkan, MD; Xiomara D. Ruiz, MD; Carl I. Schulman, MD, PhD, MSPH; Nicholas Namias, MD, MBA; Kenneth G. Proctor, PhD

Invited Commentary page 41

IMPORTANCE To date, no study has assessed whether the risk of venous thromboembolism CME Quiz at (VTE) varies with blunt or penetrating trauma. jamanetworkcme.com

OBJECTIVE To test whether the mechanism of injury alters risk of VTE after trauma.

DESIGN, SETTING, AND PARTICIPANTS A retrospective database review was conducted of adults admitted to the intensive care unit of an American College of Surgeons–verified level I trauma center between August 1, 2011, and January 1, 2015, with blunt or penetrating injuries. Univariate and multivariable analyses identified independent predictors of VTE.

MAIN OUTCOMES AND MEASURES Differences in risk factors for VTE with blunt vs penetrating trauma.

RESULTS In 813 patients with blunt trauma (mean [SD] age, 47 [19] years) and 324 patients with penetrating trauma (mean [SD] age, 35 [15] years), the rate of VTE was 9.1% overall (104 of 1137) and similar between groups (blunt trauma, 9% [n = 73] vs penetrating trauma, 9.6% [n = 31]; P = .76). In the blunt trauma group, more patients with VTE than without VTE had abnormal coagulation results (49.3% vs 35.7%; P = .02), femoral catheters (9.6% vs 3.9%; P = .03), repair and/or ligation of vascular injury (15.1% vs 5.4%; P = .001), complex leg fractures (34.2% vs 18.5%; P = .001), Glasgow Coma Scale score less than 8 (31.5% vs 10.7%; P < .001), 4 or more transfusions (51.4% vs 17.6%; P < .001), operation time longer than 2 hours (35.6% vs 16.4%; P < .001), and pelvic fractures (43.8% vs 21.4%; P < .001); patients with VTE also had higher mean (SD) Greenfield Risk Assessment Profile scores (13 [6] vs 8 [4]; P Յ .001). However, with multivariable analysis, only receiving 4 or more transfusions (odds ratio [OR], 3.47; 95% CI, 2.04-5.91), Glasgow Coma Scale score less than 8 (OR, 2.75; 95% CI, 1.53-4.94), and pelvic fracture (OR, 2.09; 95% CI, 1.23-3.55) predicted VTE, with an area under the receiver operator curve of 0.730. In the penetrating trauma group, more patients with VTE than without VTE had abnormal coagulation results (64.5% vs 44.4%; P = .03), femoral catheters (16.1% vs 5.5%; P = .02), repair and/or ligation of vascular injury (54.8% vs 25.3%; P < .001), 4 or more transfusions (74.2% vs 39.6%; P < .001), operation Author Affiliations: Ryder Trauma time longer than 2 hours (74.2% vs 50.5%; P = .01), Abbreviated Injury Score for the Center, Division of Trauma and Surgical Critical Care Services, DeWitt abdomen greater than 2 (64.5% vs 42.3%; P = .02), and were aged 40 to 59 years (41.9% Daughtry Family Department of vs 23.2%; P = .02); patients with VTE also had higher mean (SD) Greenfield Risk Assessment Surgery, University of Miami Leonard Profile scores (12 [4] vs 7 [4]; P < .001). However, with multivariable analysis, only repair M. Miller School of Medicine, Miami, and/or ligation of vascular injury (OR, 3.32; 95% CI, 1.37-8.03), Abbreviated Injury Score for Florida (Karcutskie, Meizoso, Ray, Horkan, Ruiz, Schulman, Namias, the abdomen greater than 2 (OR, 2.77; 95% CI, 1.19-6.45), and age 40 to 59 years (OR, 2.69; Proctor); Ryder Trauma Center, 95% CI, 1.19-6.08) predicted VTE, with an area under the receiver operator curve of 0.760. Division of Burns, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller CONCLUSIONS AND RELEVANCE Although rates of VTE are the same in patients who School of Medicine, Miami, Florida experienced blunt and penetrating trauma, the independent risk factors for VTE are different (Karcutskie, Meizoso, Ray, Horkan, based on mechanism of injury. This finding should be a consideration when contemplating Ruiz, Schulman, Namias, Proctor). prophylactic treatment protocols. Corresponding Author: Kenneth G. Proctor, PhD, Ryder Trauma Center, Divisions of Trauma, Surgical Critical Care, and Burns, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, 1800 NW 10th JAMA Surg. 2017;152(1):35-40. doi:10.1001/jamasurg.2016.3116 Ave, Ste T-215 (Box D40), Miami, FL Published online September 28, 2016. 33136 ([email protected]).

