SToP: Venous Thromboembolism Screening in the Trauma Population
Phase: NA
Conditions: Venous Thromboembolism, Deep Vein Thrombosis, Trauma, Multiple
Sponsor: Intermountain Health Care, Inc.

V5 SToP 
V 7/20/2017 
IRB 1050048 
 
 
 
Page 1 of 21 
 
 
Protocol 
 
 
Title: 
SToP: Venous Thromboembolism Screening in the Trauma 
Population — A Randomized Vanguard Trial 
 
 
Location: 
Intermountain Medical Center (IMC), Trauma Services 
 
 
Sponsor: 
Intermountain Research and Medical Foundation 
 
 
Principal Investigator: 
Sarah Majercik, MD, MBA 
 
 
Study Team: 
Annika Bickford, PA-C 
Joseph Bledsoe, MD 
Mark Stevens, MD 
Tom White, MD 
Don VanBoerum, MD 
Sarah Aldridge, NP 
Jody Carter, APC 
Chip DuRoss, PA-C, MPAS 
Scott Gardner, PA-C 
Aaron Pugh, PA-C 
Brittany Gerali, PA-C 
Andy Avery, PA-C 
Steve Granger, MD 
Scott Stevens, MD 
Scott Woller, MD 
Greg Elliott, MD 
 
 
 
 
Purpose of the Study: 
This is a prospective,  randomized vanguard  trial  of trauma  patients admitted  to the  trauma 
surgery service at IMC who are deemed to be at high risk for venous thromboembolism (VTE). 
Once identified and enrolled, subjects will be randomized to receive bilateral lower extremity 
duplex ultrasound (DUS) surveillance (see Appendix A) versus no surveillance. We will compare 
the two groups with regard to deep vein thrombosis (DVT) and pulmonary embolism (PE) rates, 
both during the index hospitalization and at 90 days post-discharge. To our knowledge, this is the 
first prospective, randomized study of its kind to occur since the widespread use of low molecular 
weight heparins (LMWH) for VTE chemoprophylaxis in trauma patients. The results of this trial 
will help to assess the feasibility of performing a definitive (likely multi-institutional) trial in the 

V5 SToP 
V 7/20/2017 
IRB 1050048 
 
 
 
Page 2 of 21 
future. 
 
Hypothesis/Research Questions: 
This study will determine the rate of VTE (DVT and PE) in high-risk trauma patients who have 
surveillance for lower extremity DVT versus those who do not have surveillance. It will also 
determine the rate of DVT propagation to the popliteal vein or higher by 14 days after discharge 
in high-risk trauma patients found to have isolated distal DVT. 
Background and Significance: 
Venous thromboembolism (VTE), comprised of DVT and PE, is a common complication of 
hospitalized patients. VTE affects an estimated 900,000 people in the U.S annually, and leads to 
about 300,000 deaths. [1] Major trauma patients are at an exceptionally high risk for developing 
DVT and PE. Without chemoprophylaxis, DVT incidence in trauma patients is as high as 58% in 
the lower extremities, with 18% of those being proximal [2]. Despite advances in VTE 
chemoprophylaxis and treatment with LMWH and methods of detection, VTE remains a 
significant source of morbidity and mortality in the trauma population. 
 
Current guidelines recommend against routine screening for DVT with DUS in major trauma 
patients. [4] The evidence supporting this guideline, however, is not strong and continues to be 
sorely debated. Assessing a four-year prophylaxis and screening protocol, Adams et al. found that 
86% of DVTs found on DUS are clinically silent, justifying the importance of routine surveillance 
in high-risk trauma patients. Additionally, they found that only 21% of VTE patients received 
enoxaparin within 48 hours of admission, illustrating the high incidence of delayed time to 
adequate chemoprophylaxis and the importance of this timing on risk assessment. [5] Napolitano 
et al. also identified four risk factors that place trauma patients at an increased risk of silent DVTs 
and propagation to PE, and suggested regular DUS in these patients. [6] Another approach was 
taken by Malhotra et al., who studied the cost-effectiveness of a DVT surveillance program in 
critically injured trauma patients. With a protocol of twice weekly DUS screening, they found a 
higher rate of DVT, a lower rate of PE, and concluded that their protocol was cost-effective based 
on quality adjusted life years saved. [7] On the contrary, Cipolle and colleagues found that despite 
decreasing DUS screening in major trauma patients, rate of PE was unchanged, concluding that 
strict adherence to a prophylaxis regimen was more important than surveillance. [8] They did 
recommend, however, regular DUS scans in patients they identified as high-risk, and when there 
was a delay to enoxaparin administration of greater than 48 hours. Schwarcz assessed the value 
of DUS surveillance in high-risk trauma patients and concluded that, in the setting of adequate 
chemoprophylaxis with enoxaparin, its utility is limited. [9] 
 

