eMedicine Specialties > Physical Medicine and Rehabilitation > Spinal Cord Injury
Prevention of Thromboembolism in Spinal Cord Injury: Treatment & Medication
Updated: Jan 13, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
The high risk of thromboembolic complications makes routine prophylaxis in spinal cord injury (SCI) patients essential.5 The prevention of deep vein thrombosis (DVT) and its sequelae is an important aspect of treatment for patients who have sustained SCI.
Mechanical modalities have been shown to be effective for reducing the incidence of DVT in acute SCI patients, although they must be used in conjunction with anticoagulation therapy.5 Prior to applying mechanical compression, tests to exclude the presence of lower extremity DVT should be undertaken if thromboprophylaxis has been delayed for more than 72 hours after injury. Mechanical modalities include the following6 :
- Compression hose (elastic stockings)
- Distribute pressure uniformly over the extremity
- Improve lower extremity venous return
- Help to control edema
- Require that the integrity of underlying skin be examined daily
- Are ineffective alone
- Use with all patients for the first 2 weeks following injury.
- No known study evaluating whether the incidence of DVT is different in patients wearing thigh-length elastic stockings than it is in those wearing the calf-length type
- External pneumatic devices
- Mode of compression - Graded sequential, multicompartment uniform, or single-chamber uniform pressures
- Improve lower extremity venous return
- Ineffective alone
- For use in all patients for the first 2 weeks following injury
- May be knee or thigh length
- Contraindicated in patients with severe arterial insufficiency
- Venous foot pumps - Because these have not been studied in larger trials or in SCI patients, their efficacy in the prevention of DVT in this population has not been established.
- Range of motion (ROM)
- Active and passive ROM reduce lower extremity stasis.
- Some indirect evidence exists that ROM could be beneficial in the prevention of DVT.
- ROM is ineffective alone
- Electrical stimulation
- Mechanically stimulates dorsiflexion and plantar flexion of the lower extremity
- Reduces lower extremity stasis
- Is ineffective alone
- Must be used 24 hours per day, hindering the patient's ability to participate in therapies
- Stimulation is painful in sensate patients.
- This modality has not been fully established by the medical literature.
- Pharmacologic prophylaxis - All patients should be on some type of anticoagulation therapy (see Medication for details).
Surgical Care
- Vena cava filter11
- Indicated in patients who have not achieved success with anticoagulant prophylaxis or who have a contraindication to anticoagulation
- Not a substitute for thromboprophylaxis, due to the morbidity related to deep vein thrombosis (eg, postphlebitic syndrome) and the propagation of vena caval embolisms
- Possible complications include vena caval thrombosis, filter migration, and vena caval perforation.
- Thromboembolectomy - This is indicated when anticoagulant therapy is ineffective, unsafe, or contraindicated. A thromboembolectomy can be performed to restore venous patency.
Activity
The amount of time needed for bedrest and for the discontinuation of lower extremity ROM has been debated in the literature. Most widely accepted evidence suggests mobilization of the patient 24-72 hours after the injury and maintenance of the individual on IV heparin, with an international normalized ratio (INR) goal of greater than 2.
Medication
The prevention of pulmonary embolism is the primary reason why the diagnosis and treatment of venous thrombosis are urgent. Historically, low-dose heparin has been used for deep vein thrombosis (DVT) prophylaxis, but many studies demonstrate that low–molecular weight heparin (LMWH) is superior for the prevention of thromboembolism.6,7,8,9,10 External pneumatic devices alone are not effective for DVT prevention. The Consortium for Spinal Cord Medicine developed clinical practice guidelines (CPG) for the prevention of thromboembolism in spinal cord injury (SCI), based on the best available scientific evidence.12,13
Limited evidence exists to support the use of adjusted-dose heparin versus LMWH therapy in patients with acute SCI.7,8 The CPG recommends adjusted-dose heparin or LMWH for anticoagulant prophylaxis.12,13 Studies have shown that the incidence of DVT is significantly lower when one of these anticoagulants is administered within 72 hours after SCI, provided that there is no active bleeding, evidence of head injury, or coagulopathy. Low-dose heparin therapy, external pneumatic devices, or compression stockings provide inadequate protection when used alone, but they are of benefit when used in combination in patients with SCI.
Anticoagulants
Subcutaneous anticoagulants at specified intervals inhibit factors X and XI in the clotting cascade, resulting in a decrease in the generation of thrombin and a reduction in clot formation. In the case of an already formed thrombosis, anticoagulation prevents further clot formation and allows the body's autolytic system to effectively lyse and heal deep vein thrombosis.7,8,14,15,16
Related eMedicine topics:
Factor X
Factor XI Deficiency
Heparin
Augments the activity of antithrombin III and prevents the conversion of fibrinogen to fibrin.
