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cardio.dvt.spinal-cord-injury.v1

Spinal-cord-injury DVT/VTE (highest-risk; LMWH within 24-72 h, IPC adjunct, no routine IVC filter)

cardiologyacuteadultacuteinpatienttransitionoutpatient
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Phase E variant of cardio.dvt.core.v1 — narrowed to acute/subacute spinal-cord-injury VTE, among the highest-risk conditions in medicine (~50-100% untreated DVT, symptomatic VTE ~10-15%, risk peaking days 7-14 and elevated ~3 months). Pure Virchow's triad: paralytic stasis + acute-injury hypercoagulability + endothelial activation. KEY DIFFERENCES FROM PARENT: the dominant decision is prophylaxis. LMWH is the agent of choice, started 24-72 h post-injury once haemostasis is secured (deferred across an unsecured spinal column / active bleed due to spinal epidural haematoma risk), with IPC as an adjunct from admission and the bridge when pharmacologic prophylaxis is contraindicated. Prophylaxis duration ~8-12 weeks (longer if persistently immobile/complete motor injury). Routine/prophylactic IVC filters are NOT recommended (PVA CPG; PREPIC2) — reserved only for proven proximal VTE with an absolute ongoing AC contraindication and retrieved when AC becomes feasible. Clinical detection is unreliable (sensory level abolishes pain; neurogenic oedema confounds swelling) so surveillance US + a low threshold for PE imaging are essential; a new VTE is itself a potent autonomic-dysreflexia trigger and the two plans must be coordinated (see cardio.hypertensive-emergency.autonomic-dysreflexia.v1). Manifest pointer reuses cardio.dvt.core.v1 manifest. Design-brief pointer reuses parent (SCI-specific differences documented inline). AC timing must be reconciled with neurosurgical/spinal-stabilisation timelines. Status INTEGRATED. Authored 2026-05-15 by shard-06-cardio-acute as spinal-cord-injury DVT/VTE variant. Sister-differentiated from core, long-term-immobilization, and the linked autonomic-dysreflexia engine.

Entry points (6)

  • history
    Acute traumatic or non-traumatic SCI within the first ~3 months — prophylaxis-decision pathway triggered (VTE risk among the highest of any condition)
    acute_spinal_cord_injury_within_first_3_months
  • symptom
    New unilateral lower-limb swelling/warmth in an SCI patient — DVT despite absent pain (sensory level abolishes the classic symptom)
    unilateral_limb_swelling_in_sci_patient
  • vital_abnormality
    Unexplained tachypnoea, hypoxaemia, tachycardia or new autonomic dysreflexia in an SCI patient — occult pulmonary embolism until excluded
    unexplained_tachypnoea_or_desaturation_in_sci_patient
  • imaging
    Surveillance compression ultrasound detecting proximal DVT in an acute SCI patient — route to SCI-specific treatment + duration logic
    surveillance_us_proximal_dvt_in_sci
  • problem_list
    SCI patient with active bleeding / unstable coexisting injury contraindicating pharmacologic prophylaxis — mechanical-prophylaxis + reassessment pathway
    sci_with_contraindication_to_pharmacologic_prophylaxis
  • history
    SCI patient with breakthrough VTE on prophylaxis or prior VTE — escalation + IVC-filter-restraint decision pathway
    sci_with_prior_vte_or_failed_prophylaxis

Required inputs (10)

  • agerequired
    demographic • used at CONTEXT
    Older SCI patients carry additive VTE and bleeding risk; influences prophylaxis intensity and duration
  • sex
    demographic • used at CONTEXT
    Reproductive planning and oestrogen-exposure counselling in SCI women; pregnancy alters agent choice (LMWH)
  • level_and_completeness_and_timing_of_scirequired
    history • used at FRAME
    Complete motor injury + acute phase = peak VTE risk; injury timing sets the prophylaxis-initiation window (24-72 h after haemostasis) and duration (~8-12 weeks)
  • active_bleeding_or_unstable_coexisting_injuryrequired
    history • used at RED_FLAGS
    Solid-organ injury, intracranial haemorrhage, ongoing surgical bleeding, or unsecured spinal column contraindicate early pharmacologic prophylaxis and mandate mechanical bridging
  • spinal_surgery_or_stabilisation_timelinerequired
    history • used at CONTEXT
    Neurosurgical/orthopaedic stabilisation timing must be reconciled with prophylactic and therapeutic anticoagulation start/hold
  • leg_swellingrequired
    symptom • used at ENTRY
    Cardinal DVT sign; pain is abolished by the sensory level so swelling/asymmetry and surveillance dominate detection
  • compression_usrequired
    imaging • used at INITIAL_WORKUP
    First-line confirmation; also used for surveillance given unreliable clinical signs in SCI
  • creatininerequired
    lab • used at TREATMENT
    eGFR for LMWH dose adjustment (CrCl <30 → reduced regimen) and contrast use during PE imaging
  • cbcrequired
    lab • used at INITIAL_WORKUP
    Baseline + serial platelets (HIT surveillance on heparins) and haemoglobin for bleeding surveillance
  • bleed_riskrequired
    history • used at RED_FLAGS
    Drives the pharmacologic-vs-mechanical prophylaxis decision and treatment-dose timing relative to surgery

