Devi Bavishi

Background: Best practice guidelines from trauma-focused organizations support early (<72 hours) venous thromboembolism (VTE) chemoprophylaxis initiation in traumatic brain injury (TBI) patients. Recent literature suggests that an even more aggressive initiation (24 hours) is safe and efficacious. It is unknown how current practice aligns with the existing literature and best practice guidelines. We performed a national survey to characterize variation in trauma surgeons’ reported practices and attitudes regarding VTE chemoprophylaxis initiation in TBI patients with the hypothesis that they will vary widely. Methods: All 1700 American Association for the Surgery of Trauma members were surveyed online. Members who routinely cared for patients with TBI were asked to proceed with the survey. Descriptive data were reported. The questions characterized institutional guidelines, and if none existed, individual practice patterns regarding goal timeline of VTE chemoprophylaxis in TBI patients. Results: 374 members (22%) completed the survey. Most respondents worked at academic institutions (40%) and represented a level one trauma center (44%). Enoxaparin was the most common VTE chemoprophylactic (73%) with most using weight-based dosing (76%) and anti-Xa testing (75%). Institutional policies that included a protocol for VTE chemoprophylaxis initiation in TBI patients were used by 86% of respondents. In those with established protocols, 59% reported being mostly compliant. Reasons for delay of VTE chemoprophylaxis included worry about progression of TBI and disagreement with consulting services. 293 (80%) of respondents reported protocolized repeat head CT within 4–12 hours after initial CT (60%). In response to a clinical scenario, 43% of respondents reported that their goal timeline for initiating VTE prophylaxis was within 24 hours of a stable head CT. Conclusions: Despite national guidelines, substantial variation remains in the timing of VTE chemoprophylaxis in TBI patients. Passive strategies, such as institutional guidelines alone, are insufficient. Institutions must adopt more effective implementation tactics—including protocol-enforced order sets, automated clinical decision support, and shared governance models with ancillary services—to ensure timely, evidence-based care. Level of evidence: Level V.

Objectives: Patients with traumatic intracranial hemorrhage (ICH) often undergo early stability CT scans to evaluate for progression of bleeding. The factors associated with progression after initiating venous thromboembolism (VTE) chemoprophylaxis (CP) remain poorly described. This study aimed to determine the rate of and factors associated with ICH progression following CP initiation. Methods: This retrospective observational study included adult (≥16 years) polytrauma patients with blunt or penetrating traumatic brain injury (TBI) admitted between September 2016 and December 2021. Progression was defined as a radiographic increase in ICH following VTE CP initiation, determined by neurosurgery or radiology faculty. Postprophylaxis CT scans were obtained based on clinical deterioration. Associated factors, neurosurgical intervention rates, and outcomes were evaluated. Results: Among 1390 included patients, ICH progression occurred in 3% (43) following CP initiation. Patients with progression were older (55 vs 45 years) and had higher injury severity scores (33 vs 27; p<0.05). Rates of pneumonia (49% vs 21%) and sepsis (19% vs 9%) were higher in the progression group (p<0.05). There was no difference between groups in time to prophylaxis initiation (40 vs 38 hours), survival (88% vs 92%), or VTE incidence (0% vs 4%; all p=NS). Factors associated with progression included midline shift (21% vs 6%), subdural hematoma (47% vs 26%), and prior progression on 6-hour stability CT (64% vs 34%; p<0.05). Multivariate analysis confirmed these findings. Among progression patients, 9% required intervention after CP, with only two requiring craniotomy. Conclusions: ICH progression is rare (3%) after VTE CP initiation. Associated factors align with spontaneous progression, suggesting that ICH progression is independent of early VTE prophylaxis (<48 hours). These findings support the safety of early VTE CP as the standard of care for mitigating VTE risk in TBI patients with TBI. Level of evidence: Level III, retrospective study with up to two negative criteria.

Blunt cardiac injury is a rare but potentially a highly lethal complication of blunt thoracic trauma, with a broad spectrum of presentations and structural injuries, including traumatic ventricular septal defects (VSDs). We report the case of an early adolescent female who sustained a traumatic VSD and right ventricular aneurysm following a jet ski accident without any traditional signs of cardiac injury on presentation. This case highlights the rarity of traumatic VSDs and right ventricular aneurysms, the challenges in management, and the need for early diagnosis and intervention in preventing further cardiac deterioration.