**High Risk Groups for Deep Venous Thrombosis (DVT) and Pulmonary
Embolus (PE) in General Surgery, Orthopedic Surgery and Trauma, to
Include Combat Injury Considerations**

Submitted by Donald H Jenkins, MD, FACS, Lt Col, USAF, MC

[Surgery and Trauma Patient Population]{.underline}

[Typically, trauma and surgical patients have no underlying clotting
disorder but are at 12-18 times more likely to develop DVT/PE than they
were at baseline. Injury to body tissues, whether by surgery or trauma,
increases the risk of DVT which can occur within hours; even during
operation (some reported \< 2 hours). Over 50% of DVT occur within 7
days and 90% occur within 21 days of the 'event'. There are certain
surgical sub-groups which can have even higher risk.]{.underline}

[Acquired and Inherent Risk Factors in Surgery and Trauma]{.underline}

[Non-surgical factors which increase the risk of venous thromboembolism
(VTE) in surgical patients include: obesity, cancer, prior DVT/PE,
pregnancy, certain medications (birth control), IV line placed in large
central vein, \> 72 hour ICU stay, and kidney failure. Surgical factors
which increase the risk of VTE include: pelvic surgery (gynecology and
urology surgery), orthopedic surgery (hip/knee replacement or fracture
repair), and prolonged immobilization (similar to long plane flight, 3
or more days in hospital). Trauma-specific VTE risk factors include:
spinal cord paralysis injury, multiple limb fractures, pelvis/hip socket
(acetabulum) injury, use of clotting medications (rVIIa) or transfusions
(platelets). This is the ultimate conundrum for the surgeon: stop
bleeding without causing unnecessary and unwanted excess
clotting.]{.underline}

[Screening for DVT]{.underline}

[Physical exam is less than 50% accurate in determining whether or not
the patient has a DVT. Therefore, one must rely on other means of
determining the presence of DVT. The primary screening tool is Duplex
Ultrasound of major veins. Using this technique, US waves can show blood
clots in major veins of legs, groin, arms, neck and abdomen. The exam is
ideally done at the patient's bedside, is essentially risk free, and is
repeatable. A recent study in a medical/surgical ICU population, using
DVT prevention measures in over 90% of their patients, showed 10% of
patients with DVT and 10% of those developed lung blood clot (pulmonary
embolus-PE) using this screening method. X-ray studies (CT scan,
venogram) can also be used but there are caveats: requires contrast dye
use, is not more sensitive, can cause kidney injury and must be done in
x-ray department.]{.underline}

[Risk Factor Modification in Surgery/Trauma]{.underline}

[Risk stratification in DVT/PE has been well defined in surgery and
trauma. This stratification includes: any surgery or injury, any
additional risk factors (previously outlined), more than one risk
factor. Dependant on the presence of and number of these risk factors,
the patient is placed into a high, medium or low risk group. Then
prevention measures are based on risk group. Guidelines for prevention
and risk stratification are well outlined in the literature: Eastern
Association for Surgery of Trauma and American College of Chest
Physicians are two examples of guidelines for surgery and trauma patient
risk stratification and prophylaxis.]{.underline}

[Preventive strategies]{.underline}

[Mechanical]{.underline}

[Early ambulation is the easiest mechanical preventive strategy but is
not possible in OR and is not possible for many of highest risk patients
undergoing lower extremity surgery. Sequential compression devices
(inflatable stockings worn on legs) are essentially risk free but can't
be used for all patients (leg injury or surgery). These devices can be
used during and after operations and are quite effective. The most
controversial mechanical preventive strategy is use of Vena Cava (main
abdominal and chest vein) filters. These filters are small wire cages
placed in the vena cava to prevent PE. It is inserted by radiologists or
surgeons in special x-ray suites and the latest technology allows
removal of filter once risk of PE minimal (\~3 weeks after injury or
surgery). Filters do not prevent DVT; in fact they may increase the risk
of DVT formation. Filters remain controversial due to long term
complication risks, lack of data to show decrease in mortality but
effective in PE prevention in patients unable to get other prophylaxis
(risk of hemorrhage and both legs injured).]{.underline}

