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

2. 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?

3. 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

4. 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)

5. IVCF PLACEMENT http://www.youtube.com/watch?v=UvtHCMBm0SA&app=desktop

6. GROSS ANATOMY LAB
Thanks to Dr. Hanks
and table 2.1

7. IMPORTANCE PE’s are common (Rajasekhar, 2011) PE’s are deadly
PE’s are preventable
(Stefanidis, 2006)
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)

8. 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)

9. 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)

10. 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)

11. 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)

12. 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)

13. 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)

14. POTENTIAL COMPLICATIONS WITH IVCF
Erosion through vena cava wall
Filter migration
Filter infection
Thrombus formation caudal to IVCF
Inferior vena cava occlusion
(Stefanidis, 2006)

15. 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

16. 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

17. 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.

18. 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):CD