Introduction: Patients suffering from traumatic brain injury (TBI) are at increased risk of venous thromboembolism (VTE). However, initiation of chemoprophylaxis (VTEp) may cause further intracranial hemorrhage. We reviewed the literature to determine the post-injury time interval at which VTEp can be administered without risk of TBI evolution and hematoma expansion.

Methods: MEDLINE and EMBASE databases were searched. Inclusion criteria were: studies investigating timing and safety of VTEp in TBI patients not previously on oral anticoagulation. Two investigators extracted data and graded the papers based on levels of evidence.

Results: A total of 408 studies were screened. Forty-five studies were reviewed inentirety and 21 were included in the systematic review. There were 2 prospective randomized trials and 19 comparative studies. Eighteen total studies demonstrated that VTEp post injury in patients with stable head computed tomography scan (CT) does not lead to radiographic or clinical TBI progression. Fourteen studies demonstrated that VTEp administration specifically 24 – 72 hours post injury is safe in patients with stable injury. Four studies suggested that administering VTEp within 24 hours of injury in patients with stable TBI does not lead to progressive ICH. One study – a retrospective review of 1215 patients – suggested low molecular-weight-heparin (LMWH) is a risk factor for TBI progression. One retrospective review found unfractionated-heparin was associated with higher rates of TBI progression than LMWH. It is not yet clear what exactly constitutes a low risk TBI, but a recurring theme in the literature is that hemorrhagic expansion is associated with more severe TBI.

Conclusions: Literature suggests that administering VTEp 48 hours post-injury may be safe for patients with low-hemorrhagic risk TBIs and stable injury on repeat imaging. A clinical practice guideline (CPG) was developed at our level-1 trauma center. Future research may focus on prospectively testing our CPG.

Patient Care: Delaying or avoiding thromboprophylaxis in the TBI or multitrauma population can have devastating consequences such deep vein thrombosis and pulmonary embolism. It is recognized that the TBI population is heterogenous. A portion is considered low-risk for thromboprophylaxis initiation. This research aims at encouraging physicians, from neurosurgeons at tertiary center to physicians working in the rural community, to initiate thromboprophylaxis in adequate settings.

Learning Objectives: By the conclusion of this session, participants should be able to : 1) Understand the diversity in TBI population 2) Identify low and high risk traumatic brain injuries in regards to thromboprophylaxis 2) Recognize the need to initiate thromboprophylaxis in multitrauma patients with low-risk traumatic brain injuries 3) Be familiar with the current literature in the choice of thromboprophylaxis agent 4) Recognize risk factors of TBI progression

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