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Lethal Trauma Pulmonary Embolism Is a Black Swan Event in Patients at Risk for Deep Vein Thrombosis: An Evidence-Based Review.

Abstract We delineated the incidence of trauma patient pulmonary embolism (PE) and risk conditions by performing a systematic literature review of those at risk for deep vein thrombosis (DVT). The PE proportion was 1.4 per cent (95% confidence interval = 1.2-1.6) in at-risk patients. Of 10 conditions, PE was only associated with increased age (P < 0.01) or leg injury (P < 0.01; risk ratio = 1.6). As lower extremity DVT (LEDVT) proportions increased, mortality proportions (P = 0.02) and hospital stay (P = 0.0002) increased, but PE proportions did not (P = 0.13). LEDVT was lower with chemoprophylaxis (CP) (4.9%) than without CP (19.1%; P < 0.01). PE was lower with CP (1.0%) than without CP (2.2%; P = 0.0004). Mortality was lower with CP (6.6%) than without CP (11.6%; P = 0.002). PE was similar with (1.2%) and without (1.9%; P = 0.19) mechanical prophylaxis (MP). LEDVT was lower with MP (8.5%) than without MP (12.2%; P = 0.0005). PE proportions were similar with (1.3%) and without (1.5%; P = 0.24) LEDVT surveillance. Mortality was higher with LEDVT surveillance (7.9%) than without (4.8%; P < 0.01). A PE mortality of 19.7 per cent (95% confidence interval = 18-22) × a 1.4 per cent PE proportion yielded a 0.28 per cent lethal PE proportion. As PE proportions increased, mortality (P = 0.52) and hospital stay (P = 0.13) did not. Of 176 patients with PE, 76 per cent had no LEDVT. In trauma patients at risk for DVT, PE is infrequent, has a minimal impact on outcomes, and death is a black swan event. LEDVT surveillance did not improve outcomes. Because PE was not associated with LEDVT and most patients with PE had no LEDVT, preventing, diagnosing, and treating LEDVT may be ineffective PE prophylaxis.
PMID
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Authors

Mayor MeshTerms
Keywords
Journal Title the american surgeon
Publication Year Start




PMID- 28424139
OWN - NLM
STAT- MEDLINE
DA  - 20170420
DCOM- 20170501
LR  - 20170501
IS  - 1555-9823 (Electronic)
IS  - 0003-1348 (Linking)
VI  - 83
IP  - 4
DP  - 2017 Apr 01
TI  - Lethal Trauma Pulmonary Embolism Is a Black Swan Event in Patients at Risk for
      Deep Vein Thrombosis: An Evidence-Based Review.
PG  - 403-413
AB  - We delineated the incidence of trauma patient pulmonary embolism (PE) and risk
      conditions by performing a systematic literature review of those at risk for deep
      vein thrombosis (DVT). The PE proportion was 1.4 per cent (95% confidence
      interval = 1.2-1.6) in at-risk patients. Of 10 conditions, PE was only associated
      with increased age (P &lt; 0.01) or leg injury (P &lt; 0.01; risk ratio = 1.6). As
      lower extremity DVT (LEDVT) proportions increased, mortality proportions (P =
      0.02) and hospital stay (P = 0.0002) increased, but PE proportions did not (P =
      0.13). LEDVT was lower with chemoprophylaxis (CP) (4.9%) than without CP (19.1%; 
      P &lt; 0.01). PE was lower with CP (1.0%) than without CP (2.2%; P = 0.0004).
      Mortality was lower with CP (6.6%) than without CP (11.6%; P = 0.002). PE was
      similar with (1.2%) and without (1.9%; P = 0.19) mechanical prophylaxis (MP).
      LEDVT was lower with MP (8.5%) than without MP (12.2%; P = 0.0005). PE
      proportions were similar with (1.3%) and without (1.5%; P = 0.24) LEDVT
      surveillance. Mortality was higher with LEDVT surveillance (7.9%) than without
      (4.8%; P &lt; 0.01). A PE mortality of 19.7 per cent (95% confidence interval =
      18-22) x a 1.4 per cent PE proportion yielded a 0.28 per cent lethal PE
      proportion. As PE proportions increased, mortality (P = 0.52) and hospital stay
      (P = 0.13) did not. Of 176 patients with PE, 76 per cent had no LEDVT. In trauma 
      patients at risk for DVT, PE is infrequent, has a minimal impact on outcomes, and
      death is a black swan event. LEDVT surveillance did not improve outcomes. Because
      PE was not associated with LEDVT and most patients with PE had no LEDVT,
      preventing, diagnosing, and treating LEDVT may be ineffective PE prophylaxis.
FAU - Dunham, C Michael
AU  - Dunham CM
FAU - Huang, Gregory S
AU  - Huang GS
LA  - eng
PT  - Journal Article
PT  - Review
PL  - United States
TA  - Am Surg
JT  - The American surgeon
JID - 0370522
SB  - IM
MH  - Humans
MH  - Incidence
MH  - Leg Injuries/complications
MH  - Pulmonary Embolism/*etiology/*mortality/prevention &amp; control
MH  - Risk Factors
MH  - Venous Thrombosis/*complications/prevention &amp; control
MH  - Wounds and Injuries/*complications
EDAT- 2017/04/21 06:00
MHDA- 2017/05/02 06:00
CRDT- 2017/04/21 06:00
PST - ppublish
SO  - Am Surg. 2017 Apr 1;83(4):403-413.

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