Prevention of Pulmonary Embolism in high risk trauma patients Inferior vena cava filters, pharmaceuticals, vasocompressive devices Sean Beard, Jimmy Crick, Ashton Curry, Erica Essex

PICO QUESTION P: Trauma patients at high risk for PE I: Use of inferior vena cava filter C: Prophylactic pharmaceuticals and vasocompressive devices O: Incidence of PE In trauma patients who are at high risk for developing a pulmonary embolism (PE), is the use of an inferior vena cava filter (IVCF) better than the standard care of prophylactic pharmaceuticals and vasocompressive devices for the prevention of a PE?

OBJECTIVES Background Indications vs. Contraindications Effectiveness PE background & incidence IVC filters (IVCF) Why trauma patients? Indications vs. Contraindications Effectiveness Conclusions Clinical Relevance Risks associated with IVCF http://www.uwmedicine.org/Patient-Care/eHealth-Articles/PublishingImages/Inferior-Vena-Cava-Filter.jpg

BACKGROUND PE IVCF Blood clot in lungs Originates in lower extremity Fragments and travels to lungs via the inferior vena cava IVCF Metal alloy device Inserted in the inferior vena cava Traps blood clots Prevents pulmonary emboli (Young, 2010) http://www.youtube.com/watch?v=o-_wL3XWZ1I&app=desktop

IVCF PLACEMENT http://www.youtube.com/watch?v=UvtHCMBm0SA&app=desktop http://www.mbcgraphics.com/images/img_port_ivcfilter.jpg http://www.youtube.com/watch?v=UvtHCMBm0SA&app=desktop

GROSS ANATOMY LAB Thanks to Dr. Hanks and table 2.1

IMPORTANCE PE’s are common (Rajasekhar, 2011) PE’s are deadly PE’s are preventable (Stefanidis, 2006) http://medicalcenter.osu.edu/patientcare/healthcare_services/lung_diseases/lung/embolism/Pages/index.aspx PE is 3rd most common cause of in hospital death in trauma patients surviving the first 24h (Rajasekhar, 2011) Venous thrombolytic event (VTE) is a leading cause of morbidity and mortality in trauma patients PE: most common preventable cause of death in surgical patients (Stefanidis, 2006)

PATIENT PROFILE Types of high risk patients Factors increasing venous thrombotic event (VTE) risk SCI TBI Fractures Pelvic, acetabulum, tibia-fibula, femoral shaft, foot/ankle (Carlin, 2002) History of venous thrombotic event Prolonged immobility Pelvic trauma Age Vascular injury Obesity Blood transfusions (Helling, 2009)

STANDARD OF CARE Prophylactic low dose subcutaneous heparin (LDH) and sequential compression devices (SCD) Effectively reduces the incidence of DVT or PE to <10% 35% of trauma patients are unable to have SCD 14% of high risk trauma patients unable to have LDH (Sekharan, 2001) (Khansarinia, 1995)

CONTRAINDICATIONS TO STANDARD OF CARE Low dose heparin (LDH) TBI SCI Major pelvic and/or acetabulum fractures Spleen or liver injury Gastrointestinal bleeding Hematuria Stroke Traumatic aortic rupture Sequential compression devices (SCD) LE orthopedic fractures Casting (Carlin, 2002)

INDICATIONS FOR USE OF IVCF Patients with known VTE Anticoagulants contraindicated Recurrent PE despite anticoagulant therapy Hx of complication related to anticoagulant therapy (Young, 2010) (Rajasekhar, 2011) Inserted within 48 hours of injury (Carlin, 2002)

EFFECTIVENESS IVCF’s are considered safe and reduce incidence of VTE (Kidane, 2012) Compared to matched controls, PE incidence was significantly lower in IVCF group (Rajasekhar, 2011) http://www.uofmmedicalcenter.org/fv/groups/public/documents/images/277293.jpg

EFFECTIVENESS After 5 year follow-up, IVCF placement is safe and durable in young active trauma patients (Sekharan, 2001) In patients with IVCF, compared to no IVCF: 12 days: 22% decrease in incidence of PE 2 years: 50% decrease in incidence of PE (Decousus, 1998)

POTENTIAL COMPLICATIONS WITH IVCF Erosion through vena cava wall Filter migration Filter infection Thrombus formation caudal to IVCF Inferior vena cava occlusion (Stefanidis, 2006) http://www.youtube.com/watch?v=qlaDA_FRA48

CONCLUSION In trauma patients who are at high risk for PE IVCF’s are more effective than standard of care at preventing the incidence of a PE In patients for whom standard of care is contraindicated IVCF placement is safe and recommended

RELEVANCE TO PHYSICAL THERAPY Awareness of IVCF Indicates patient is at high risk for VTE Prolonged IVCF use correlated with increased incidence of DVT Wells criteria Recognition of IVCF complication Awareness  in the acute care setting we will be working with lots of post surgical patients i.e THR, TKR, pelvic fracutes and other high trauma patients and we must recognize these patients are at a high risk for DVT and PE Indicates pt is at high risk for VTE  if you see this in their past medical hx it’s a good indicator that you should be aware of the S/S of a DVT with this patient

REFERENCES Carlin AM, Tyburski JG, Wilson RF, Steffes C. Prophylactic and therapeutic inferior vena cava filters to prevent pulmonary emboli in trauma patients. Arch. Surg. 2002;137(5): 521–5. Decousus H, Leizorovicz A. A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis. N. Engl. J. Med. 1998;338(7):409–415. Helling TS, Kaswan S, Miller SL, Tretter JF. Practice patterns in the use of retrievable inferior vena cava filters in a trauma population: a single-center experience. J. Trauma. 2009;67(6):1293–6. Khansarinia S, Dennis JW, Veldenz HC, Butcher JL, Hartland L. Prophylactic Greenfield filter placement in selected high-risk trauma patients. J. Vasc. Surg. 1995;22(3):231–5. Kidney B, Madani AM, Vogt K, Girotti M, Malthaner R a, Parry NG. The use of prophylactic inferior vena cava filters in trauma patients: a systematic review. Injury, Int. J. Care Injured. 2012;43(5):542–7.

REFERENCES Rajasekhar A, Lottenberg R, Lottenberg L, Liu H, Ang D. Pulmonary embolism prophylaxis with inferior vena cava filters in trauma patients: a systematic review using the meta-analysis of observational studies in epidemiology (MOOSE) guidelines. J. Thromb. Thrombolysis. 2011;32(1):40–6. Sekharan J, Dennis JW, Miranda FE, et al. Long-term follow-up of prophylactic greenfield filters in multisystem trauma patients. J. Trauma. 2001;51(6):1087–90. Stefanidis D, Paton BL, Jacobs DG, et al. Extended interval for retrieval of vena cava filters is safe and may maximize protection against pulmonary embolism. Am. J. Surg. 2006;192(6):789–94. Young T, Tang H, Hughes R. Vena caval filters for the prevention of pulmonary embolism. Cochrane Database of Systematic Reviews. 2010; (2):CD006212.