By: AJ Cushman

Discuss potential impact of a pulmonary embolism (PE)/deep vein thrombosis (DVT) on recovery from a traumatic injury.

My Patient-Mr. Salesman
 27 y/o African-American male
 Car salesman
 Runs 3 miles daily
 No family hx, prior sx, comorbidities
 Lives with father
 Admitted May 26, 2014 for gun shot wound (GSW)

History of present illness
 ORIF of L distal femur fx s/p GSW
 TTWB LLE
 Hgb dropped: 12  5.0 mmHg
 Tachycardic/orthostatic: 130  180bpm on standing
 Transferred to STICU
 C/o pain RLE
 Possible DVT/PE
 Chest CT found small/moderate PE L lower lobe.
 Heparin bolus

PT Evaluation
Subjective
 8/10 pain
 R (uninjured) > L at beginning of session
 L > R at end
 Odd sensations in L foot
 Activity Level
 Living Situation/equipment
 With father, stairs, crutches
 Goals
Objective
 Observe: lethargic
 Vitals: Tachycardic throughout
 Integument: clammy, temperature R>L, Swelling L>R
 Sensation: L=paresthesias,
R=pain
 ROM: R-WFLs, L-0-35˚ knee flexion
 Mobility: supine  EOB, sit  stand, ambulation

Relevant Findings
 Pain (BLE)
 Decreased strength
 Decreased ROM (L knee flexion)
 Ability to maintain WB status
 Activity tolerance/endurance
 Independence with ambulation and ADLs…

Prognosis and GOALS
 Pt is good candidate for PT
 Likely return to previous level of function and d/c home
 (+)- age, prior activity level, no comorbidities, pt motivation, cognition, family assistance at home
 (-)- severity of pain and injuries, level of dysfunction, and…complications aka DVT/PE???

Goals and Plan
 At time of discharge (1 week), patient will be able to:
1) Actively achieve 90 degrees of knee flexion
2) Ambulate 150 feet independently using LRAD
3) Up/down one flight of stairs using LRAD
 Plan: 5x/wk. Expected d/c = home

Interventions
 Functional mobility
 (Gait training)
 Therapeutic exercise
 Activity Tolerance
 Increase endurance
Patient education
 WB status
 DVT/PE

Outcomes/Re-eval
 Assessment of re-eval…
 Goals Met (1/3): Pt able to achieve 90˚ L knee flexion
 Rationale for other goals NOT met:
 Delays in PT visits
 Unable to ambulate/maintain WB status
 Information I am missing…

Does the incidence of a pulmonary embolism negatively impact the prognosis in a healthy, young adult recovering from a lower extremity fracture?

A meta-analysis of best rest versus early ambulation in the management of pulmonary embolism, deep vein thombosis, or both.
International Journal of Cardiology; Volume 137,
Issue 1, Pages 37-41
Nadia Aissaoui, Edith Martins, Stéphane Mouly, Simon Weber and
Christophe Meune
Copyright 2008 Elsevier Ireland Ltd

Purpose
 Determine the best recommendation for PE/DVT management
 Ambulation versus bed rest
 Along with anticoagulants
 Previous arguments in literature versus recent articles
 End to confusion?

Method
 5 studies selected (out of original 363 found) comprising a total of 3048 patients
 Inclusion criteria:
 Relative risk (RR), 95% confidence intervals (CI)

Results
Early ambulation:
1. Not associated with higher risk of new PE
(RR 1.03, 95% CI 0.65-1.63)
2. Associated with a lower trend of new/progression of
DVT
(RR 0.79; 95% CI 0.55–1.14)
3. Not associated with higher rate of mortality
(RR 0.79, 95% CI 0.40-1.56)

Discussion and Conclusion
 Must achieve effective level of anticoagulation first!
 Confirmed efficacy as first line
 EARLY AMBULATION DOES NOT INCREASE RISK OF
ADVERSE OUTCOMES
 Trend toward lower risk in previously stated areas
 Other positive benefits…

Study Limitations
 Timing of early ambulation range = 0-2 days
 Addition of compression devices not assessed
 Massive PE excluded
 No distinction between:
 PE and DVT
 symptomatic and asymptomatic PE