V5 SToP 
V 7/20/2017 
IRB 1050048 
 
 
 
Page 3 of 21 
In debating the utility of DUS in patients receiving prophylaxis with LMWH, one must 
acknowledge the emerging evidence questioning the current standard of LWMH dosing. Fixed 
twice-daily enoxaparin dosing for all patients has been found to result in subtherapeutic anti-Xa 
levels and thus may not constitute adequate prophylaxis. Data exists suggesting that a one-size-
fits-all approach is inferior to a weight-based regimen using enoxaparin for VTE prophylaxis in 
trauma patients. [10] [11] As illustrated by the conflicting and poor retrospective data cited 
above, more evidence and prospective data is needed regarding the impact of DUS surveillance 
in trauma patient outcomes. 
 
When assessing which trauma patients might warrant DUS screening, a risk assessment tool must 
be applied. The most common risk factors identified in the literature include age, ISS, specific 
underlying conditions, spinal cord injury, long bone and pelvic fractures. [7] [8] [9] [10] Two 
validated VTE risk assessment tools exist for hospitalized patients, one by Caprini and one by 
Maynard and Stein. [12] [13] Neither of these scoring systems, however, have been validated in 
the trauma patient population. 
 
The risk assessment profile (RAP) score, developed by Greenfield in 1997, [14] has been validated 
retrospectively in two analyses, and may be more applicable to assessing the trauma patient 
population. [13] [15] 
 
At IMC, our trauma service has adopted an aggressive VTE prophylaxis protocol that involves risk-
stratifying patients upon admission. Currently, only high-risk patients for VTE in whom 
enoxaparin is contraindicated undergo regularly scheduled bilateral lower extremity DUS as 
surveillance for DVT. We hypothesize that high-risk trauma patients, regardless of 
chemoprophylaxis, who undergo scheduled DUS surveillance for lower extremity DVT will have a 
lower rate of symptomatic DVT, DVT propagation, and symptomatic or fatal pulmonary embolism 
(PE) than those who do not have screening. 
 
Significance:  
VTE has been deemed a major threat by the US Surgeon General and the Centers for Medicare 
and Medicaid Services (CMS). Hospitals are under pressure to reduce or even eliminate VTE, or 
risk financial repercussions. The current ACCP guidelines do not differentiate high-risk trauma 
patients from lower-risk patients in the recommendations against routine DUS screening. Haut 
et al. identified significant variability in opinion and protocols among trauma surgeons and 
hospitals regarding regular screening for DVT, and found that the VTE rate may be more a 
function of surveillance bias than of the quality of care. [3] At our trauma service at IMC, our DVT 
rate is currently about 3%, [16] which has been deemed “too high” according to Intermountain 

V5 SToP 
V 7/20/2017 
IRB 1050048 
 
 
 
Page 4 of 21 
Healthcare and national targets. Most (approximately 85%) of the DVTs that we diagnose are 
clinically silent and are found during DUS surveillance of high risk patients. 
 
If we were to discontinue routine DUS surveillance of the highest risk trauma patients, our DVT 
rate would certainly decrease. It is not at all clear, however, that this would translate to better 
overall patient outcomes, e.g., less PE, less major bleeding episodes, less mortality. It is very 
important to answer this question in a prospective, randomized fashion, as this has never been 
done since the advent of LMWH use for chemoprophylaxis. 
 
Recruitment: 
Subjects will be recruited from the trauma surgery service at IMC. This project involves direct 
patient contact and the collection of protected health information (PHI). The measures to protect 
PHI include: 
1. The original subject data files and study data collection forms will be kept in a secure, 
locked cabinet in the Shock Trauma ICU at IMC, accessible only by study personnel. 
Electronic data files will be stored on a password-protected Intermountain Healthcare 
computer in a locked office. 
2. Each subject in the research study will be assigned a unique identification number. 
3. There will be no third party disclosure of patient identifying information. 
 
