Traumatic Brain Injury

1. Enoxaparin 30mg SQ twice daily remains the dosing of choice.

2. Prior to starting chemical VTE prophylaxis in TBI patients:

a. Consult a neurosurgeon.

b. Obtain CT scan of the head 24 hours post injury to assess for intracranial hemorrhage stability.

3. Prophylaxis should be withheld in the setting of progression of intracranial hemorrhage or presence of an intracranial monitor.

4. In patients with stable intracranial hemorrhage on repeat head CT, initiating chemical VTE prophylaxis 24-72 hours following traumatic brain injury does not increase the progression of intracranial hemorrhage.26,27

5. Initiating VTE chemical prophylaxis is recommended in TBI patients with a stable head CT 24 hours after injury. Even in the setting of combat related penetrating TBI, for those patients with a stable repeat head CT, initiating pharmacologic prophylaxis 24 hours after injury was safe, with similar rates of progression.34 Caution should be taken in starting chemical VTE prophylaxis 24 hours post injury and discussion with neurosurgeon is recommended for TBI patients with the following conditions:

a. Polytrauma with or at risk for coagulopathy

b. Have intracranial monitor/drain in place.

c. Have one or more of the following TBI features that are “high risk” for progression according to the Norwood-Berne criteria:

SDH > 8mm

Epidural hemorrhage > 8mm

Largest single contusion > 2cm

More than one contusion per lobe

Diffuse or scattered subarachnoid hemorrhage.

Diffuse or scattered intraventricular hemorrhage.

For these patients, chemical VTE prophylaxis is typically restarted 72 hours post-injury or from last stable CT head, or as neurosurgeon recommends. 35,36

6. Avoid interruptions in dosing for TBI patients who are started on chemical VTE prophylaxis. Interrupted dosing in this patient population causes a 600% increase in the VTE rate.37