[Chemical]{.underline}

[Heparin is a 'blood thinner' anticoagulant medication with rapid onset
(within minutes) and is given by IV or subcutaneous injection once or
twice a day or by an IV drip. It is now available in various low
molecular weight versions which are equally potent with lower side
effect (bleeding) profile but may require blood tests to monitor and can
be used during operations as well as at home. Coumadin is a daily pill
anticoagulant that is slow in onset (days), must be monitored with
frequent blood tests, has increased risk of bleeding complications
compared to heparin but does have a long track record of success.
Coumadin is typically not administered during operation (stopped several
days before surgery) due to the bleeding risk.]{.underline}

[Combination Preventive Strategies]{.underline}

[The combination of mechanical and chemical measures may yield the best
results as the preventive effects are additive. Combination prevention
is recommended in higher risk groups, are best used in OR at beginning
of operation or as soon after injury as feasible (within hours/days) but
are limited, as one cannot always use anticoagulants due to risk of
bleeding in this patient population.]{.underline}

[Complications of prophylaxis]{.underline}

[Risks associated with preventive measures are dependent on the type of
preventive strategy. Mechanical stockings cannot be use in all patients
and are less effective than chemical or combined treatment; therefore,
the risk of DVT/PE is higher. Vena Cava filters decrease PE but increase
risk of DVT long term and have no proven decreased death rate. Removable
filters may be best temporary measure in highest risk group unable to
use other measures but should be removed when the risk is decreased or
when other preventive strategies can be implemented. Chemical preventive
strategies can cause hemorrhage. Bleeding is a problem after operation
or injury, especially with organ injury or brain/spine surgery; and
limits or delays the ability to use this form of prevention. Rarely, a
platelet decrease disorder occurs (heparin induced thrombocytosis or
HIT) and chemical prophylaxis must be discontinued.]{.underline}

[Military Considerations ]{.underline}

[ Bottom line up front, I think that clinical teams need reminding about
the importance of DVT/PE prevention and that we need pneumatic
compression devices added to the inventory for Level II and III
facilities (field surgical hospitals) and in the Critical Care Air
Transport Team/Aeromedical Evacuation (CCATT/AE) system. The quick tempo
of injury, surgical intervention and evacuation out of theater often
does not allow DVT/PE preventive strategy to 'kick in' prior to
evacuation. Several categories of patients (ambulatory, severe brain
injury, etc) may not routinely get prophylaxis and some of them
(ambulatory with minor injury) don\'t need it. Sometimes, however,
physicians just simply forget. ]{.underline}

[Blast injury seen in theater today is a unique injury mechanism not
often seen in the civilian environment. High-explosive (HE),
thermobaric, and nuclear detonations cause extreme compression of
molecules in surrounding air or water creating thin bands of locally
high overpressure, which are propagated away from the origin of the
explosion as a blast shock wave. Most casualties within the injury
radius of a HE detonation will have common penetrating, blunt, and burn
injuries managed no differently than similar non-blast trauma. When the
blast wave arrives at the surface of an object (vehicle, structure, or
human body), it is transmitted into that object as a stress wave. As the
blast wave separates from the stress wave due to the latter moving
slower through objects than the blast wave moves around them, pressure
differentials cause forces that accelerate surfaces. When transmitted
into the human body, the shock wave causes stress-induced tears at
air-tissue interfaces, which result in internal bleeding, weakening of
tissue resistance to additional insults, and possible rupture with
escape of air from the respiratory tract or spillage of gastrointestinal
contents. This HE blast effect may cause increased risk of DVT/PE
formation in combat casualties.]{.underline}

[The problem often times precedes entry into the AE system. There are
several civilian case reports of patients dying of PE within 6 hours of
injury. In another scenario, if a patient with liver fragmentation wound
is operated upon, put into ICU, CCATT mission generated, the
post-operative orders most often state to start low molecular weight
heparin (LMWH) 24 hours post-op (many surgeons don\'t want to give it in
solid organ injury, or brain injury, right away). CCATT often times has
that patient out in 6 hours and to Germany before the first scheduled
dose of LMWH can be given. The standard order set at the Air Force
Theater Hospital in Balad, Iraq specifically calls for LMWH to begin at
24 hour point for the severely brain injured patients. ]{.underline}