Research Subjects: 
Inclusion Criteria: 
1. Inpatient status on IMC trauma surgery service, admitted within 24 hours of injury. 
2. Age ≥18 at the time of injury 
3. Meets the definition of high-risk for VTE according to current IMC trauma service 
guidelines (see Appendix A) 
 
Exclusion Criteria: 
1. Patient age <18 years at the time of admission to the hospital 
2. Pregnancy 
3. Prisoners 
4. Patients with a life expectancy of less than 30 days 
5. Patients with a known hypercoagulable state including: 
a. Factor V Leiden 
b. Protein C and S deficiencies 
c. Dysfibrogenemia of any sort 
d. Active cancer 

V5 SToP 
V 7/20/2017 
IRB 1050048 
 
 
 
Page 5 of 21 
e. Antiphospholipid antibody syndrome 
f. History of DVT or PE within past 6 months 
g. Myeloproliferative disorders 
6. Patients on therapeutic anticoagulation who do not have their agent held upon 
admission to the hospital. 
7. Patient elects to opt-out of the study 
 
Methods/Procedures: 
This is a prospective, randomized study with outcomes determined by blinded event adjudication 
(PROBE). Patients will be screened upon admission to the hospital, and enrolled within 24 hours 
from admission. Subjects will then be randomized to either the surveillance arm or the no 
surveillance arm. Subjects enrolled in the surveillance arm will undergo bilateral DUS on post-
injury days 1, 3, 7, and every 7 days thereafter until discharge from the hospital. Subjects in the 
no surveillance arm will have routine hospital care on the trauma service, with no DUS performed 
unless symptomatic for DVT. (See Appendix B) Trauma physicians and advanced practice 
clinicians (APCs) will perform daily history and physical examinations targeted at eliciting 
symptoms and signs of potential VTE in all subjects. 
 
All subjects enrolled in both arms of the study will have appropriate VTE prophylaxis provided 
(enoxaparin 30mg SQ every 12 hours if BMI<30, enoxaparin 0.5mg/kg SQ every 12 hours if 
BMI>30) according to the current IMC trauma service guidelines. VTE chemoprophylaxis will be 
started upon admission, or when deemed clinically safe according to the trauma service 
protocols. If chemoprophylaxis is not begun right away (because of solid organ injury, traumatic 
brain injury, etc.), those subjects will receive mechanical prophylaxis according to the trauma 
service guidelines. 
 
Asymptomatic DVT in the surveillance group will be determined on the day of the DUS, prior to 
hospital discharge. Symptomatic DVT and PE during hospitalization in both groups will be pursued 
using the Wells score as guidance for DVT diagnosis and using objective imaging as diagnostic 
confirmation. 90 day follow-up of all subjects will be performed by reviewing medical records in 
the Intermountain Healthcare computerized medical record to look for evidence of VTE. All 
outcomes will be adjudicated by a panel of independent physician adjudicators blinded as to 
whether the patients were randomized to surveillance or not. 
 
All subjects diagnosed with acute proximal DVT or PE will be treated with therapeutic doses of 
anticoagulants while in the hospital and after discharge, as appropriate. Subjects who are 
diagnosed with isolated calf DVT while in the hospital will have a follow up DUS on day 14 after 

V5 SToP 
V 7/20/2017 
IRB 1050048 
 
 
 
Page 6 of 21 
the initial diagnosis to check for thrombus propagation, per current ACCP guidelines. Patients in 
whom thrombus propagates to the proximal deep veins will receive therapeutic anticoagulation 
unless contraindicated, according to the usual standard of care. See Appendix B for a flow chart 
that depicts treatment decisions throughout the study. 
 
In order to investigate our hypothesis, this study will compare outcome variables between the 
surveillance and the non-surveillance groups. 
 
Randomization:  
Randomization will be performed by the randomization module in the REDcap system. Subjects 
will be randomized to either the screening group or a non-screening group. 
 
Informed Consent: 
Potential subjects will be approached by the investigators or by authorized members of the study 
team in the ICU. They will be given a form that briefly explains the study and, if they desire, by 
signing at the bottom of the form, they may opt out of the study. Patients will be given as much 
time to consider participation as they need and they will be able to ask questions about the study. 
 
Risks: 
Participation in this study poses minimal risks. There are no risks associated with the duplex 
ultrasound procedure. 
 
Benefits: 
We do not know if this study will directly benefit subjects. Most DVT that we diagnose is clinically 
silent and is found with DUS imaging. Being evaluated with DUS may benefit subjects if it helps 
us to see DVT that we would not otherwise know is there, so we can treat it. 
 
The information gained from this research may help future patients and will contribute to 
knowledge regarding ultrasound surveillance in high risk trauma patients. Answering this 
research question is important as it may lead to less PE, fewer major bleeding episodes, and less 
mortality for patients in the future. 
 