12-phase flow (11)

  1. 1FRAME
    Acute SCI = near-maximal Virchow's-triad VTE substrate (stasis from paralysis + hypercoagulable injury state + endothelial activation); untreated DVT incidence ~50-100%. Two parallel questions: (a) prophylaxis strategy/timing for the at-risk patient, (b) treatment + duration for confirmed VTE
    inputs: level_and_completeness_and_timing_of_sci
    advance: SCI VTE phenotype + clinical question framed
  2. 2ENTRY
    Wells DVT score (limited utility — pain absent below the lesion); compression US for symptoms or surveillance; baseline limb circumferences (distinguish neurogenic oedema from DVT swelling); screen for PE features (tachypnoea, desaturation, AD)
    inputs: leg_swelling
    advance: pretest assessment + baseline limb metrics documented
  3. 3CONTEXT
    SCI level/completeness/timing; coexisting trauma; spinal-stabilisation surgery timeline; mobility status; renal function; prior VTE/prophylaxis failure; pregnancy; concurrent autonomic-dysreflexia phenotype (a new DVT is itself an AD trigger)
    inputs: age, spinal_surgery_or_stabilisation_timeline
    advance: context complete
  4. 4RED_FLAGS
    Active bleeding / unstable coexisting injury / unsecured spinal column (pharmacologic-prophylaxis contraindication → mechanical bridge); massive or submassive PE; phlegmasia; HIT; absolute AC contraindication with proven proximal VTE (the only IVC-filter indication)
    inputs: active_bleeding_or_unstable_coexisting_injury, bleed_risk
    actions: pe_full
    advance: bleeding-risk + life-threatening features adjudicated
  5. 5INITIAL_WORKUP
    Compression US (diagnostic or surveillance) + CBC + BMP + coagulation panel; CXR/ABG if respiratory features; baseline platelets for heparin HIT surveillance; CTPA if PE suspected (clinical detection unreliable in SCI — low threshold)
    inputs: compression_us, cbc, creatinine
    actions: panel.cardiac, panel.coag, panel.abg
    advance: imaging + baseline labs available
  6. 6BRANCHING_WORKUP
    Extent of DVT (proximal vs distal); CTPA for suspected PE; bilateral lower-limb duplex (high bilateral-DVT rate in SCI); HIT 4T score + anti-PF4 if platelets fall on heparin; reconcile findings with spinal-surgery timeline for AC timing
    inputs: bleed_risk
    actions: panel.renal
    advance: VTE extent + PE status + HIT status established
  7. 7RISK_STRATIFICATION
    Stratify by injury completeness/level, mobility trajectory, bleeding risk, renal function. Decide: pharmacologic prophylaxis (LMWH preferred) vs mechanical-only bridge; treatment-dose AC for confirmed VTE; duration ~8-12 weeks prophylaxis (longer if persistently immobile/complete motor injury); treatment ≥3 months for provoked SCI-VTE with reassessment of ongoing risk
    inputs: bleed_risk
    actions: calc.ckd_epi_2021
    advance: prophylaxis/treatment strategy + duration plan documented
  8. 8TREATMENT
    Prophylaxis: LMWH (e.g., enoxaparin 40 mg SC daily; weight/renal-adjusted) started 24-72 h post-injury once haemostasis secured + IPC adjunct from admission; mechanical-only if pharmacologic contraindicated, then add LMWH when bleeding risk acceptable. Treatment of confirmed VTE: therapeutic LMWH (1 mg/kg SC BID; reduce if CrCl <30) — DOAC acceptable for stable patients without contraindication once spinal-surgery bleeding window passed; warfarin after LMWH bridge if preferred. NO routine IVC filter; reserve retrievable filter for proven proximal VTE with absolute ongoing AC contraindication and remove when AC feasible
    inputs: creatinine, bleed_risk
    advance: prophylaxis or treatment initiated with timing reconciled to surgery + IVC-filter restraint applied
  9. 9DISPOSITION
    Acute SCI VTE management is inpatient (often ICU/spinal unit). Confirmed VTE rarely outpatient in the acute phase; rehabilitation-phase VTE may be co-managed on the SCI rehab unit with anticoagulation continued
    advance: disposition documented
  10. 10MONITORING
    Serial platelet counts (HIT surveillance days 4-14 on heparins); haemoglobin/bleeding surveillance; renal function for LMWH dosing; limb reassessment + surveillance US per unit protocol; PE vigilance (desaturation, tachypnoea, new AD); Villalta PTS later for post-thrombotic syndrome
    actions: panel.cardiac, panel.coag
    advance: monitoring schedule active without bleeding/HIT
  11. 11FOLLOWUP
    SCI rehab + haematology co-management: complete the ~8-12-week prophylaxis course (extend if persistently immobile); for treated VTE complete ≥3-month course and reassess ongoing provoking risk; remove any retrievable IVC filter once AC feasible; reproductive counselling (oestrogen avoidance) for women; PTS surveillance; reconcile with the autonomic-dysreflexia plan (DVT is an AD trigger)
    advance: prophylaxis/treatment duration plan + filter-removal + rehab co-management documented