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Observational Study
. 2022 Feb 1;157(2):e216356.
doi: 10.1001/jamasurg.2021.6356. Epub 2022 Feb 9.

Challenging Traditional Paradigms in Posttraumatic Pulmonary Thromboembolism

M Margaret Knudson  1 , Ernest E Moore  2 , Lucy Z Kornblith  1 , Amy M Shui  3 , Scott Brakenridge  4   5 , Brandon R Bruns  6   7 , Mark D Cipolle  8   9 , Todd W Costantini  10 , Bruce A Crookes  11 , Elliott R Haut  12 , Andrew J Kerwin  5   13 , Laszlo N Kiraly  14 , Lisa M Knowlton  15 , Matthew J Martin  16 , Michelle K McNutt  17 , David J Milia  18 , Alicia Mohr  5 , Ram Nirula  19 , Fredrick B Rogers  20 , Thomas M Scalea  6 , Sherry L Sixta  8 , David A Spain  15 , Charles E Wade  17 , George C Velmahos  21
Affiliations
Observational Study

Challenging Traditional Paradigms in Posttraumatic Pulmonary Thromboembolism

M Margaret Knudson et al. JAMA Surg. .

Erratum in

  • Error in Author's Name.
    [No authors listed] [No authors listed] JAMA Surg. 2022 Feb 1;157(2):177. doi: 10.1001/jamasurg.2021.7682. JAMA Surg. 2022. PMID: 35138353 Free PMC article. No abstract available.

Abstract

Importance: Pulmonary clots are seen frequently on chest computed tomography performed after trauma, but recent studies suggest that pulmonary thrombosis (PT) and pulmonary embolism (PE) after trauma are independent clinical events.

Objective: To assess whether posttraumatic PT represents a distinct clinical entity associated with the nature of the injury, different from the traditional venous thromboembolic paradigm of deep venous thrombosis (DVT) and PE.

Design, setting, and participants: This prospective, observational, multicenter cohort study was conducted by the Consortium of Leaders in the Study of Traumatic Thromboembolism (CLOTT) study group. The study was conducted at 17 US level I trauma centers during a 2-year period (January 1, 2018, to December 31, 2020). Consecutive patients 18 to 40 years of age admitted for a minimum of 48 hours with at least 1 previously defined trauma-associated venous thromboembolism (VTE) risk factor were followed up until discharge or 30 days.

Exposures: Investigational imaging, prophylactic measures used, and treatment of clots.

Main outcomes and measures: The main outcomes of interest were the presence, timing, location, and treatment of any pulmonary clots, as well as the associated injury-related risk factors. Secondary outcomes included DVT. We regarded pulmonary clots with DVT as PE and those without DVT as de novo PT.

Results: A total of 7880 patients (mean [SD] age, 29.1 [6.4] years; 5859 [74.4%] male) were studied, 277 with DVT (3.5%), 40 with PE (0.5%), and 117 with PT (1.5%). Shock on admission was present in only 460 patients (6.2%) who had no DVT, PT, or PE but was documented in 11 (27.5%) of those with PE and 30 (25.6%) in those with PT. Risk factors independently associated with PT but not DVT or PE included shock on admission (systolic blood pressure <90 mm Hg) (odds ratio, 2.74; 95% CI, 1.72-4.39; P < .001) and major chest injury with Abbreviated Injury Score of 3 or higher (odds ratio, 1.72; 95% CI, 1.16-2.56; P = .007). Factors associated with the presence of PT on admission included major chest injury (14 patients [50.0%] with or without major chest injury with an Abbreviated Injury Score >3; P = .04) and major venous injury (23 [82.1%] without major venous injury and 5 [17.9%] with major venous injury; P = .02). No deaths were attributed to PT or PE.

Conclusions and relevance: To our knowledge, this CLOTT study is the largest prospective investigation in the world that focuses on posttraumatic PT. The study suggests that most pulmonary clots are not embolic but rather result from inflammation, endothelial injury, and the hypercoagulable state caused by the injury itself.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Kornblith reported receiving personal fees from Cerus SAB outside the submitted work. Dr Bruns reported receiving grants from the US Department of Defense during the conduct of the study. Dr Cipolle reported receiving grants from the US Army Medical Research Acquisition Activity during the conduct of the study. Dr Crookes reported receiving grants from the National Trauma Institute during the conduct of the study. Dr Haut reported receiving grants from the US Army Medical Research Acquisition Activity during the conduct of the study and grants from the Agency for Healthcare Research and Quality, the Patient-Centered Outcomes Research Institute, the National Heart, Lung, and Blood Institute, and the Henry M. Jackson Foundation for the Advancement of Military Medicine and speaker fees from Vizient (paid speaker for the Vizient Hospital Improvement Innovation Network VTE Prevention Acceleration Network) outside the submitted work. Dr Kerwin reported receiving grants from the US Army Medical Research Acquisition Activity during the conduct of the study. Dr Kiraly reported receiving grants from the Coalition for National Trauma Research of the US Department of Defense during the conduct of the study. Dr Martin reported receiving grants from the US Department of Defense during the conduct of the study. Dr Mohr reported receiving grants from the National Trauma Institute during the conduct of the study. Dr Wade reported having stock in Decisio LLC and receiving grants from Grifols outside the submitted work. Dr Velmahos reported receiving grants from the National Institutes of Health during the conduct of the study. No other disclosures were reported.

Figures

Figure.
Figure.. Algorithm for the Treatment of Posttraumatic Pulmonary Thromboembolism (PT) and Proposed New Triad for Posttraumatic PT
DVT indicates deep venous thrombosis; IVC, inferior vena cava.
See this image and copyright information in PMC

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