[Information that is missing from our military system as it relates to
DVT/PE includes several things: the number of thrombotic and
thromboembolic events, information on what, if any, prophylaxis was used
in those cases (including timing) and surveillance mechanism at Level IV
and V (major hospitals in Germany and the USA) to detect asymptomatic
DVT to define the true incidence in our combat casualties. I suspect
several of the patients who developed DVT/PE did get prophylaxis. The
question would involve timing and dose and combination preventive
strategy and screening. Also, no real data exists on AE-system related
stressors which may exacerbate DVT/PE rates other than immobility
(accelerative/decelerative forces, lower ambient oxygen tension,
dehydration, vibration, immobility for extended periods during AE
process, elevation in thrombin-antithrombin complex, etc) which may not
affect patients in the regular hospital setting but do affect the combat
casualty in our echelons of care system.]{.underline}

[In the DoD CONUS trauma system, intermittent pneumatic compression
devices are used routinely, beginning in the OR. Unfortunately, we
don\'t have that in theater and we also don\'t have a great body of
trauma literature about use of LMWH without pneumatic devices, as it is
such a routine part of care back home. There also are not any pneumatic
devices currently in use or even approved for flight. While the exact
impact pneumatic compression device use might have is unknown, based on
the CONUS trauma experience, suspect it could be of great benefit for
those patients not immediately put on LMWH prophylaxis, at a minimum.
All military field hospitals in theater have procured pneumatic
compression devices for use on combat casualties but these devices are
not a part of the standard inventory.]{.underline}

[Regarding policy formation on DVT/PE prevention, a theater-wide policy
is in place (attached) which is a strong statement about use of DVT/PE
prevention for all at-risk patients (every litter patient with an injury
and any litter DNBI patient with usual/standard risk factors). This
protocol includes drug/dose of choice. Another avenue is the use of a
template AE request form (3899) to facilitate and remind the providers
regarding the use of DVT/PE prevention; it is pre-printed on the form,
along with many other commonly used medications for the combat
casualties and is thus used or simply deleted from the e-form when not
applicable, as it is easier than typing in all the medications being
used.]{.underline}

[Vena Cava filters are available for very select use in theater. There
are clear indications for IVC filter placement for treatment and
controversial indications for prophylactic IVC filter placement. The two
DoD CONUS Level I trauma centers (Brooke Army Medical Center and Wilford
Hall Medical Center) base DVT/PE preventive measures on the EAST
guidelines, including indications for IVC filter placement. IVC filters
are a tiny part of the answer and would require a tremendous increase in
interventional radiology footprint in theater but would rarely be
indicated in US casualties. The vast majority of casualties transported
out of theater have no indication for IVC filter placement.
Unfortunately, little/ no information exists on those casualties who
developed DVT/PE at CONUS facilities; a clear priority for further
research. Another area of research interest would be the long-term
outcome (morbidity and mortality) of those casualties who develop
DVT/PE.]{.underline}

[Conclusions]{.underline}

[DVT and PE can be prevented in 90% or more of surgical and trauma
patients without additional risk factors by use of a systematic
preventive strategy. The risk of DVT, PE and death related to PE in high
risk surgical and trauma patients is significantly reduced by 60-70%
using a preventive strategy. Mechanical and/or chemical preventive
strategies should be individualized based on patient risk factors found
in existing guidelines. Screening for DVT in high risk groups using
Duplex US is cost-effective and should be part of comprehensive DVT
prevention strategy. Combat casualties are at higher risk of DVT/PE for
numerous reasons and should be further studied.]{.underline}

[Bibliography]{.underline}

[Timing of Pulmonary Emboli after Trauma: Implications for Retrievable
Vena Cava Filters. Sing RF, Camp SM et al; J Trauma 2006;
60:732-735]{.underline}

[Deep Venous Thrombosis in medical-surgical critically ill patients;
prevalence, incidence and risk factors. Cook D, et al. Crit Care Med
2005; 33:1565-1571]{.underline}

[ (trauma practice guidelines) ]{.underline}

[Sixth ACCP Consensus Conference on Antithrombotic Therapy, CHEST;
119:1(Supplement) January 2001]{.underline}