Adult
Fixed dose: Usually 5,000 U SC q12h-q8h; ineffective alone for DVT prophylaxis
Adjusted dose: Based on patient's weight and requires monitoring of prothrombin time to maintain at 1.5-2 times control (doses averaging 13,200 U SC q12h); increased risk for hemorrhage; IM use not recommended
Treat uncomplicated complete motor patients for 8 wk; treat complete motor injury patients with other risk factors for 12 wk
Pediatric
Not established
Digoxin, nicotine, tetracycline, and antihistamines may decrease effects; NSAIDs, ASA, dextran, dipyridamole, and hydroxychloroquine may increase heparin toxicity
Documented hypersensitivity; subacute bacterial endocarditis, active bleeding, history of heparin-induced thrombocytopenia
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in severe hypotension and shock; monitor blood coagulation tests, platelets, hematocrit, and for occult blood in stool
Enoxaparin (Lovenox)
Enhances the inhibition of factor Xa and thrombin by increasing antithrombin III activity. In addition, enoxaparin preferentially increases the inhibition of factor Xa. This product has been FDA approved for the prophylaxis of thrombosis in patients undergoing surgical procedures on the abdomen, pelvis, hip, and knee; it is more efficacious for prophylaxis than is low-dose unfractionated heparin. Enoxaparin has fewer bleeding complications, as well as a longer half-life and more bioavailability, than does unfractionated heparin. Because there is no requirement for monitoring, enoxaparin is suitable for home treatment.
Adult
30 mg SC q12h
Pediatric
Not established
Oral anticoagulants or platelet inhibitors, such as dipyridamole, salicylates, aspirin, NSAIDs, sulfinpyrazone, and ticlopidine, may increase risk of bleeding
Documented hypersensitivity to heparin or pork products, major bleeding, and thrombocytopenia associated with antiplatelet antibody in presence of enoxaparin
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
If thromboembolic event occurs despite LMWH prophylaxis, discontinue drug and initiate alternate therapy; elevation of hepatic transaminases may occur but is reversible; heparin-associated thrombocytopenia may occur with fractionated LMWH; 1 mg of protamine sulfate will reverse effect of approximately 1 mg of enoxaparin if significant bleeding complications develop; caution in thrombocytopenia, severe uncontrolled hypertension, bacterial endocarditis, bleeding disorders, hemorrhagic stroke, and recent brain, spinal, or ophthalmic surgery
Dalteparin (Fragmin)
Enhances the inhibition of factor Xa and thrombin by increasing antithrombin III activity. In addition, dalteparin preferentially increases the inhibition of factor Xa.
Adult
5000 IU SC qd
Pediatric
Not established
Platelet inhibitors or oral anticoagulants, such as dipyridamole, salicylates, aspirin, NSAIDs, sulfinpyrazone, and ticlopidine, may increase risk of bleeding
Documented hypersensitivity to heparin or pork products, major bleeding, and thrombocytopenia
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
If thromboembolic event occurs despite LMWH prophylaxis, discontinue drug and initiate alternate therapy; elevation of hepatic transaminases may occur but is reversible; heparin-associated thrombocytopenia may occur with fractionated LMWH; 1 mg of protamine sulfate will reverse effect of approximately 1 mg of dalteparin if significant bleeding complications develop; caution in thrombocytopenia, severe uncontrolled hypertension, bacterial endocarditis, bleeding disorders, hemorrhagic stroke, and recent brain, spinal, or ophthalmic surgery
Warfarin (Coumadin)
Interferes with the hepatic synthesis of vitamin K – dependent coagulation factors. Warfarin is used for the prophylaxis and treatment of venous thrombosis, pulmonary embolism, and thromboembolic disorders. Adjust the dose as needed to maintain an INR in the range of 2 to 3.
Adult
2-5 mg/d PO qd initial dose; 2-10 mg/d PO maintenance dose; adjust dose according to desired INR
Pediatric
Not established
Drugs that may decrease anticoagulant effects include griseofulvin, carbamazepine, glutethimide, estrogens, nafcillin, phenytoin, rifampin, barbiturates, cholestyramine, colestipol, vitamin K, spironolactone, oral contraceptives, and sucralfate; medications that may increase anticoagulant effects of warfarin include oral antibiotics, phenylbutazone, salicylates, sulfonamides, chloral hydrate, clofibrate, diazoxide, anabolic steroids, ketoconazole, ethacrynic acid, miconazole, nalidixic acid, sulfonylureas, allopurinol, chloramphenicol, cimetidine, disulfiram, metronidazole, phenylbutazone, phenytoin, propoxyphene, sulfonamides, gemfibrozil, acetaminophen, and sulindac
Documented hypersensitivity; severe liver or kidney disease; open wounds or GI ulcers
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Do not switch brands after achieving therapeutic response; caution in active tuberculosis or diabetes; patients with protein C or S deficiency are at risk of developing skin necrosis
Fondaparinux (Arixtra)
Selectively binds to antithrombin III and potentiates the neutralization of factor Xa. The neutralization of factor Xa interrupts the blood coagulation cascade and thus inhibits thrombin formation and thrombus development.