Compensation: 
Subjects will not be compensated. 
 

V5 SToP 
V 7/20/2017 
IRB 1050048 
 
 
 
Page 7 of 21 
Data Collection: 
The following variables will be collected for all subjects in both arms of the study in a secure, 
computerized database (REDcap): 
 
1. Patient demographics 
2. Past medical/surgical/family/social history 
3. Mechanism of injury 
4. Injuries sustained and Injury Severity Score (ISS) 
5. All items in the Caprini DVT risk assessment model (See Appendix C)—this information 
will be used for descriptive purposes and as a means of comparing the two study 
groups. 
6. All items in the Risk Assessment Profile (RAP) for VTE (See Appendix D)—this 
information will be used for descriptive purposes and as a means of comparing the two 
study groups. 
7. VTE pharmacoprophylaxis agent, dose, time from admission to first dose, interruptions 
in pharmacoprophylaxis and for what reason 
8. Mechanical prophylaxis modality used 
9. Asymptomatic DVT in surveillance group with location 
10. Symptomatic DVT/PE with location during hospitalization and at 90 days 
11. DVT propagation with location during hospitalization and at 14 days 
12. Major and clinically relevant bleeding during hospitalization and at 90 days (see 
Appendix E). 
13. All cause mortality during hospitalization and at 90 days 
 
Data Analysis/Statistics:   
A historic baseline incidence of the composite outcome of major bleeding events plus proximal 
DVT on the trauma service is about 5.5%. We expect that in the no surveillance group, the 
incidence of the composite outcome will be higher. We are not entirely sure how much higher, 
which is one of the reasons for performing this vanguard trial. The below power analysis reflects 
that. Based on this power analysis, we would need to enroll at least 1000 subjects in each arm to 
discern a true difference, perhaps more, depending on the difference in events between the two 
groups. It is unreasonable given current financial and time constraints to do this definitively at a 
single center. 
 

V5 SToP 
V 7/20/2017 
IRB 1050048 
 
 
 
Page 8 of 21 
Based on historical trauma service admissions of 3000 per year, we estimate that 65-75% of 
admitted patients will qualify for the study, and 50-75% of those will agree to enroll. Thus, we 
estimate that over the course of one year, we could enroll about 300 patients per arm. This 
number of patients should be sufficient to help us determine the feasibility of a definitive, likely 
multi-institutional future trial. 

V4 SToP 
V 4/26/2017 
IRB 1050048 
 
Page 9 of 21 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
A chi-squared test will be calculated to 
compare the rate of VTE between the 
surveillance group and the no surveillance 
group 
 
 
 
 
 
 
 
 
 
 
 
 
 
Effect Size 
Minimum Sample Size per Group 
6.5% (+1.0%) 
Doesn’t achieve 80% power at n=5000 per group 
7.0% (+1.5%) 
4,200 
7.5% (+2.0%) 
2,500 
8.0% (+2.5%) 
1,600 
8.5% (+3.0%) 
1,200 
9.0% (+3.5%) 
900 
9.5% (+4.0%) 
700 
10.0% (+4.5%) 
600 

V4 SToP 
V 4/26/2017 
IRB 1050048 
 
Page 10 of 21 
 
Funding: 
We have applied for a research grant through the Intermountain Research and Medical 
Foundation. 
 