[Blast Injuries: Recognition and Management Lt Col John Wightman, USAF,
MC in Operational Medicine 2001,  Health Care in Military Settings
NAVMED P-5139 May 1, 2001]{.underline}

[Use of Emboli-blocking Filter Increases, but Rigorous Data are Lacking,
Brender E, JAMA March 1, 2006, V 295 N 9]{.underline}

[Retrievable vena cava filters in trauma patients for high-risk
prophylaxis and prevention of pulmonary embolism, Allen TL, Carter JL,
et al: Am J Surg 189 (2005) 656-661]{.underline}

[Medical Literature and Vena Cava Filters: So Far So Weak, Girard P,
Stern JB and Parent F: Chest 2002; 122; 963-967]{.underline}

[Eight-year Follow-up of Patients with Permanent Vena Cava Filters in
the Prevention of Pulmonary Embolism, The PREPIC Randomized Study, The
PREPIC Study Group: Circulation 2005; 112:416-422]{.underline}

[A clinical trial of vena caval filters in the prevention of pulmonary
embolism in patients with proximal deep-vein throbosis, Decousus H,
Leizorovicz A, et al: N Eng J Med Feb 12 1998 V 338, Iss 7,
409-415]{.underline}

[Thromboembolic Adverse Events After Use of Recombinant Human
Coagulation Factor VIIa, O'Connell KA, Wood JJ, et al: JAMA Jan 18, 2006
V295 N 3; 293-298]{.underline}

[Use of Recombinant Activated Factor VII to Treat the Acquired
Coagulopathy of Trauma, Holcomb JB: J Trauma 2005; 58:
1298-1293]{.underline}

[Treatment of Deep-vein Thrombosis, Bates SM and Ginsberg JS: N Eng J
Med 2004:351; 268-277]{.underline}

[Schreijer AJ et al, Lancet 2006; 367:832-838]{.underline}

[Appendix]{.underline}

**[ANTITHROMBOTIC THERAPY FOR THE PREVENTION AND TREATMENT OF THROMBOSIS
IN A THEATER OF OPERATIONS]{.underline}**

[1. ]{.underline}**[REFERENCES.]{.underline}**

[ a. Sixth ACCP Consensus Conference on Antithrombotic Therapy, CHEST;
119:1(Supplement) January 2001.]{.underline}

[ b. Scurr JH; Machin SJ; Bailey-King S; Mackie IJ; McDonald S; Smith
PD, "Frequency and Prevention of Symptom-less Deep Venous Thrombosis in
Long Haul Flights: A Randomized Trial, Lancet 2001 May
12;357(9267):1485-9]{.underline}

[ c. JCAHO Accreditation Manual for Hospitals, current
edition]{.underline}

[2. ]{.underline}**[PURPOSE.]{.underline}**[ The purpose of this
memorandum is to establish guidelines for antithrombotic therapy for the
prevention and treatment of thrombosis. ]{.underline}

[3. ]{.underline}**[APPLICABILITY.]{.underline}**[ This memorandum
applies to personnel assigned or attached to OIF intra-theatre medical
facilities who are involved in the management of patients.]{.underline}

[4. ]{.underline}**[BACKGROUND.]{.underline}**

[ a. The Sixth American College of Chest Physicians Conference
recommended that, "every hospital should develop a written policy or
other formal strategy for preventing thromboembolic complications,
especially for high-risk patients."]{.underline}

[ b. Proximal deep venous thrombosis (DVT) continues to be a frequent
illness in hospitalized patients. Pulmonary Embolism, a very serious
potential outcome has been seen in up to 20% of patients hospitalized
with DVTs in national reviews.]{.underline}

[ c. There is an increasing recognition of deep venous thrombosis in
individuals who complete an extended period on an airplane. One study
noted a 10% prevalence of asymptomatic DVT in individuals undergoing
flights of 8 hours or more. ]{.underline}

[5. ]{.underline}**[RESPONSIBILITIES.]{.underline}**

[ a. ]{.underline}**[All Health Care Providers will:]{.underline}**

**[ ]{.underline}**[(1) Become familiar with the guidelines for the
prevention of venous thromboembolism (see Appendix A).]{.underline}

