Can anticoagulation be started in a patient with grade 4 splenic injury and grade 3 left renal injury, managed conservatively, who develops a pulmonary embolus (pulmonary embolism) in a right subsegmental branch on day 10?

From the Guidelines

Anticoagulation can be cautiously initiated in this patient with a subsegmental pulmonary embolism (PE) at day 10 post-trauma, but requires careful risk-benefit assessment. I would recommend starting with a low-molecular-weight heparin such as enoxaparin at a therapeutic dose (1 mg/kg twice daily or 1.5 mg/kg once daily), with close monitoring for bleeding complications. Before starting anticoagulation, obtain a repeat CT scan of the abdomen to confirm stability of the splenic and renal injuries, as these high-grade injuries (grade 4 splenic and grade 3 renal) carry significant bleeding risk. Laboratory tests including hemoglobin, platelet count, and coagulation studies should be checked before initiation and monitored regularly. If bleeding risk is deemed too high, an inferior vena cava filter could be considered as a temporary alternative. The decision to anticoagulate balances the risk of PE progression against potential hemorrhagic complications from the abdominal injuries. While subsegmental PEs sometimes can be managed without anticoagulation in low-risk patients, the post-trauma setting creates a hypercoagulable state that may warrant treatment, as suggested by the guidelines for splenic trauma management 1. Additionally, the guidelines for antithrombotic therapy for VTE disease support the use of anticoagulation in patients with PE, including those with subsegmental PE 1. Duration of anticoagulation would typically be 3-6 months, with consideration for transition to an oral anticoagulant after initial stabilization. It is essential to weigh the benefits of anticoagulation against the risks of bleeding, particularly in a patient with significant abdominal injuries, and to closely monitor the patient for any signs of bleeding or other complications. The most recent guidelines and expert panel reports should be consulted to inform the decision-making process, as they provide the most up-to-date recommendations based on the latest evidence 1.

Some key points to consider in this patient's management include:

• The risk of bleeding associated with anticoagulation in a patient with high-grade splenic and renal injuries
• The potential benefits of anticoagulation in preventing PE progression and reducing the risk of recurrent VTE
• The need for close monitoring of laboratory tests and clinical status to promptly identify any complications
• The importance of consulting the latest guidelines and expert panel reports to inform decision-making 1.

Overall, the decision to initiate anticoagulation in this patient should be made on a case-by-case basis, taking into account the individual patient's risk factors, clinical status, and potential benefits and risks of treatment.

From the Research

Anticoagulation in Patients with Splenic and Renal Injuries

• The decision to start anticoagulation in a patient with grade 4 splenic injury and grade 3 left renal injury, managed conservatively, who develops a pulmonary embolus (pulmonary embolism) in a right subsegmental branch on day 10, is complex and requires careful consideration of the risks and benefits 2, 3, 4.
• According to the study by 2, anticoagulation is the first line therapy to prevent pulmonary embolism, but in some instances, anticoagulation fails to prevent more emboli, or cannot be given because the person has a high risk of bleeding.
• The study by 3 presents a case of a woman with DVT, complicated with high-risk PE, who develops retroperitoneal hematoma originating from undiagnosed renal angiomyolipoma, and therefore, long-term anticoagulation is considered contraindicated, and an IVC filter is installed.
• The management of anticoagulation therapy in patients with renal impairment is more complicated, as all direct oral anticoagulants (DOACs) have a degree of renal excretion 5.
• The study by 4 recommends that anticoagulation protects against recurrence, which has a high mortality rate, and the recommended duration of anticoagulation for patients with reversible PE risk factors is 3 months.
• Inferior vena cava filters are not routinely recommended and should only be used in patients who have a contraindication to anticoagulation 4.

Considerations for Anticoagulation Therapy

• The risk of bleeding is a major concern in patients with splenic and renal injuries, and the decision to start anticoagulation therapy should be based on a careful assessment of the individual patient's risk of hemorrhage 2, 3, 4.
• The use of inferior vena cava filters may be considered in patients who have a contraindication to anticoagulation, but the clinical efficacy and adverse event profile of these filters is unclear 2.
• The management of anticoagulation therapy in patients with renal impairment requires careful consideration of the degree of renal excretion of the anticoagulant, and the risk of bleeding 5.