References: 
1. Raskob GE, Silverstein R, Bratzler DW, Heit JA, White RH. Surveillance for deep vein 
thrombosis and pulmonary embolism: recommendations from a national workshop. Am 
J Prev Med. 2010 Apr;38(4 Suppl):S502-9. 
2. Geerts, WH, Code KI, Jay RM, Chen E, Szalai JP. A prospective study of venous 
thromboembolism after major trauma. N Engl J Med. 1994 Dec 15;331(24):1601-6. 
3. Haut ER, Schneider EB, Patel A, Streiff MB, Haider AH, Stevens KA, Chang DC, Neal ML, 
Hoeft C, Nathens AB, Cornwell EE 3rd, Pronovost PJ, Efron DT. Duplex ultrasound 
screening for deep vein thrombosis in asymptomatic trauma patients: a survey of 
individual trauma surgeon opinions and current trauma center practices. J Trauma. 2011 
Jan;70(1):27-33. 
4. Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schünemann HJ. Antithrombotic 
Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians 
Evidence- Based Clinical Practice Guidelines CHEST 2012; 141(2)(Suppl):7S–47S. 
5. Adams RC, Hamrick M, Berenguer C, Senkowski C, Ochsner MG. Four Years of an 
Aggressive Prophylaxis and Screening Protocol for Venous Thromboembolism in a Large 
Trauma Population. J Trauma. 2008 Aug;65(2):300-6. 
6. Napolitano LM, Garlapati VS, Heard SO, Silva WE, Cutler BS, O’Neill AM, Anderson FA Jr, 
Wheeler HB. Asymptomatic deep venous thrombosis in the trauma patient: is an 
aggressive screening protocol justified? J Trauma. 1995 Oct;39(4):651-7. 
7. Malhotra AK, Goldberg SR, McLay L, Martin NR, Wolfe LG, Levy MM, Khiatani V, 
Borchers TC, Duane TM, Aboutanos MB, Ivatury RR. DVT Surveillance Program in the 
ICU: Analysis of Cost-Effectiveness. PLoS One. 2014 Sep 30;9(9):e106793 . doi: 
10.1371/journal.pone.0106793. 
8. Cipolle MD, Wojcik R, Seislove E, Wasser TE, Pasquale MD. The role of surveillance 
duplex scanning in preventing venous thromboembolism in trauma patients. J Trauma. 
2002 Mar;52(3):453-62. 

V4 SToP 
V 4/26/2017 
IRB 1050048 
 
Page 11 of 21 
 
 
9. Schwarcz TH, Quick RC, Minion DJ, Kearney PA, Kwolek CJ, Endean ED. Enoxaparin 
treatment in high-risk trauma patients limits the utility of surveillance venous duplex 
scanning. J Vasc Surg. 2001 Sep;34(3):447-52. 
10. Bickford A, Majercik S, Bledsoe J, Smith K, Johnston R, Dickerson J, White T. Weight- 
based enoxaparin dosing for venous thromboembolism prophylaxis in the obese trauma 
patient. Am J Surg. 2013 Dec;206(6):847-51 
11. Constantini TW, Min E, Box K, Tran V, Winfield RD, Fortlage D, Doucet J, Bansal V, 
Coimbra R. Dose adjusting enoxaparin is necessary to achieve adequate venous 
thromboembolism prophylaxis in trauma patients. J Trauma Acute Care Surg. 2013 
Jan;74(1):128-33. 
12. Caprini JA. Thrombosis risk assessment as a guide to quality patient care. Dis Mon 2005; 
51: 70-78. 
13. Maynard G, Stein J. Designing and implementing effective venous thromboembolism 
prevention protocols: lessons from collaborative efforts. J Thromb Thrombolysis 
2010;29:159-66. 
14. Greenfield LJ, Proctor MC, Rodriguez  JL, et al. Posttraumatic  thromboembolism 
prophylaxis. J Trauma 1997;42:100-3. 
15. Hegsted D, Gritsiouk Y, Schlesinger P, Gardiner S, Bugler KD. Utility of the risk 
assessment profile for risk stratification of venous thrombotic events for trauma 
patients. Am J Surg. 2013 May;205(5):517-20. 
16. Intermountain  Medical  Center  Trauma  Registry  (TraumaBase  7,  Conifer,  Colorado). 
Accessed 5/12/15. 
 
 
 

V4 SToP 
V 4/26/2017 
IRB 1050048 
 
Page 12 of 21 
 
 
APPENDIX 
 
Appendix A: Factors that Identify Trauma Patients as High Risk for VTE 
From Intermountain Medical Center Trauma Program Guideline for Venous 
Thromboembolism, revised 2013. 
 
Any one of these factors identifies a patient as high risk: 
 
1. Pre-Injury Risk Factors 
a. Obesity (BMI > 30) 
b. Age > 40 years 
c. History of VTE 
d. History of malignancy 
e. Any known hypercoagulable state 
 
2. Injury-Related Risk Factors 
a. Major venous injury 
b. Spinal cord injury 
c. Spinal fracture 
d. Major operative procedure of any kind 
e. Pelvic fracture 
f. Lower extremity fracture 
g. Hemorrhagic shock 
h. Moderate or severe head injury (GCS <13 at presentation) 
i. ISS > 9 
j. Central venous line 

V4 SToP 
V 4/26/2017 
IRB 1050048 
 
Page 13 of 21 
 
 

V4 SToP 
V 4/26/2017 
IRB 1050048 
 
Page 14 of 21 
 
Appendix C: Caprini Risk Factor Assessment 
From “Thrombosis Risk Assessment as a Guide to Quality Patient Care”, Joseph Caprini, MD, 
2005. Available online at: http://williams.medicine.wisc.edu/caprini_score.pdf 
 
 
 
 
 

V4 SToP 
V 4/26/2017 
IRB 1050048 
 
Page 15 of 21 
 
 
Appendix D: Risk Assessment Profile (RAP) 
From Greenfield LJ, Proctor MC, Rodriquez JL, et al. Posttrauma thromboembolism prophylaxis. 
J Trauma 1997; 42:100-3. 
 