[ (2) Appropriately manage patients who may be at risk of a
thromboembolism.]{.underline}

[ (3) Provide feedback on these guidelines and suggestions for changes
to the Chief of Professional Services of the MEDCOM (Medical
Command).]{.underline}

[ b. ]{.underline}**[Chief, Surg/Med QA Committee]{.underline}**[
]{.underline}

[ (1) Review all thromboembolic events in the Level III facility to
assess ways to reduce the risk to the patient.]{.underline}

[ (2) Coordinate with the CPS of the MEDCOM or Theatre Trauma
Coordinator, on the appropriateness of the guidelines being used and
update on an as needed basis.]{.underline}

[ c. ]{.underline}**[Chief of Professional Services of the MEDCOM and
Theatre Trauma Coordinator will:]{.underline}**

[(1) Be the subject matter experts on the guidelines to be used in the
entire OIF theatre for antithrombotic therapy for the prevention and
treatment of thrombosis.]{.underline}

[ (2) Coordinate with the Chief Med/Surg QA of the particular Level III
facility, on the appropriateness of the guidelines being used and update
on an as needed basis.]{.underline}

[APPENDIX A: Prevention and Treatment of Thrombosis Guidelines
]{.underline}

**[APPENDIX A]{.underline}**

+----------------------------------+----------------------------------+
| **[Risk Group]{.underline}**     | **[Recommended                   |
|                                  | Prophylaxis]{.underline}**       |
+----------------------------------+----------------------------------+
|                                  |                                  |
+----------------------------------+----------------------------------+
| **[GENERAL                       |                                  |
| SURGERY]{.underline}**           |                                  |
+----------------------------------+----------------------------------+
|                                  |                                  |
+----------------------------------+----------------------------------+
| [Low Risk (minor procedure in    | [Early ambulation]{.underline}   |
| patients \< 40 yr, no additional |                                  |
| risk factors]{.underline}        |                                  |
+----------------------------------+----------------------------------+
|                                  |                                  |
+----------------------------------+----------------------------------+
| [Moderate Risk (minor procedure  | [Low molecular weight heparin    |
| with additional risk factors for | (LMWH) 30-40 mg sc BID and       |
| thrombosis; non-major surgery in | intermittent pneumatic           |
| patients 40 to 60 yrs, with no   | compression (IPC)                |
| additional risk factors; major   | device]{.underline}              |
| surgery in patients \< 40 yrs    |                                  |
| with no additional risk          | [LDUH (low dose unfractionated   |
| factors]{.underline}             | heparin) only if LMWH not        |
|                                  | available]{.underline}           |
|                                  |                                  |
|                                  | [Early ambulation, as            |
|                                  | possible]{.underline}            |
+----------------------------------+----------------------------------+
|                                  |                                  |
+----------------------------------+----------------------------------+
| [Higher risk (non-major surgery  | [LMWH and IPC                    |
| in patients \>60 yr, or with     | device]{.underline}              |
| additional risk factors, major   |                                  |
| surgery in patients \> 40 yrs,   | [Early ambulation, as            |
| or with additional risk          | possible]{.underline}            |
| factors)]{.underline}            |                                  |
|                                  |                                  |
| [All litter patient transfers    |                                  |
| out of theatre ]{.underline}     |                                  |
+----------------------------------+----------------------------------+
|                                  |                                  |
+----------------------------------+----------------------------------+
| [Higher risk, with greater than  | [Mechanical prophylaxis with IPC |
| usual risk for                   | device, at least                 |
| bleeding]{.underline}            | initially]{.underline}           |
+----------------------------------+----------------------------------+
|                                  |                                  |
+----------------------------------+----------------------------------+
| [Very High Risk (multiple risk   | [Effective pharmacologic method  |
| factors)]{.underline}            | (LMWH) combined with mechanical  |
|                                  | methods (IPC device)             |
|                                  | ]{.underline}                    |
+----------------------------------+----------------------------------+
|                                  |                                  |
+----------------------------------+----------------------------------+
| **[TRAUMA SURGERY]{.underline}** |                                  |
+----------------------------------+----------------------------------+
|                                  |                                  |
+----------------------------------+----------------------------------+
|                                  |                                  |
+----------------------------------+----------------------------------+
|                                  |                                  |
+----------------------------------+----------------------------------+
| [Emergency trauma surgical       | [Low molecular weight heparin    |
| procedures in all patients, if   | (LMWH) and intermittent          |
| not contraindicated              | pneumatic compression (IPC)      |
| ]{.underline}                    | device]{.underline}              |
|                                  |                                  |
|                                  | [Low-dose unfractionated heparin |
|                                  | (LDUH) if LMWH not               |
|                                  | available]{.underline}           |
+----------------------------------+----------------------------------+
| [Very high risk trauma emergency | [Higher doses of LMWH and IPC    |
| surgery as determined by the     | device, possible IVC             |
| operating surgeon (spinal cord   | filter]{.underline}              |