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rauma patients are typically classified according to the mechanism of injury—blunt or penetrating. However, Key Points advanced trauma life support guidelines do not distin- T Question Does mechanism of injury influence the independent 1 guish management based on the mechanism of injury. Sev- risk factors for venous thromboembolism after trauma? eral studies have found significantly different outcomes be- Finding This cohort study finds that, although the Greenfield Risk tween patients who experienced blunt and penetrating trauma Assessment Profile accurately predicts venous thromboembolism who were resuscitated to similar end points,2-5 even when se- after blunt and penetrating trauma, independent risk factors are 6-12 verity of the injuries are closely matched. different based on the mechanism of injury. Venous thromboembolism (VTE) is a significant cause Meaning Risk assessment and prophylactic strategies for venous of late morbidity and mortality after trauma13 despite thromboembolism may improve if mechanism of injury is thromboprophylaxis.14-27 At least 2 models stratify risk of VTE considered. specifically in trauma patients to guide surveillance and prophylaxis: the Trauma Embolic Scoring System28 and the Green- field Risk Assessment Profile (RAP).18 To our knowledge, no groups using χ2 or Fisher exact test, as appropriate. Paramet- study has assessed the differences in risk of VTE from the in- ric data are expressed as mean (SD) and compared using t tests dependent risk factors of blunt and penetrating trauma. for 2 independent samples. Nonparametric data are ex- We stratified patients in the intensive care unit by either pressed as median (interquartile range) and compared using blunt or penetrating trauma mechanism, and then deter- the Mann-Whitney test. Variables demonstrating statistical sig- mined which RAP risk factors are associated with VTE. We hy- nificance on univariate analyses were entered into a multi- pothesized that the mechanism of injury alters the indepen- variable logistic regression model. Odds ratios (ORs) and dent VTE risk factors. 95% CIs are reported. Area under the receiver operator curve (AUROC) was used to assess predictive values of models. P ≤.05 was considered statistically significant for all results. Methods