Tobias Lindner, Andrew J Cockbain, Mohamed A El Masry, Paul
Katonis, Evgenios Tsiridis, Constantin Schizas & Eleftherios
Tsiridis
Expert Opin. Pharmacother. (2008) 9 (7):1169-1187

Purpose
 Consider potential recommendations between specific agents and dosage in trauma patients (ie fracture)
 Current guidelines distinguish between low versus high risk
(provoked and idiopathic)
 Presents evidence concerning the effect of common anticoagulants on:
1) Fracture healing (in vivo) - 7 studies
2) Bone metabolism (in vivo) – 6 studies
3) Bone cells (in vitro) – 8 studies

Anticoagulants in clinical use
 Heparin
 Low molecular weight heparins (LMWHs) (Enoxaparin)
 Synthetic pentasaccharides (Fondaparinux)
 Vitamin K antagonists (Warfarin/coumarins)
 Acetylsalicylic acid (aspirin, Bayer Leverkusen)
 Direct thrombin inhibitors (DTIs) (argatroban, lepirudin and hirudin )
 HIT alternative

Biology of fracture healing

Anticoagulants on fracture healing (in vivo)
LMWH
Study #1
Warfarin
*Worst union delay with earlier Rx
Heparin
*Worst union delay with earlier Rx
Study #2
Aspirin
NO LONGER
CLINICAL
Study #3 Hard callus formation
(>soft)
Study #4
Study #5
Bone formation & strength
No impair
Study #6
Study #7
Bone formation
No impair No impair
No impair

Anticoagulants on bone biology
(in vivo)
Heparin LMWH
Study #1
Warfarin
Bone form/resorb
(osteocalcin)
Study #2
Study #3
Study #4
Cancellous bone
(inc resorb, dec form)
Same as #3
*Prolonged effects ≥56days
Cancellous bone
(dec form only)
Same as #3
Study #5 Bone volume and strength
(both ends)
Study #6 Bone mineral content
Not significant

Anticoagulants on bone cells (in vitro)
Heparin
Study #1 Bone nodule formation
(greater osteoporosis risk than LMWH)
Study #2 Cell concentration
(osteoblast growth)
Study #3 Gene expression
LMWH
Bone nodule formation
Cell concentration
(osteoblast growth)
Gene expression
Fondaparinux
*Inc matrix calcium/type 1 collagen)
Study #4 *Biphasic effect (low vs high dose)
Study #5 Osteoblast/gene expression (4x)
Study #6
Study #7
Study #8 Osteoclast formation
Osteoblast/gene expression
Blast prolif, protein synthesis, osteocalcin
Osteoblast/osteocalcin
No inhib

Discussion
 Anticoagulants impair fracture healing and bone health
 All different stages in healing
Considerations
 Type
 Heparin, Warfarin, and aspirin are worst
 LMWHs are better
 Fondaparinux is best per this review
(further study required)
 Dosage
 Less is more
 Onset
 Immediate = worst
 Early mechanical thromboprophylaxis
 Duration
 Early termination in patients with provoked PE

Study Limitations
 Lack of clinical studies
 Must assume adequate comparison between animal and human
 Unknown degree/significance of effects
 Variable mechanisms expressed
 Method for study selection
 Not systematic

According to the research…

Short term
 NO
 Ambulation recommended. Begin addressing his problem list without restriction (once properly anticoagulated)
 Length of stay not increased
 Patient will have altered WB status with or without anticoagulants

Long Term
 (+) Provoked = lower risk of reoccurrence
 No issue resuming independence with work and ADLs
 (-) Provoked = prescribed anticoagulants for 3-6 months…
 Delay fx healing  delay normal WB progression?
 Residual effects?
 NO CONCLUSION on severity and duration of Heparin effects
 Patient education of potential risk
 Slower progression of WB and return to running
 Imaging?

Union delays
Bone strength
Osteoblast
Osteoclast
Heparin LMWH Warfarin Aspirin Fondaparinux

Heparin
-Delayed unions
-Bone formation
LMWH Warfarin
-Delayed unions
-Soft callus > hard callus
Fondaparinux