| injury, pelvic fracture with     |                                  |
| long bone fracture, multiple     |                                  |
| long bone                        |                                  |
| fractures)]{.underline}          |                                  |
+----------------------------------+----------------------------------+
|                                  |                                  |
+----------------------------------+----------------------------------+
| **[UROLOGIC                      |                                  |
| SURGERY]{.underline}**           |                                  |
+----------------------------------+----------------------------------+
|                                  |                                  |
+----------------------------------+----------------------------------+
| [Transurethral surgery, or other | [Prompt                          |
| low-risk procedure]{.underline}  | mobilization]{.underline}        |
+----------------------------------+----------------------------------+
|                                  |                                  |
+----------------------------------+----------------------------------+
| [Major open urologic procedure   | [Routine prophylaxis: LDUH, ES,  |
| ]{.underline}                    | IPC device, or LMWH]{.underline} |
+----------------------------------+----------------------------------+
| [Highest-risk                    | [Elastic Stockings (ES) with or  |
| patients]{.underline}            | without IPC device PLUS LDUH or  |
|                                  | LMWH ]{.underline}               |
+----------------------------------+----------------------------------+
|                                  |                                  |
+----------------------------------+----------------------------------+
| **[MAJOR ORTHOPEDIC TRAUMA       |                                  |
| SURGERY]{.underline}**           |                                  |
+----------------------------------+----------------------------------+
|                                  |                                  |
+----------------------------------+----------------------------------+
| [Emergency major orthopedic      | [LMWH therapy if not             |
| surgery of extremities, pelvis   | contraindicated]{.underline}     |
| and spine. ]{.underline}         |                                  |
|                                  | [Mandatory IPC device if         |
|                                  | technically possible.            |
|                                  | ]{.underline}                    |
|                                  |                                  |
|                                  | [Higher doses of LMWH and IPC    |
|                                  | device, possible IVC filter (We  |
|                                  | do                               |
|                                  | ]{.                              |
|                                  | underline}**[not]{.underline}**[ |
|                                  | recommend sole therapy with      |
|                                  | LDUH, aspirin, dextran, or IPC   |
|                                  | device) ]{.underline}            |
+----------------------------------+----------------------------------+
|                                  |                                  |
+----------------------------------+----------------------------------+
| **[Risk Group]{.underline}**     | *                                |
|                                  | *[Recommendations]{.underline}** |
+----------------------------------+----------------------------------+
|                                  |                                  |
+----------------------------------+----------------------------------+
| [Prophylactic anticoagulant      |                                  |
| therapy is recommended for at    |                                  |
| least 7 to 10 d after            |                                  |
| surgery]{.underline}             |                                  |
+----------------------------------+----------------------------------+
|                                  |                                  |
+----------------------------------+----------------------------------+
| [In addition:]{.underline}       |                                  |
+----------------------------------+----------------------------------+
|                                  |                                  |
+----------------------------------+----------------------------------+
| [Recommend outpatient            |                                  |
| prophylaxis with LMWH be offered |                                  |
| beyond 7 to 10 d after major     |                                  |
| orthopedic surgery, at least for |                                  |
| high-risk patients]{.underline}  |                                  |
+----------------------------------+----------------------------------+
|                                  |                                  |
+----------------------------------+----------------------------------+
| [Do                              | [ ]{.underline}**[Do             |
| ]{.                              | ]{.underline}**[recommend        |
| underline}**[not]{.underline}**[ | routine duplex at the receiving  |
| recommend routine duplex         | institution after evacuation to  |
| ultrasonography screening at     | LRMC and/or CONUS, especially    |
| hospital discharge or during     | for highest risk groups despite  |
| outpatient follow-up in          | signs/symptoms (present in \<    |
| asymptomatic                     | 50%)]{.underline}                |
| patients.]{.underline}           |                                  |
+----------------------------------+----------------------------------+
|                                  |                                  |
+----------------------------------+----------------------------------+
| **[NEUROSURGERY, TRAUMA, AND     |                                  |
| ACUTE SPINAL CORD                |                                  |
| INJURY]{.underline}**            |                                  |
+----------------------------------+----------------------------------+
|                                  |                                  |
+----------------------------------+----------------------------------+
| [Intracranial                    | [IPC device]{.underline}         |
| neurosurgery]{.underline}        |                                  |
+----------------------------------+----------------------------------+
