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. 2025 Sep 1;282(3):382-388.
doi: 10.1097/SLA.0000000000006784. Epub 2025 Jun 10.

Timing Is Everything: Early Initiation of VTE Prophylaxis Following Major Trauma Is Effective and Safe

Andrew J Kerwin  1 , Saskya Byerly  1 , Dina M Filiberto  1 , Emily K Lenart  1 , Martin A Croce  1 , Ernest E Moore  2   3 , Mary Margaret Knudson  4 ; CLOTT Study Group
Affiliations

Timing Is Everything: Early Initiation of VTE Prophylaxis Following Major Trauma Is Effective and Safe

Andrew J Kerwin et al. Ann Surg. .

Abstract

Objective: To examine the efficacy and safety of the initiation of pharmacologic venous thromboembolism (VTE) prophylaxis within 24 hours of admission for major trauma patients at risk for VTE.

Background: Pharmacologic VTE prophylaxis following major trauma is essential, but there is a fear of bleeding complications. The safety of initiating treatment within 24 hours of admission has not been established.

Methods: We examined the efficacy and safety of early initiation of pharmacologic VTE prophylaxis. Patients were stratified by time to initiation [≤24 h (EARLY) or >24 h (LATE)] and compared. VTE, VTE prophylaxis agents, and bleeding complications secondary to VTE prophylaxis were analyzed. A generalized linear mixed model (GLMM) was performed to identify predictors of VTE.

Results: There were 3369 EARLY group patients and 3200 LATE group patients. More patients in the LATE group developed VTE (7.8% vs. 2.8%; P <0.001). Among 345 patients with VTE, deep venous thrombosis (DVT) alone [181 (72%) vs. 61 (65%)], pulmonary embolism (PE) alone [46 (18%) vs. 22 (23%)] and both DVT and PE [24 (10%) vs. 11 (12%)] were present in the LATE compared with the EARLY group. The LATE group had a higher incidence of increased or new intracranial hemorrhage following prophylaxis initiation (0.5% vs. 0.2%; P =0.009) and higher mortality (1.8% vs. 0.6%; P <0.001). GLMM demonstrated that EARLY VTE prophylaxis was associated with a lower risk of VTE [odds ratio (OR): 0.58; 95% CI: 0.44-0.78; P <0.001], after controlling for covariates.

Conclusions: Initiating VTE prophylaxis within the first 24 hours after admission resulted in a 42% reduction of the risk of VTE without increased risk of bleeding and should be regarded as the standard of care, even in traumatic brain injury patients.

Keywords: deep venous thrombosis; prophylaxis; trauma; venous thromboembolism.

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Conflict of interest statement

A.J.K.: Grants from the US Army Medical Research Activity during the conduct of the study; Expert review of medical malpractice case for Roberts &Stevens, PA, and Salfield Shad, PA, outside the scope of this work; Board Member of the University of Tennessee Regional One Physicians outside the scope of this work. E.E.M.: Grants from the US Army Medical Research Activity during the conduct of the study; research grants from Humacyte and Prytime. M.M.K.: Grants from the US Army Medical Research Activity during the conduct of the study. The remaining authors report no conflicts of interest.

References

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    1. Kudsk KA, Fabian TC, Baum S, et al. Silent deep vein thrombosis in immobilized multiple trauma patients. Am J Surg. 1989;158:515–519.

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