Knudson M M, Collins J A, Goodman S B, McCrory D W
Department of Surgery, University of California, San Francisco General Hospital 94110.
J Trauma. 1992 Jan;32(1):2-11. doi: 10.1097/00005373-199201000-00002.
The true incidence of thromboembolic complications following multiple trauma is unknown, and no method of prophylaxis has been shown to be both safe and effective in managing seriously injured patients. In this prospective study, 113 trauma patients were assigned on admission to receive either low-dose heparin (LDH), (5,000 U subcutaneously every 12 hours) or to wear sequential compression devices (SCDs) as prophylaxis against the development of deep venous thrombosis (DVT). Both groups of patients were serially studied with duplex venous ultrasound imaging to detect thrombus in the veins of the thigh. Ventilation-perfusion lung scans and pulmonary angiograms were performed when pulmonary embolism (PE) was suspected clinically. There were 12 patients who had thromboembolic complications, including 9 of 76 in the SCD group (12%) and 3 of 37 in the LDH group (8%). Five patients had DVT only, four had PE without detectable DVT, and three had both DVT and PE. None of the patients with PE died, and there were no major complications associated with either method of prophylaxis. Compared with the patients who did not develop DVT/PE, those with thromboembolic complications were older (49 +/- 23 vs. 36 +/- 17 years, p less than 0.02), spent more hospital days immobilized (24 +/- 15 vs. 10 +/- 13 days, p less than 0.001), received more transfusions (11 +/- 12 vs. 3 +/- 5 U, p less than 0.001) and had clotting abnormalities on admission, as demonstrated by prolonged PTT values (39 +/- 28 vs. 26 +/- 5 seconds, p less than 0.001). It appears that there is an identifiable subgroup of injured patients at highest risk for PE who warrant both prophylaxis and close surveillance for DVT.
多发伤后血栓栓塞并发症的真实发生率尚不清楚，而且在治疗严重受伤患者方面，尚未有任何预防方法被证明既安全又有效。在这项前瞻性研究中，113例创伤患者在入院时被分配接受低剂量肝素（LDH，每12小时皮下注射5000单位）或使用序贯加压装置（SCDs），以预防深静脉血栓形成（DVT）。两组患者均通过双功静脉超声成像进行连续研究，以检测大腿静脉内的血栓。当临床怀疑有肺栓塞（PE）时，进行通气-灌注肺扫描和肺血管造影。有12例患者出现血栓栓塞并发症，其中SCD组76例中有9例（12%），LDH组37例中有3例（8%）。5例患者仅发生DVT，4例发生PE但未检测到DVT，3例同时发生DVT和PE。所有发生PE的患者均未死亡，且两种预防方法均未出现重大并发症。与未发生DVT/PE的患者相比，发生血栓栓塞并发症的患者年龄更大（49±23岁对36±17岁，p<0.02），住院期间制动时间更长（24±15天对10±13天，p<0.001），接受输血更多（11±12单位对3±5单位，p<0.001），且入院时存在凝血异常，表现为部分凝血活酶时间延长（39±28秒对26±5秒，p<0.001）。似乎存在一个可识别的受伤患者亚组，他们发生PE的风险最高，需要进行DVT的预防和密切监测。