|                                  |                                  |
+----------------------------------+----------------------------------+
|                                  | [High-risk patients: IPC device  |
|                                  | with postoperative LMWH may be   |
|                                  | more effective than either       |
|                                  | prophylactic modality alone;     |
|                                  | timing of chemoprophylaxis on    |
|                                  | case-by-case basis]{.underline}  |
+----------------------------------+----------------------------------+
|                                  |                                  |
+----------------------------------+----------------------------------+
| [Neuro trauma, with identifiable | [Prophylaxis with LMWH, as soon  |
| risk factor for                  | as considered safe; if delayed,  |
| thromboembolism]{.underline}     | or contraindicated because of    |
|                                  | bleeding concerns: initial use   |
|                                  | of IPC device, or both           |
|                                  | ]{.underline}                    |
+----------------------------------+----------------------------------+
|                                  |                                  |
+----------------------------------+----------------------------------+
|                                  | [If prophylaxis is suboptimal,   |
|                                  | offer weekly screening of        |
|                                  | high-risk patients with duplex   |
|                                  | ultrasound]{.underline}          |
+----------------------------------+----------------------------------+
|                                  |                                  |
+----------------------------------+----------------------------------+
|                                  | [If proximal DVT is demonstrated |
|                                  | and anticoagulation is           |
|                                  | contraindicated, we recommend    |
|                                  | inferior vena cava (IVC) filter  |
|                                  | insertion, but we do             |
|                                  | ]{.                              |
|                                  | underline}**[not]{.underline}**[ |
|                                  | recommend IVC filter insertion   |
|                                  | as primary                       |
|                                  | prophylaxis]{.underline}         |
+----------------------------------+----------------------------------+
|                                  |                                  |
+----------------------------------+----------------------------------+
| [Acute spinal cord               | [Prophylaxis with LMWH and       |
| injury]{.underline}              | IPC]{.underline}                 |
+----------------------------------+----------------------------------+
|                                  |                                  |
+----------------------------------+----------------------------------+
|                                  | **[We do                         |
|                                  | ]{.underline}[not]{.underline}[  |
|                                  | recommend LDUH, ES,              |
|                                  | ]{.underline}[or]{.underline}[   |
|                                  | IPC as sole                      |
|                                  | prophylaxis]{.underline}**       |
+----------------------------------+----------------------------------+
|                                  |                                  |
+----------------------------------+----------------------------------+
|                                  | [In the rehabilitation phase, we |
|                                  | recommend continued LMWH         |
|                                  | therapy, or full-dose oral       |
|                                  | anticoagulation]{.underline}     |
+----------------------------------+----------------------------------+
|                                  |                                  |
+----------------------------------+----------------------------------+
| **[MEDICAL                       |                                  |
| CONDITIONS]{.underline}**        |                                  |
+----------------------------------+----------------------------------+
|                                  |                                  |
+----------------------------------+----------------------------------+
| [Acute myocardial                | [Most patients: prophylactic or  |
| infarction]{.underline}          | therapeutic anticoagulant        |
|                                  | therapy with SC LDUH or IV       |
|                                  | heparin]{.underline}             |
+----------------------------------+----------------------------------+
|                                  |                                  |
+----------------------------------+----------------------------------+
| [Ischemic stroke, with impaired  | [Routine use of LDUH, LMWH, or   |
| mobility]{.underline}            | danaparoid ]{.underline}         |
+----------------------------------+----------------------------------+
|                                  |                                  |
+----------------------------------+----------------------------------+
|                                  | [If anticoagulant prophylaxis is |
|                                  | contraindicated: IPC             |
|                                  | device]{.underline}              |
+----------------------------------+----------------------------------+
|                                  |                                  |
+----------------------------------+----------------------------------+
| [General medical patients with   | [LDUH or LMWH (with IPC for      |
| risk factors for VTE (eg,        | litter and bed ridden            |
| cancer, bed rest, heart failure, | patients)]{.underline}           |
| severe lung disease) especially  |                                  |
| consider for patients arriving   |                                  |
| after \>8 hr air                 |                                  |
| evacuation]{.underline}          |                                  |
+----------------------------------+----------------------------------+
|                                  |                                  |
+----------------------------------+----------------------------------+