This was a retrospective cohort study conducted at the Ryder Results Trauma Center in the University of Miami and Jackson Memo- rial Medical Center and was approved by the University of Mi- The study population comprised 1137 patients: 813 with blunt ami Institutional Review Board with a waiver of informed con- trauma and 324 with penetrating trauma. Patient demograph- sent. Adult patients sustaining blunt or penetrating trauma and ics and injury characteristics are shown in Table 2. admitted to the Ryder Trauma Center intensive care unit from There was no difference in rates of VTE, deep vein throm- August 1, 2011, to January 1, 2015, were included. Patients who bosis, or pulmonary embolism based on mechanism of in- were younger than 18 years, incarcerated, pregnant, or died less jury. In patients with blunt trauma, the overall VTE rate was than 72 hours after admission were excluded. 9% (n = 73), with a deep vein thrombosis rate of 6.6% (n = 54) Thirty percent of the population was concurrently en- and a pulmonary embolism rate of 2.7% (n = 22). In patients rolled in a prospective observational trial evaluating hyperco- with penetrating trauma, the overall VTE rate was 9.6% (n = 31), agulability and VTE in patients who have undergone trau- with a deep vein thrombosis rate of 7.7% (n = 25) and a pul- matic injury. This group was deemed to be at high risk for VTE, monary embolism rate of 2.5% (n = 8). using a RAP score of 10 or more, based on previous work.25,29 In patients with blunt trauma, those with VTE had a worse All high-risk patients enrolled in this concurrent study re- mean (SD) Injury Severity Score (29 [14] vs 21 [11]; P ≤ .001), ceived weekly surveillance venous duplex ultrasonography admission heart rate (102 [26] vs 95 [23] beats/min; P = .03), (VDU) of the lower extremities, in addition to chemical and me- admission systolic blood pressure (122 [30] vs 135 [32]; P = .01), chanical prophylaxis. Deep vein thrombosis was diagnosed admission Glasgow Coma Scale score (11 [5] vs 13 [4]; P ≤ .001), with VDU. Pulmonary embolism was identified by computed and base deficit (–4 [5] vs –2 [5]; P = .007). As expected, mean tomography with angiography of the chest. The VDU proto- (SD) RAP score (13 [6] vs 8 [4]; P ≤ .001) and median (inter- cols at our institution have been previously reported.30 quartile range) hospital length of stay (40 [22-78] vs 12 [7-26] Briefly, all VDUs were performed by certified ultrasonog- days; P ≤ .001) were also higher in patients with VTE. There raphy technologists and interpreted by an attending radiolo- was no difference in time to first prophylaxis between pa- gist. The deep venous systems of both lower extremities are tients with VTE and those without VTE. examined from the inguinal ligament to the ankles using B- When all RAP factors were considered for predicting VTE mode compression, color augmentation, and spectral Dop- in patients with blunt trauma, the AUROC was 0.745. The in- pler ultrasound. Studies were considered positive if abnor- dividual RAP factors are assessed for patients with blunt trauma malities were detected in a deep vein at any level, above or in Table 3. More patients with VTE than without VTE had ab- below the knee. In all patients, the RAP score (Table 1) was cal- normal coagulation laboratory values (49.3% vs 35.7%; P = .02), culated prospectively by a trained research associate. femoral catheters (9.6% vs 3.9%; P = .03), 4 or more transfu- All statistical analyses were performed using SPSS Statis- sions (51.4% vs 17.6%; P < .001), operation time longer than 2 tics, version 22.0 (IBM Corp). Categorical variables are ex- hours (35.6% vs 16.4%; P < .001), repair and/or ligation of vas- pressed as frequency (percentage) and compared between cular injury (15.1% vs 5.4%; P = .001), Glasgow Coma Scale score

