Discharge Guidelines for Prophylactic Anticoagulation for Trauma Patients
exp date isn't null, but text field is
Objectives
To provide standardized recommendations for prophylactic anticoagulation for trauma patients at the time of hospital discharge
All non-ambulatory patients or patients with spine trauma, orthopedic injuries, or traumatic brain injury will have a Caprini Score calculated at the time of discharge. The choice of anticoagulation will be determined based on Caprini score, injuries, procedures, and existing medical conditions. Refer to the table on the next page for recommendations. Many patients will require prophylaxis for a total of four weeks from the time of injury. Two weeks may be adequate if the patient is weight bearing and has a low risk injury/procedure or a moderate risk injury/procedure in addition to a low Caprini score (≤7).
If warfarin is selected, patients should receive low molecular weight heparin (LMWH) bridiging until a therapeutic INR (2-3) is achieved. The patient’s primary care phyisician (PCP) will be contacted to arrange warfarin follow up. If the patient does not have a PCP, a referral to the Michigan Medicine Anticoagulation Clinic will be made with the trauma/burn attending at time of discharge designated as the patient’s PCP (patients can only be seen at the Anticoagulation Clinic if their primary care physician is affiliated with Michigan Medicine). A referral to the Michigan Medicine Anticoagulation Clinic can also be made if the patient’s PCP is affiliated with Michigan Medicine.
|
|
Patient Characteristics |
||
|
Caprini Score >7 |
Caprini Score ≤ 7 |
High risk for Bleeding (defined as coagulopathy, recent hemorrhagic stroke, or recent GI Bleed) |
|
|
High Risk Injury/Procedure
|
Preferred
If CrCl is <30 mL/min or DOAC is not covered by insurance
|
|
|
|
Moderate Risk Injury/Procedure
|
Preferred
If DOAC is not covered by insurance
If CrCl is <30 mL/min
|
Preferred
If DOAC is not covered by insurance
If CrCl is <30 mL/min
|
|
|
Low Risk Injury/Procedure
|
Preferred
If CrCl is <30 mL/min
|
|
|
- Calculate duration from time of injury
- *Patients with a pending operative intervention within two weeks of discharge should be discharged on LMWH for a total of 4 weeks
- ₸Avoid enoxaparin in patients receiving renal replacement therapy
- ¥Bridge with SQ enoxaparin 30 mg twice daily (preferred) or SQ heparin 5000 units three times daily (for CrCl <30 mL/min)
- Consider discharge prophylaxis in patients with a Caprini score >7 and an active cancer diagnosis, prior VTE, or a known hypercoagulability disorder
Caprini Score
| Each Risk Factor Represents 1 Point | |
| Age 41-60 years | |
| Minor surgery planned | |
| History of prior major surgery (<1 month) | |
| Varicose veins | |
| History of inflammatory bowel disease | |
| Swollen legs (current) | |
| Obesity (BMI > 25) | |
| Acute myocardial infarction | |
| Congestive heart failure (< 1 month) | |
| Sepsis (<1 month) | |
| Serious lung disease incl. pneumonia (<1 month) | |
| Abnormal pulmonary function (COPD) | |
| Medical patient currently at bed rest | |
| Orther risk factors ____________________ |
| Each Risk Factor Represents 2 Points | |
| Age 60-74 years | |
| Arthroscopic surgery | |
| Malignancy (present or previous) | |
| Major surgery (>45 minutes) | |
| Laparoscopic surgery (>45 minutes) | |
| Patient confined to bed (>72 hours) | |
| Immobilizing plaster cast (<1 month) | |
| Central Venous Catheter |
| Each Risk Factor Represents 5 Points | |
| Elective major lower extremity arthroplasty | |
| Hip, pelvis or leg fracture (<1 month) | |
| Stroke (<1 month) | |
| Multiple trauma (<1 month) | |
| Acute spinal cord injury (paralysis) (< 1 month) |
| Age over 75 years | |
| History of DVT/PE | |
| Family history of thrombosis * | |
| Positive Factor V Leiden | |
| Positive Prothrombin 20210A | |
| Elevated serum homocysteine | |
| Positive lupus anticoagulant | |
| Elevated anticardiolipin antibodies | |
| Heparin-induced thrombocytopenia (HIT) | |
| Other congenital or acquired thrombophilia If Yes: _______________________________ |
|
| * most frequently missed risk factor |
| For Women Only (Each Represents 1 Point) | |
| Oral contraceptives or hormone replacement therapy | |
| Pregnancy or postpartum (<1 month) | |
| History of unexplained stillborn infant, recurrent spontaneous abortion (≥3), premature birth with toxemia or growth- restricting infant |
Total Risk Factor Score ___________