[Sample of Standard Order Set to Enhance DVT Prevention Algorithm
Compliance]{.underline}

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  **[Date/Time of Order]{.underline}**                                                                                                                                                                                                                                                                                          **[Order Noted]{.underline}**
                                                                                                                                                                                                                                                                                                                                
  [ ]{.underline}**[Antibiotics.]{.underline}**                                                                                                                                                                                                                                                                                 **[and Signed]{.underline}**
                                                                                                                                                                                                                                                                                                                                
  [ ]{.underline}**[Patient with Open Fx, Shock, Active Infection, Prolonged Pre-Hospital Transport, or Heavy Wound Contamination]{.underline}**                                                                                                                                                                                
                                                                                                                                                                                                                                                                                                                                
                                                                                                                                                   [□Imipenum 500 mg IV q 6hr x 48hrs or Meropenum 1 gm IV q 8hr x 48hrs (select according to pharmacy stock)]{.underline}                                                      
                                                                                                                                                                                                                                                                                                                                
  [ ]{.underline}**[Major Soft Tissue Wounds]{.underline}**                                                                                        [□Unasyn 3gm IV q6hrs x 24hrs & Amikacin 15mg/kg IV qd x 1 dose (estimate weight \_\_\_\_\_\_\_\_)]{.underline}                                                              
                                                                                                                                                                                                                                                                                                                                
                                                                                                                                                   [□Levofloxacin 500mg IV qd x 24hrs & Amikacin 15mg/kg IV qd x 1 dose (]{.underline}**[For PCN Allergic Patients Only]{.underline}**[) (est weight \_\_\_\_\_)]{.underline}   
                                                                                                                                                                                                                                                                                                                                
  [ ]{.underline}**[GI Prophylaxis.]{.underline}**                                                                                                 [□ Zantac 50 mg IV q 8 hrs.]{.underline}                                                                                                                                     
                                                                                                                                                   [□ Protonix 40 mg IV q day.]{.underline}                                                                                                                                     
                                                                                                                                                                                                                                                                                                                                
  [ ]{.underline}**[DVT Prophylaxis.]{.underline}**                                                                                                [□ Heparin 5000 units SC BID.]{.underline}                                                                                                                                   
                                                                                                                                                                                                                                                                                                                                
                                                                                                                                                   [□ Lovenox 30 mg SC BID.]{.underline}                                                                                                                                        
                                                                                                                                                                                                                                                                                                                                
                                                                                                                                                   [□ Lovenox 40 mg SC q day.]{.underline}                                                                                                                                      
                                                                                                                                                                                                                                                                                                                                
  [ ]{.underline}**[Other Medications.]{.underline}**                                                                                              [□ IV Insulin gtt, titrate to BG \<140 & \>100.]{.underline}                                                                                                                 
                                                                                                                                                   [□ Tetanus 0.5 cc SC x 1.]{.underline}                                                                                                                                       
                                                                                                                                                   [□ Epogen 40,000 units SC q week]{.underline}                                                                                                                                
                                                                                                                                                                                                                                                                                                                                
  [REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED]{.underline}                                                                                    [Subject to the Privacy Act of 1974]{.underline}                                                                                                                             [ Page 4 of 4]{.underline}
                                                                                                                                                                                                                                                                                                                                
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