Can trauma patients with concussions receive Deep Vein Thrombosis (DVT) prophylaxis?

DVT Prophylaxis in Trauma Patients with Concussions

Yes, trauma patients with concussions can and should receive DVT prophylaxis, but the timing and modality depend on the severity of the traumatic brain injury and bleeding risk. 1

Risk Assessment in Concussion Patients

Traumatic brain injury, including concussions, significantly elevates VTE risk in trauma patients:

• Patients with traumatic brain injury have a 3-5% VTE risk when pharmacologic prophylaxis is initiated within 24-48 hours 1
• The VTE risk increases dramatically to 15% when pharmacologic prophylaxis is delayed beyond 48 hours 1
• Head injury is an independent risk factor for VTE in trauma patients 1
• The baseline VTE risk in major trauma patients is 3-5%, but rises to 8-10% in those with traumatic brain injury 1

Bleeding Risk Considerations

Severe head injuries are listed as a relative contraindication to pharmacologic prophylaxis, not an absolute contraindication 1:

• In patients with traumatic brain injury judged eligible for LMWH within 48 hours, progressive hemorrhagic changes occurred in only 3.4% on head CT, with changes in management in just 1.1% 1
• The baseline bleeding risk requiring >4 units transfusion is 4.7% in trauma patients 1
• Pharmacologic prophylaxis prevents approximately 4 times as many nonfatal VTE events as nonfatal bleeding complications it causes in average-risk trauma patients 1

Recommended Prophylaxis Strategy

For Mild-Moderate Concussions (Average Bleeding Risk):

Initiate pharmacologic prophylaxis with LDUH or LMWH as soon as clinically appropriate 1:

• LMWH (enoxaparin 30 mg subcutaneously every 12 hours or 40 mg once daily) is preferred over unfractionated heparin 1, 2
• LDUH 5,000 units subcutaneously every 8 hours is an acceptable alternative 1, 2
• Add mechanical prophylaxis (preferably IPC) to pharmacologic prophylaxis in high-risk patients with traumatic brain injury 1

For Severe Traumatic Brain Injury with Active Bleeding Concerns:

Start with mechanical prophylaxis alone until bleeding risk diminishes 1:

• Use intermittent pneumatic compression (IPC) devices over graduated compression stockings 1, 2
• With intracranial hemorrhage, delay pharmacological prophylaxis for 24 hours and confirm stability on repeat head CT before initiating 2
• Add pharmacologic prophylaxis with LMWH or LDUH when the contraindication resolves 1

Timing of Initiation

The critical window is 24-48 hours after admission 1:

• Without intracranial hemorrhage, initiate pharmacological prophylaxis immediately upon ICU admission 2
• Delaying beyond 48 hours triples the VTE risk from 5% to 15% 1
• Daily reassessment of bleeding risk is necessary to transition from mechanical to pharmacologic prophylaxis as soon as safe 2

Common Pitfalls to Avoid

Do not withhold prophylaxis indefinitely due to theoretical bleeding concerns—the VTE risk typically outweighs bleeding risk after initial stabilization 1, 2:

• Do not use IVC filters for primary VTE prevention in trauma patients with concussions 1, 2
• Do not perform routine surveillance ultrasound screening for asymptomatic DVT 1, 2
• Do not assume all concussions require withholding pharmacologic prophylaxis—only severe head injuries with active bleeding or coagulopathy warrant delay 1

Duration of Prophylaxis

Continue prophylaxis throughout hospitalization until the patient is fully ambulatory 2:

• Minimum 7-10 days of prophylaxis is recommended for critically ill trauma patients 2
• The usual duration in clinical trials was 5-10 days postoperatively, with up to 14 days well-tolerated 3

Special Populations

For elderly trauma patients (>60-65 years) with concussions, age is an additional independent VTE risk factor requiring heightened vigilance 1:

• Older age has been consistently implicated as a VTE risk factor across multiple trauma studies 1
• The combination of traumatic brain injury and advanced age places patients in the highest risk category 1