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less than 8 (31.5% vs 10.7%; P < .001), complex leg fractures after penetrating trauma, vascular injury, severe abdominal in- (34.2% vs 18.5%; P = .001), and pelvic fractures (43.8% vs jury, and younger age independently predict VTE. These find- 21.4%; P < .001). Controlling for these factors in a multivari- ings, in context with previous work, suggest that mechanism able logistic regression, independent predictors of VTE in- of injury may influence the body’s subsequent compensatory cluded receiving 4 or more transfusions (OR, 3.47; 95% CI, 2.04- response, and that current scoring systems do not account for 5.91), Glasgow Coma Scale score less than 8 (OR, 2.75; 95% CI, the differences between blunt vs penetrating trauma. 1.53-4.94), and pelvic fracture (OR, 2.09; 95% CI, 1.23-3.55) (Table 4). The AUROC for this reduced model was 0.730. a When all RAP factors were considered for predicting VTE Table 1. Greenfield Risk Assessment Profile in patients with penetrating trauma, the AUROC was 0.803. Factor Points The individual RAP risk factors are assessed for patients with Underlying conditions penetrating trauma in Table 5. More patients with VTE than Obesity (BMI >30) 2 without VTE had abnormal coagulation laboratory values Malignancy 2 (64.5% vs 44.4%; P = .03), femoral catheters (16.1% vs 5.5%; Abnormal coagulation factors at admission 2 P = .02), 4 or more transfusions (74.2% vs 39.6%; P < .001), op- History of thromboembolism 3 eration time longer than 2 hours (74.2% vs 50.5%; P = .01), re- Iatrogenic factors pair and/or ligation of vascular injury (54.8% vs 25.3%; Femoral central venous catheter >24 h 2 P < .001), and Abbreviated Injury Score for the abdomen greater ≥4 Transfusions in 24 h 2 than 2 (64.5% vs 42.3%; P = .02), and were aged 40 to 59 years Surgical procedure longer than >2 h 2 (41.9% vs 23.2%; P = .02). Controlling for these factors in a mul- Repair or ligation of major vascular injury 3 tivariable logistic regression, independent predictors of VTE Injury-associated factors included repair and/or ligation of vascular injury (OR, 3.32; 95% CI, 1.37-8.03), Abbreviated Injury Score for the abdomen greater Abbreviated Injury Scale score >2 than 2 (OR, 2.77; 95% CI, 1.19-6.45), and age 40 to 59 years (OR, Chest 2 2.69; 95% CI, 1.19-6.08) (Table 4). The AUROC for this re- Abdomen 2 duced model was 0.760. Head 2 GCS score <8 for >4 h 3 Complex lower extremity fracture 3 Discussion Pelvic fracture 4 Spinal cord injury with paraplegia or quadriplegia 4 The results of this study affirm the validity of RAP for assess- Age, y ing overall risk of VTE in either blunt (AUROC = 0.745) or pen- 40-59 2 etrating (AUROC = 0.803) trauma patients. The major new find- 60-74 3 ings are that blunt vs penetrating injury mechanism influences ≥75 4 the individual risk factors for VTE. After blunt trauma, transfusion status, neurologic status, Abbreviations: BMI, body mass index (calculated as weight in kilograms divided by height in meters squared), GCS, Glasgow Coma Scale. and pelvic fracture independently predict VTE. Transfusion a The Greenfield Risk Assessment Profile is explained in Greenfield et al.18 status was the strongest predictor in this group. In contrast,

Table 2. Baseline Characteristics

Value Blunt Injury Penetrating Injury Characteristic (n = 813) (n = 324) P Value Admission Heart rate, mean (SD), beats/min 96 (23) 97 (23) .46 SBP, mean (SD), mm Hg 134 (32) 117 (35) <.001a GCS score, mean (SD) 13 (4) 14 (3) <.001a Length of stay, median (IQR), d Hospital 14 (7-30) 11 (6-21) .001a Intensive care unit 5 (2-15) 3 (0-9) <.001a a Injury Severity Score, mean (SD) 22 (12) 18 (12) <.001 Abbreviations: DVT, deep vein VTE, No. (%) 73 (9) 31 (9.6) .76 thrombosis; GCS, Glasgow Coma Scale; IQR, interquartile range; DVT, No. (%) 54 (6.6) 25 (7.7) .52 PE, pulmonary embolism; PE, No. (%) 22 (2.7) 8 (2.5) .82 RAP, Greenfield Risk Assessment RAP score, mean (SD) 9 (5) 8 (4) .002a Profile; SBP, systolic blood pressure; VTE, venous thromboembolism. First prophylaxis, mean (SD), d 2 (2) 2 (2) .10 a Significant difference between Age, mean (SD), y 47 (19) 35 (15) <.001a groups.

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Table 3. Greenfield Risk Assessment Profile Risk Factors in Blunt Trauma