 
Variable 
Points 
 
 
Underlying Condition 
 
    Obesity 
2 
    Malignancy 
2 
    Abnormal Coagulation 
2 
    History of Thromboembolism 
3 
Iatrogenic Factors 
 
    Femoral Central Line >24 hrs 
2 
    Transfusion, >4 units in 24 hrs 
2 
    Surgery lasting >2 hrs 
2 
    Repair or ligation of major vascular injury 
3 
Injury-related Factors 
 
    Chest AIS > 2 
2 
    Abdomen AIS >2 
2 
    Head AIS > 2 
2 
    Spinal Fracture 
3 
    GCS <8 for >4 hrs 
3 
    Complex lower extremity fracture 
4 
    Pelvis fracture 
4 
    Spinal Cord injury, paraplegia or quadriplegia 
4 
Age (yrs) 
 
    ≥40 but <60 
2 
    ≥60 but <75 
3 
    ≥75 
4 
 

V4 SToP 
V 4/26/2017 
IRB 1050048 
 
Page 16 of 21 
 
 
Appendix E: Definition of Major and Clinicall Relevant Bleeding 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Büller HR, Cohen AT, Davidson B, et al. Idraparinux versus standard therapy  
for venous thromboembolic disease. N Engl J Med. 2007;357:1094–1104. 
 
 

V4 SToP 
V 4/26/2017 
IRB 1050048 
 
Page 17 of 21 
 
 
OMB No. 0925-0001/0002 (Rev. 08/12 Approved Through 8/31/2015) 
BIOGRAPHICAL SKETCH 
Provide the following information for the Senior/key personnel and other significant contributors. 
Follow this format for each person. DO NOT EXCEED FIVE PAGES. 
NAME:  Sarah Dawn Majercik 
eRA COMMONS USER NAME (credential, e.g., agency login): SMAJERCIK 
POSITION TITLE:  Co-Director, Trauma Research, Trauma and Surgical Critical Care 
EDUCATION/TRAINING (Begin with baccalaureate or other initial professional education, such as nursing, 
include postdoctoral training and residency training if applicable. Add/delete rows as necessary.) 
INSTITUTION AND LOCATION 
DEGREE 
(if 
applicable) 
 
Completion 
Date 
MM/YYYY 
 
FIELD OF STUDY 
 
Harvard College, Cambridge, MA 
 
University of Vermont, Burlington, VT 
 
Brown University, Providence, RI 
 
Washington University, St. Louis, MO 
A.B. 
 
M.D. 
 
n/a 
 
M.B.A.  
06/1993 
 
05/1997 
 
06/2002 
 
05/2007 
History of Science 
 
Medicine 
 
General Surgery 
Residency 
Finance 
 
 
A. Personal Statement 
I am a clinical general, trauma, and critical care surgeon at Intermountain Medical Center (IMC), an ACS-
verified Level I trauma center. I also serve as the co-director of research for the trauma service at IMC. 
Since starting in this role in 2011, I have gained expertise in conducting clinical trauma research, and I 
have led the trauma research group and all projects that have been done in our division. Further, I have 
generated multiple peer-reviewed publications since my arrival at IMC. 
 
I have more than thirteen years of clinical experience with traumatically-injured patients. I have 
extensive experience with enrolling trauma patients into research studies, most recently as an 
investigator in a randomized double blind controlled trial of weight-based versus standard dosing of 
enoxaparin for venous thromboembolism (VTE) prophylaxis in the trauma population. I am the PI of 
several Intermountain Research and Medical Foundation funded grants, one of which focuses on 
hypercoagulability as measured by thromboelastography in patients with solid organ injury. This 
application is a logical extension of my interest in coagulation and VTE in the trauma population. 
 
From 2008-2011, my research career was interrupted by a corporate position in a medical device 
company. This was done because of family obligations. When I returned to trauma surgery/surgical 
critical care, I immediately embarked upon new research projects. 
 

