Deep venous thrombosis has been a problem in adult trauma patients for some time. Turns out, it’s a problem in injured children as well although much less common (<1%). However, the subset of kids admitted to the ICU for trauma have a much higher rate if not given prophylaxis (approx. 6%). Most trauma centers have protocols for chemical prophylaxis of adult patients, but not many have similar protocols for children.

The Medical College of Wisconsin looked at trends prior to and after implementation of a DVT protocol for patients < 19 years old. They used the following protocol to assess risk in patients admitted to the PICU and to determine what type of prophylaxis was warranted:

The need for and type of prophylaxis was balanced against the risk for significant bleeding, and this was accounted for in the protocol. The following significant findings were noted:

• The overall incidence of DVT decreased significantly (65%) after the protocol was introduced, from 5.2% to 1.8%
• The 1.8% incidence after protocol use is still higher than most other non-trauma pediatric populations 
• After the protocol was used, all DVT was detected via screening. Suspicion based on clinical findings (edema, pain) only occurred pre-implementation.
• Use of the protocol did not increase use of anticoagulation, it standardized management in pediatric patients

Bottom line: DVT does occur in injured children, particularly in severely injured ones who require admission to the ICU. Implementation of a regimented system of monitoring and prophylaxis decreases the overall DVT rate and standardizes care in this group of patients. This is another example of how the use of a well thought out protocol can benefit our patients and provide a more uniform way of managing them.

Related posts:

• Does central line insertion promote DVT?
• Does interrupting DVT prophylaxis increase risk?
• Microparticles and DVT
• Does pulmonary embolism really arise from DVT?

Reference: Effectiveness of clinical guidelines for deep vein thrombosis prophylaxis in reducing the incidence of venous thromboembolism in critically ill children after trauma. J Trauma 72(5):1292-1297, 2012.

Adult trauma patients are at risk for venous thromboembolism (VTE). Children seem not to be. The big question is, when do children become adults? Or, at what age do we need to think about screening and providing prophylaxis to kids? As of yet, there are no national guidelines for dealing with DVT in children.

Researchers at Johns Hopkins went to the NTDB to try to answer this question. They looked at the records of over 400,000 trauma patients aged 21 or less who were admitted to the hospital. 

Here are the interesting factoids:

• Only 1,655 patients (0.4%) had VTE (1,249 DVT, 332 PE, 74 DVT+PE)
• VTE patients were older, male, and frequently obese
• VTE patients were more severely injured, with higher ISS and lower GCS
• Patients with VTE were more likely to be intubated and receive blood transfusions, and had longer hospital and ICU stays

The risk of VTE stratified by age was as follows:

Bottom line: Risk of VTE in pediatric trauma patients follows the usual injury severity pattern. But it also demonstrates a predictable age distribution. Risk increases as the teen years begin (13), and rapidly becomes adult-like at age 16. Begin your standard surveillance practices on all 16 year olds, and consider it in 13+ year olds if their injury severity warrants.

Related post:

• DVT in children

Reference: Venous thromboembolism after trauma: when do children become adults. JAMA Surgery online first October 31, 2013.