No. (%) No VTE VTE Factor (n = 740) (n = 73) P Value Obesity 121 (16.4) 16 (21.9) .23 Malignant neoplasm 17 (2.3) 0 .19 Abnormal coagulation values 264 (35.7) 36 (49.3) .02a History of VTE 1 (0.1) 0 .75 Femoral catheter 29 (3.9) 7 (9.6) .03a ≥4 Transfusions 130 (17.6) 37 (51.4) <.001a Operation time >2 h 121 (16.4) 26 (35.6) <.001a Repair and/or ligation of vascular injury 40 (5.4) 11 (15.1) .001a Abbreviated Injury Scale score >2 Chest 378 (51.1) 39 (53.4) .70 Abdomen 193 (26.1) 27 (37) .06 Head 261 (35.3) 33 (45.2) .09 GCS score <8 79 (10.7) 23 (31.5) <.001a Complex leg fracture 137 (18.5) 25 (34.2) .001a Pelvic fracture 158 (21.4) 32 (43.8) <.001a Spinal cord injury 8 (1.1) 2 (2.7) .22 Age, y Abbreviations: GCS, Glasgow Coma 40-59 236 (31.9) 28 (38.4) .26 Scale; VTE, venous 60-74 125 (16.9) 15 (20.5) .43 thromboembolism. a Significant difference between >75 69 (9.3) 6 (8.2) .76 groups.

13 Table 4. Multivariable Logistic Regression of Blunt public health concern. Furthermore, many national agen- 31 and Penetrating Trauma cies, including the Centers for Medicare & Medicaid Services, have placed VTE in a category of reasonably preventable hos- Risk Factor OR (95% CI) P Value pital-acquired conditions. A study in 2012 showed that, in high- Blunt risk trauma patients with a RAP score of 10 or more, routine ≥4 Transfusions 3.47 (2.04-5.91) <.001 screening VDU identified a rate of VTE of 28%, with two- GCS score <8 2.75 (1.53-4.94) .001 thirds of those being asymptomatic.25 In addition, there is evi- Pelvic fracture 2.09 (1.23-3.55) .006 dence that a significant number of VTEs occur in low-risk pa- Penetrating tients with a RAP score less than 5,27 a population that both 22 Repair and/or ligation of vascular injury 3.32 (1.37-8.03) .008 the Eastern Association for the Surgery of Trauma and the 16 AIS score for abdomen >2 2.77 (1.19-6.45) .02 American College of Chest Physicians claim may be cost in- efficient to screen with VDU. Thus, current assessment of risk Age 40-59 y 2.69 (1.19-6.08) .02 for VTE is somewhat deficient. Abbreviations: AIS, Abbreviated Injury Scale; GCS, Glasgow Coma Scale; The RAP is an accepted tool for trauma patients and is OR, odds ratio. routinely used in our institution for risk stratification. Developed in 1997 by Greenfield et al,18 it was intended to Several previous investigators have shown that blunt or identify patients who would best benefit from chemical pro- penetrating injury mechanism influences mortality and/or phylaxis. It compiled a set of several factors that were acute renal failure outcomes even with the same resuscita- known to increase risk of VTE among patients who have tion fluid.2-5 Martin et al6 showed that functional disability and sustained traumatic injury. Each factor was assigned a severe disability for feeding, expression, or locomotion dif- weight that influences the overall risk. A RAP score greater fered after blunt and penetrating carotid artery injuries even than 5 was deemed high risk. To our knowledge, no study to when the injuries were similar. George et al7 reported that the date has questioned whether mechanism of injury influ- physiological pattern of premenopausal adult female sex hor- ences the individual VTE risk factors identified by Green- mones may provide a survival advantage in patients who un- field et al.18 derwent blunt trauma; however, the converse pattern pre- Our results show that independent predictors of VTE af- vails for those who underwent penetrating trauma. These ter blunt trauma included transfusion status, neurologic sta- findings all support a fundamental difference associated with tus, and pelvic fracture, whereas after penetrating trauma, the mechanism of injury. independent predictors were severe abdominal injury, vascu- In 2008, the US Surgeon General published a call to ac- lar injury, and younger age. Because of these differences, it is tion for prevention of VTE, underscoring its significance as a logical to question whether the weights for the individual risk

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Table 5. Greenfield Risk Assessment Profile Risk Factors in Penetrating Traumaa