V4 SToP 
V 4/26/2017 
IRB 1050048 
 
Page 18 of 21 
 
 
B. Positions and Honors 
 
Positions and Employment 
2002-2005  
Assistant Professor of Surgery, Brown University, Providence, RI 
2005-2007 
Clinical Assistant Professor of Surgery, University of Missouri, Columbia, MO 
2007-2008 
Assistant Professor of Surgery, Brown University, Providence, RI 
2008-2010 
Medical Director, Becton Dickinson, Sandy, UT 
2011-      
Trauma and Critical Care Surgeon, Co-Director of Trauma Research, Intermountain Medical 
Center, Salt Lake City, UT 
 
Professional Certifications and Memberships 
2002- 
Diplomate, American Board of Surgery (exp. 9/2024) 
2003- 
Fellow, American College of Surgeons 
2013- 
Member, Southwestern Surgical Congress 
2014- 
Member, American Association for the Surgery of Trauma 
2015- 
Member, Eastern Association for the Surgery of Trauma 
 
Honors 
1997 
James Demeules award for excellence in surgical research, University of Vermont 
2002 
Haffenreffer award for excellence in medical sciences, Brown University 
2005 
Harold and Joyce Wood Fellowship, Olin School of Business, Washington University 
2014 
Peter C. Canizaro award, American Association for the Surgery of Trauma 
 
C. Contribution to Science 
 
1. The incidence of major trauma in the elderly is increasing globally. Mortality after trauma is 
significantly higher for patients over the age of 60 for any given injury severity. My earliest 
research work addressed the issue of cervical spine fractures in the elderly. Specifically, these 
papers examined the effect of different treatment modalities (halo-vest immobilization, hard 
collar immobilization, or surgical fixation) on outcomes in this population. This work resulted in 
a change in how cervical spine fractures in the elderly were treated at my home institution, and 
the manuscripts have been extensively cited in the medical literature. I was the PI or co-
investigator on these papers. 
a. Majercik S, Biffl WL, Tashjian RZ, Harrington DT, Cioffi W. Halo vest immobilization in 
the elderly:  a death sentence. Journal of Trauma 2005; 59(2):  350-357. 
b. Tashjian RZ, Majercik S, Biffl WL, Cioffi WG. Halo-vest immobilization increases early 
morbidity and mortality in elderly odontoid fractures. Journal of Trauma 2006; 60(1): 
199-203. 
 

V4 SToP 
V 4/26/2017 
IRB 1050048 
 
Page 19 of 21 
 
 
2. Risk stratification is necessary to predict outcomes after trauma. There is currently no validated 
mortality prediction model for injured patients that can be calculated immediately after injury in 
the emergency department. The Intermountain Risk Score (IMRS) is a tool that was developed at 
Intermountain Healthcare to evaluate individual mortality risk based on admission laboratory 
values, age, and gender. My work using the IMRS was the first time that the score was used to 
calculate mortality in trauma patients. It was found to be highly predictive of mortality in 
moderate and high-risk groups of males and females at both 30 days and one year after injury in 
a large historical cohort. As a corollary, I studied the red cell distribution width (RDW) as an 
independent predictor of mortality in trauma patients. I found that higher RDW is correlated 
with an increased risk of mortality in a historic cohort of patients. I was the PI on both of these 
studies. Currently, I am analyzing data on a one year, prospective validation of the use of the 
IMRS in trauma patients. Results of this study should be available in the next six months. 
a. Majercik S, Knight S, Horne BD. The Intermountain risk score predicts mortality in 
trauma patients. J Crit Care 2014; 29:882. 
b. Majercik S, Fox J, Knight S, Horne BD. Red cell distribution width is predictive of 
mortality in trauma patients. J Trauma Acute Care Surg 2013;74:1021-6. 
c. Majercik S. Re: Red Cell distribution width is predictive of mortality in trauma patients. J 
Trauma Acute Care Surg 2013 Aug;75(2):346. 
 