Adult
2.5 mg SC qd
Pediatric
Not established
None reported; increased risk of bleeding possible with concurrent administration of platelet inhibitors, oral anticoagulants, or thrombolytic agents
Documented hypersensitivity; seriously impaired kidney function (CrCl <30 mL/min) or in patients who weigh <110 lb; patients given spinal anesthesia or spinal puncture; active bleeding, bacterial endocarditis, thrombocytopenia associated with positive in vitro test for antiplatelet antibody in presence of fondaparinux therapy
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
When spinal anesthesia or spinal puncture is used, may develop blood clot in spine, which can result in long-term or permanent paralysis (holding 2 doses prior to LP or surgery is recommended); major bleeding risk increased when initiated before 6 h following surgery; elimination decreased in elderly and renal impairment
Thrombolytics
The use of thrombolytic therapy (eg, t-PA, urokinase, streptokinase) in patients with spinal cord injury for the treatment of deep vein thrombosis and pulmonary embolism has not been established.
Urokinase (Abbokinase)
Direct plasminogen activator that acts on the endogenous fibrinolytic system and converts plasminogen to the enzyme plasmin, which in turn degrades fibrin clots, fibrinogen, and other plasma proteins.
Adult
Loading dose: 4400 U/kg IV over 10 min and increase to 6000 U/kg/h
Maintenance dose: 4400-6000 U/kg/h IV
Pediatric
Not established
Thrombolytic enzymes, alone or in combination with anticoagulants and antiplatelets, may increase risk of bleeding complications
Documented hypersensitivity; internal bleeding, recent trauma, history of intracranial or intraspinal surgery or trauma, cerebrovascular accident, intracranial neoplasm, AV malformation, aneurysm, bleeding diathesis, severe uncontrolled hypertension
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in patients receiving intramuscular administration of medications, severe hypertension, trauma, or surgery in previous 10 d; avoid dislodging possible deep vein thrombi, do not measure blood pressure in lower extremities; monitor therapy by performing PT, aPTT, TT, or fibrinogen approximately 4 h after initiation of therapy
Streptokinase (Kabikinase, Streptase)
Acts with plasminogen to convert plasminogen to plasmin. Plasmin degrades fibrin clots, as well as fibrinogen and other plasma proteins. An increase in fibrinolytic activity that degrades fibrinogen levels for 24-36 h takes place with IV infusion of streptokinase.
Adult
Loading dose: 250,000 U IV over 30 min
Maintenance: 100,000 U/h IV for 24-72 h
Pediatric
Not established
Antifibrinolytic agents may decrease effects of streptokinase; heparin, warfarin, and aspirin may increase risk of bleeding
Documented hypersensitivity; active internal bleeding, intracranial neoplasm, aneurysm, diathesis, and severe uncontrolled arterial hypertension
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in severe hypertension, intramuscular administration of medications, trauma, or surgery in the previous 10 days; measure hematocrit, platelet count, aPTT, TT, PT, or fibrinogen levels before therapy is implemented; either TT or aPTT should be less than twice the normal control value following infusion of streptokinase and before (re)instituting heparin; do not take blood pressure in the lower extremities, as it may dislodge a possible deep vein thrombus; PT, aPTT, TT, or fibrinogen should be monitored 4 h after initiation of therapy
Alteplase (Activase)
Tissue plasminogen activator used in the management of acute myocardial infarction, acute ischemic stroke, and pulmonary embolism.
Adult
Infuse 0.9 mg/kg (not to exceed 90 mg) over 60 min, with 10% of total dose administered as initial IV bolus over 1 min
Pediatric
Not established
Drugs that alter platelet function (eg, aspirin, dipyridamole, abciximab) may increase risk of bleeding prior to, during, or after alteplase therapy; may give heparin with and after alteplase infusions to reduce risk of recurrence of thrombosis; either heparin or alteplase may cause bleeding complications
Documented hypersensitivity; active internal bleeding, cerebrovascular accident or stroke within last 2 mo, intracranial or intraspinal surgery or trauma, intracranial hemorrhage on pretreatment evaluation, suspicion of subarachnoid hemorrhage, intracranial neoplasm, AV malformation or aneurysm, bleeding diathesis, or severe uncontrolled hypertension
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Monitor for bleeding, especially at arterial puncture sites, with coadministration of vitamin K antagonists; control and monitor blood pressure frequently during and following alteplase administration (when managing acute ischemic stroke); do not use >0.9 mg/kg to manage acute ischemic stroke; doses >0.9 mg/kg may cause ICH
More on Prevention of Thromboembolism in Spinal Cord Injury |
| Overview: Prevention of Thromboembolism in Spinal Cord Injury |
| Differential Diagnoses & Workup: Prevention of Thromboembolism in Spinal Cord Injury |
 Treatment & Medication: Prevention of Thromboembolism in Spinal Cord Injury |
| Follow-up: Prevention of Thromboembolism in Spinal Cord Injury |
| References |
| « Previous Page | Next Page » |
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Further Reading
Keywords
deep venous thrombosis, embolism, DVT, pulmonary embolism, spinal cord injury, clot, blood clot, blood clots, paralysis, spinal cord, spinal, platelet, platelets, thromboembolism, vein thrombosis, deep vein thrombosis, venous thrombosis, anticoagulation, paraplegia, thromboembolic disease, vein thrombosis treatment, venous thrombosis treatment