No. (%) No VTE VTE Factor (n = 293) (n = 31) P Value Obesity 50 (17.1) 5 (16.1) .90 Malignant neoplasm 0 0 NA Abnormal coagulation values 130 (44.4) 20 (64.5) .03b History of VTE 0 0 NA Femoral catheter 16 (5.5) 5 (16.1) .02b ≥4 Transfusions 116 (39.6) 23 (74.2) <.001b Operation time >2 h 148 (50.5) 23 (74.2) .01b Repair and/or ligation of vascular injury 74 (25.3) 17 (54.8) <.001b Abbreviated Injury Scale score >2 Chest 114 (38.9) 13 (41.9) .74 Abdomen 124 (42.3) 20 (64.5) .02b Head 19 (6.5) 3 (9.7) .50 GCS score <8 13 (4.4) 4 (12.9) .07 Complex leg fracture 19 (6.5) 4 (12.9) .19 Pelvic fracture 15 (5.1) 4 (12.9) .08 Abbreviations: GCS, Glasgow Coma Scale; NA, not applicable; Spinal cord injury 15 (5.1) 3 (9.7) .29 VTE, venous thromboembolism. Age, y a The Greenfield Risk Assessment 40-59 68 (23.2) 13 (41.9) .02b Profile is explained in Greenfield 18 60-74 19 (6.5) 3 (9.7) .50 et al. b Significant difference between >75 2 (0.7) 0 .64 groups.

factors should be altered to reflect the mechanism of injury. Thus, the overall rate of VTE in the low-risk patients may be An adjustment based on this finding may allow the RAP to fur- an underestimate. ther identify cases of VTE that are currently classified as low risk with the current scoring system. In addition, any changes based on mechanism of injury could aid in the development Conclusions of appropriate prophylactic protocols. The results and interpretations of our study must be con- Rates of VTE are the same in blunt or penetrating trauma pa- sidered with the context of several limitations. First, this is a tients, but the independent risk factors for VTE are different retrospective study; therefore, cause and effect cannot be es- based on mechanism of injury; this finding should be consid- tablished. Second, there is no obvious biological mechanism ered when contemplating thromboprophylaxis strategies. Fac- to explain the difference between the 2 injury mechanisms. tors that increase risk of VTE in patients with blunt trauma are Although we are able to identify the differences between our blood transfusions, decreased neurologic status, and pelvic frac- 2 cohorts, we are unable to identify the exact cause. Third, the ture. Factors that increase risk in patients with penetrating diagnosis of VTE differed based on whether the patient was trauma are vascular injury, severe abdominal injury, and age 40 high risk or low risk. Patients with a RAP score of 10 or more to 59 years. We believe these findings show an inherent differ- were prescreened on admission and received weekly VDU, al- ence in risk of VTE that is dependent on mechanism of injury. lowing for discovery of asymptomatic VTE, thereby introduc- With this evidence, it is possible to further investigate whether ing surveillance bias to our sample. For patients with a RAP an adjusted RAP incorporating mechanism of injury could cap- score of less than 10, there was no screening protocol and VTEs ture missed VTE in the patient population currently classified were only studied and identified if they were symptomatic. as low risk and better guide prophylactic efforts.

ARTICLE INFORMATION Acquisition, analysis, or interpretation of data: Conflict of Interest Disclosures: None reported. Accepted for Publication: June 1, 2016. Karcutskie, Meizoso, Ray, Horkan, Ruiz, Schulman, Funding/Support: This study was supported in Proctor. part by grants from the Naval Medical Research Published Online: September 28, 2016. Drafting of the manuscript: Karcutskie, Proctor. doi:10.1001/jamasurg.2016.3116 Center, and the US Army Medical Research and Critical revision of the manuscript for important Material Command. Author Contributions: Dr Proctor had full access to intellectual content: All authors. all the data in the study and takes responsibility for Statistical analysis: Karcutskie, Meizoso, Ray, Role of the Funder/Sponsor: The Naval Medical the integrity of the data and the accuracy of the Proctor. Research Center and the US Army Medical Research data analysis. Administrative, technical, or material support: and Material Command partially supported the Study concept and design: Karcutskie, Meizoso, Horkan, Ruiz, Schulman, Proctor. design and conduct of the study. They had no role Namias, Proctor. Study supervision: Namias, Proctor. in the collection, management, analysis, and