3. Rib fractures are a common injury, occurring in over 10% of patients who present to trauma 
centers. They can also be very disabling, with about 50% of patients who suffer significant rib 
injury reporting chronic pain and/or chest wall deformity, often precluding full-time 
employment. Traditional therapy of rib fractures consists of aggressive pain management, 
pulmonary toilet, and mechanical ventilatory support as needed. In the past decade, there has 
been increased interest in the surgical stabilization of rib fractures, especially in patients with 
the most complex injuries. It is not yet considered the standard of care for treatment, with many 
surgeons citing a lack of compelling data as a reason for not adopting the procedure. At 
Intermountain Medical Center, we are at the clinical forefront of surgical rib fracture repair. I 
have worked as the PI on several projects reporting our experience, ranging from a 2012 poster 
to several publications and national presentations on the topic. The results of my work have 
been important in increasing the visibility and adoption of the procedure at trauma centers 
throughout the United States. 
a. Majercik S, Wilson E, Gardner S, Granger S, VanBoerum DH, et al. In-hospital outcomes 
and costs of surgical stabilization versus nonoperative management of severe rib 
fractures. J Trauma Acute Care Surg. 2015 Oct;79(4):533-9. PubMed PMID: 26402525. 
b. Majercik S, Cannon Q, Granger SR, Van Boerum DH, White TW. Regarding: Long-term 
patient outcomes after surgical stabilization of rib fractures. Am J Surg. 2015 
Jul;210(1):199-200. PubMed PMID: 26072282. 

V4 SToP 
V 4/26/2017 
IRB 1050048 
 
Page 20 of 21 
 
 
c. Majercik S, Cannon Q, Granger SR, VanBoerum DH, White TW. Long-term patient 
outcomes after surgical stabilization of rib fractures. Am J Surg. 2014 Jul;208(1):88-92. 
PubMed PMID: 24507379. 
 
4. Venous thromboembolism (VTE) is a source of major morbidity and mortality in trauma 
patients. The trauma population is unique in that patients are at major risk for bleeding early on 
in their hospital course, and then rapidly switch over to being at major risk for thrombosis. VTE 
prophylaxis has been extensively studied in trauma, yet optimal dosing and surveillance 
regimens are still not known. In the area of VTE prophylaxis in trauma patients, I am a part of 
several ongoing and completed projects. The first was a prospective, observational study of the 
efficacy of weight-based enoxaparin dosing in the obese trauma population. In this study, we 
measured anti-Xa levels to assess the efficacy of enoxaparin, and to adjust the dose as 
necessary. [10] The second, ongoing project is a prospective, randomized, control trial of 
standard versus weight-based enoxaparin dosing in all adult trauma patients, with VTE events as 
the primary endpoint. The third ongoing prospective, observational trial examines the 
thromboelastography coagulation profile in the first several days after trauma in a population 
with solid organ (spleen, liver, kidney, brain) injury. 
a. Bickford A, Majercik S, Bledsoe J, Smith K, Johnston R, et al. Weight-based enoxaparin 
dosing for venous thromboembolism prophylaxis in the obese trauma patient. Am J 
Surg. 2013 Dec;206(6):847-51, discussion 851-2. PubMed PMID: 24070664. 
 
Complete list of published works in MyBibliography: 
http://www.ncbi.nlm.nih.gov/sites/myncbi/collections/bibliography/48834237/ 
 
D. Research Support 
 
Ongoing Research Support 
 
Intermountain Research and Medical Foundation 
 
 
 
12/01/2012-present 
Weight Based Enoxaparin VTE Prophylaxis in Trauma Patients 
Role: Co-Investigator 
 
Intermountain Research and Medical Foundation 
 
 
 
7/1/13-present 
VALIDation of Bedside Ultrasound of the Muscle Layer  
Thickness of the Quadriceps in the Critically Ill Patient:   
The VALIDUM Study. A multi-institutional study of the  
utility of using ultrasound of the quadriceps muscle to  
diagnose sarcopenia in the critically ill patient. 
Role: Site PI 
 

V4 SToP 
V 4/26/2017 
IRB 1050048 
 
Page 21 of 21 
 
 
Intermountain Research and Medical Foundation 
 
 
 
06/1/2014-present 
Determining the incidence of perioperative hypercoagulability using  
thromboelastography in the colorectal cancer population 
Role: Co-Investigator 
 
 
Intermountain Research and Medical Foundation 
 
 
 
06/1/2014-present 
Prospective observation study of post-injury hypercoagulability 
in patients with blunt solid organ injury, by serial measurements 
with thromboelastography 
Role: PI 
 
Completed Research Support 
The Deseret Foundation  
 
 
 
 
 
 
01/01/12-2/01/14 
Traumatic Brain Injury:  Early Imaging and Treatment Affecting  
Rehabilitation Outcomes 
Role: Co-PI (co-PI’s Mark Stevens, MD and Joel MacDonald, MD) 
 
The Deseret Foundation 
 
 
 
 
 
 
05/1/2012-9/1/2015 
The Effects of Hypobaric Conditions on Traumatic Pneumothoraces 
Role: PI