Ortho/Trauma VTE Protocol

Question 1

Q: What are the guidelines for VTE prophylaxis in patients with traumatic orthopedic fractures?

Answer 1

1. Patient Eligibility:
   
   • Applies to patients ≥ 18 years old with isolated traumatic orthopedic fractures, regardless of whether they receive operative or non-operative management.
   • Managed by the primary team (ortho, medicine, trauma, ED), which is responsible for prescribing VTE prophylaxis both inpatient and post-discharge.
2. Exclusions:
   
   • Trauma VTE guidelines apply to patients with traumatic orthopedic fractures and other traumatic injuries.
   • Elective orthopedic procedures (e.g., joint arthroplasty) are not covered; refer to general orthopedic VTE prophylaxis guidelines.
3. Discharge from ED:
   
   • For stable patients with orthopedic fractures discharged directly from the ED, prescribe aspirin 81 mg BID (unless contraindicated).
   • Follow-up in orthopedic clinic should be arranged before ED discharge.

Question 2

Q: How should VTE prophylaxis be managed peri-operatively in patients with isolated traumatic orthopedic fractures?

Answer 2

1. Enoxaparin Administration:
   
   • Most patients will be on prophylactic enoxaparin BID.
   • Hold the AM dose (0900) on the day of surgery only for the following procedures:
     
     • Open pelvis surgeries
     • Acetabulum surgeries
     • Fracture-related joint arthroplasty surgeries (not elective arthroplasties).
2. Responsibility:
   
   • The orthopedic service is responsible for placing the order to suspend/hold VTE prophylaxis for the listed procedures.
3. For all other orthopedic surgeries:
   
   • Do not hold VTE prophylaxis (enoxaparin, heparin, or aspirin).
   • Do not hold antiplatelet agents (aspirin, clopidogrel, ticagrelor, prasugrel) unless explicitly stated in consult documents.
4. Post-operative VTE prophylaxis:
   
   • For the 3 procedures listed above, pharmacologic VTE prophylaxis should be held until 12 hours post-operatively.
   • For all other procedures, check the “brief op note” for instructions on resuming VTE prophylaxis.

Question 3

Inpatient VTE prophylaxis regimens according to type of traumatic orthopedic fracture

Answer 3

Question 4

Q: When should Sequential Compression Devices (SCDs) be applied in patients with traumatic orthopedic fractures?

Answer 4

1. SCD Application:
   
   • All patients should have SCDs applied unless their injuries prohibit it.
   • Femoral traction pins are not a contraindication to below-the-knee SCDs unless the distal lower leg also has a fracture.
2. If SCDs are refused:
   
   • Consider using graduated compression stockings (GCS) as an alternative.
   • Pharmacologic prophylaxis should be used whenever possible.

Question 5

Contraindications to Starting Immediate Pharmacologic VTE Prophylaxis:

Answer 5