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interpretation of the data; preparation, review, or 10. McSwain NE, Champion HR, Fabian TC, et al. thromboembolism in trauma patients. J Trauma. approval of the manuscript; and decision to submit State of the art of fluid resuscitation 2010: 1994;37(3):480-487. the manuscript for publication. prehospital and immediate transition to the 22. Rogers FB, Cipolle MD, Velmahos G, Rozycki G, Previous Presentation: This paper was presented hospital [published correction appears in J Trauma. Luchette FA. Practice management guidelines for at the 2016 Annual Meeting of the Association of 2011;71(2):520]. J Trauma. 2011;70(5)(suppl): the prevention of venous thromboembolism in VA Surgeons; April 10, 2016; Virginia Beach, S2-S10. trauma patients: the EAST practice management Virginia. 11. James MF, Michell WL, Joubert IA, Nicol AJ, guidelines work group. J Trauma. 2002;53(1): Additional Contributions: Ronald J. Manning, Navsaria PH, Gillespie RS. Resuscitation with 142-164. ARNP, MSPH, University of Miami, assisted with hydroxyethyl starch improves renal function and 23. Shackford SR, Davis JW, Hollingsworth- compliance and adherence to institutional review lactate clearance in penetrating trauma in a Fridlund P, Brewer NS, Hoyt DB, Mackersie RC. board regulatory procedures. He received no randomized controlled study: the FIRST trial (Fluids Venous thromboembolism in patients with major financial compensation. We thank the nurses and in Resuscitation of Severe Trauma). Br J Anaesth. trauma. Am J Surg. 1990;159(4):365-369. 2011;107(5):693-702. staff of the Ryder Trauma Center Trauma 24. Shackford SR, Moser KM. Deep venous Resuscitation Unit and Trauma Intensive Care Unit. 12. Moore HB, Moore EE, Liras IN, et al. Acute thrombosis and pulmonary embolism in trauma fibrinolysis shutdown after injury occurs frequently patients. J Intensive Care Med. 1988;3(2):87-98. REFERENCES and increases mortality: a multicenter evaluation of doi:10.1177/088506668800300205 1. Kortbeek JB, Al Turki SA, Ali J, et al. Advanced 2,540 severely injured patients. J Am Coll Surg. 2016;222(4):347-355. 25. Thorson CM, Ryan ML, Van Haren RM, et al. trauma life support, 8th edition, the evidence for Venous thromboembolism after trauma: a never change. J Trauma. 2008;64(6):1638-1650. 13. Office of the Surgeon General; National Heart, event?*. Crit Care Med. 2012;40(11):2967-2973. 2. Allen CJ, Valle EJ, Jouria JM, et al. Differences Lung, and Blood Institute. The Surgeon General’s Call to Action to Prevent Deep Vein Thrombosis and 26. Velmahos GC, Nigro J, Tatevossian R, et al. between blunt and penetrating trauma after Inability of an aggressive policy of resuscitation with hydroxyethyl starch. J Trauma Pulmonary Embolism. Rockville, MD: Office of the Surgeon General; 2008. thromboprophylaxis to prevent deep venous Acute Care Surg. 2014;77(6):859-864. thrombosis (DVT) in critically injured patients: are 3. Ryan ML, Ogilvie MP, Pereira BM, 14. Freeark RJ, Boswick J, Fardin R. Posttraumatic current methods of DVT prophylaxis insufficient? Gomez-Rodriguz JC, Livingstone AS, Proctor KG. venous thrombosis. Arch Surg. 1967;95(4):567-575. J Am Coll Surg. 1998;187(5):529-533. doi:10.1001/archsurg.1967.01330160037005 Effect of hetastarch bolus in trauma patients 27. Zander AL, Van Gent JM, Olson EJ, et al. requiring emergency surgery. J Spec Oper Med. 15. Gearhart MM, Luchette FA, Proctor MC, et al. Venous thromboembolic risk assessment models 2012;12(3):57-67. The risk assessment profile score identifies trauma should not solely guide prophylaxis and surveillance 4. Allen CJ, Ruiz XD, Meizoso JP, et al. Is patients at risk for deep vein thrombosis. Surgery. in trauma patients. J Trauma Acute Care Surg. 2015; hydroxyethyl starch safe in penetrating trauma 2000;128(4):631-640. 79(2):194-198. patients? Mil Med. 2016;181(5)(suppl):152-155. 16. Geerts WH, Bergqvist D, Pineo GF, et al. 28. Rogers FB, Shackford SR, Horst MA, et al. 5. Ogilvie MP, Pereira BM, McKenney MG, et al. Prevention of venous thromboembolism: American Determining venous thromboembolic risk First report on safety and efficacy of hetastarch College of Chest Physicians Evidence-Based Clinical assessment for patients with trauma: the Trauma solution for initial fluid resuscitation at a level 1 Practice Guidelines (8th Edition). Chest. 2008;133 Embolic Scoring System. J Trauma Acute Care Surg. trauma center. J Am Coll Surg. 2010;210(5):870-880, (6)(suppl):381S-453S. 2012;73(2):511-515. 880-882. 17. Geerts WH, Code KI, Jay RM, Chen E, Szalai JP. 29. Van Haren RM, Valle EJ, Thorson CM, et al. 6. Martin MJ, Mullenix PS, Steele SR, et al. A prospective study of venous thromboembolism Hypercoagulability and other risk factors in trauma Functional outcome after blunt and penetrating after major trauma. N Engl J Med. 1994;331(24): intensive care unit patients with venous carotid artery injuries: analysis of the National 1601-1606. thromboembolism. J Trauma Acute Care Surg. Trauma Data Bank. J Trauma. 2005;59(4): 18. Greenfield LJ, Proctor MC, Rodriguez JL, 2014;76(2):443-449. 860-864. Luchette FA, Cipolle MD, Cho J. Posttrauma 30. Allen CJ, Murray CR, Meizoso JP, et al. 7. George RL, McGwin G Jr, Windham ST, et al. thromboembolism prophylaxis. J Trauma. 1997;42 Surveillance and early management of deep vein Age-related gender differential in outcome after (1):100-103. thrombosis decreases rate of pulmonary embolism blunt or penetrating trauma. Shock. 2003;19(1): 19. Hegsted D, Gritsiouk Y, Schlesinger P, in high-risk trauma patients. J Am Coll Surg. 2016; 28-32. Gardiner S, Gubler KD. Utility of the risk assessment 222(1):65-72. 8. Schreiber MA, Meier EN, Tisherman SA, et al; profile for risk stratification of venous thrombotic 31. Centers for Medicare & Medicaid Services. ROC Investigators. A controlled resuscitation events for trauma patients. Am J Surg. 2013;205(5): Hospital-acquired conditions. https://www.cms.gov strategy is feasible and safe in hypotensive trauma 517-520. /medicare/medicare-fee-for-service-payment patients: results of a prospective randomized pilot 20. Johnbull EA, Lau BD, Schneider EB, Streiff MB, /hospitalacqcond/hospital-acquired_conditions trial. J Trauma Acute Care Surg. 2015;78(4): Haut ER. No association between hospital-reported .html. Updated August 19, 2015. Accessed August 687-695. perioperative venous thromboembolism 24, 2016. 9. Holcomb JB. Fluid resuscitation in modern prophylaxis and outcome rates in publicly reported combat casualty care: lessons learned from data. JAMA Surg. 2014;149(4):400-401. Somalia. J Trauma. 2003;54(5)(suppl):S46-S51. 21. Knudson MM, Lewis FR, Clinton A, Atkinson K, Megerman J. Prevention of venous

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