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cardio.dvt.spinal-cord-injury.v1PRODUCTION
cardio.dvt.spinal-cord-injury.v1

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

cardiologyacuteadult
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11/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

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

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SCI VTE phenotype + clinical question framed

Patient inputs (10)

Older SCI patients carry additive VTE and bleeding risk; influences prophylaxis intensity and duration

Neurosurgical/orthopaedic stabilisation timing must be reconciled with prophylactic and therapeutic anticoagulation start/hold

Cardinal DVT sign; pain is abolished by the sensory level so swelling/asymmetry and surveillance dominate detection

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)

First-line confirmation; also used for surveillance given unreliable clinical signs in SCI

Baseline + serial platelets (HIT surveillance on heparins) and haemoglobin for bleeding surveillance

Solid-organ injury, intracranial haemorrhage, ongoing surgical bleeding, or unsecured spinal column contraindicate early pharmacologic prophylaxis and mandate mechanical bridging

Drives the pharmacologic-vs-mechanical prophylaxis decision and treatment-dose timing relative to surgery

eGFR for LMWH dose adjustment (CrCl <30 → reduced regimen) and contrast use during PE imaging

Reproductive planning and oestrogen-exposure counselling in SCI women; pregnancy alters agent choice (LMWH)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (5)

5 need judgement
  • informationalseveremassive_or_submassive_pe_in_sci_patient
    SCI patient with PE causing hypotension (relative to the low SCI baseline), RV strain, or hypoxaemia — clinical detection is unreliable in SCI so presentation is often late and severe; a new PE can also precipitate autonomic dysreflexia
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereproven_proximal_vte_with_absolute_anticoagulation_contraindication
    Objectively confirmed proximal DVT/PE in an SCI patient with an absolute, ongoing contraindication to anticoagulation — the only accepted indication for an IVC filter (retrievable, to be removed when AC feasible)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereheparin_induced_thrombocytopenia_with_thrombosis_in_sci
    Platelet fall ≥50% (or to <100k) on days 4-14 of heparin/LMWH exposure with new or extending thrombosis — HIT in a patient already at maximal VTE risk
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateactive_bleeding_or_unsecured_spinal_column_precluding_pharmacologic_prophylaxis
    Acute SCI with active bleeding, solid-organ/intracranial injury, or an unsecured/unstable spinal column — pharmacologic prophylaxis must be deferred and mechanical prophylaxis used as the bridge
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatebreakthrough_vte_on_appropriate_prophylaxis
    New objectively confirmed VTE despite correctly dosed, adherent LMWH prophylaxis in an SCI patient — escalate to therapeutic anticoagulation and reassess dose, adherence, occult malignancy, and HIT
    Trigger could not be auto-evaluated — needs clinician judgement.

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RISK_STRATIFICATIONrequiredDrives dose adjustment
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Recommended regimen

SCI VTE — LMWH prophylaxis within 24-72 h of injury after haemostasis + IPC adjunct; therapeutic LMWH for confirmed VTE; ~8-12-week prophylaxis duration; routine IVC filter NOT recommended (Consortium for Spinal Cord Medicine; ACCP/CHEST 2021)
axis: sci_vte_lmwh_early_prophylaxis_ipc_adjunct_no_routine_ivc_filter
Selected axis "SCI VTE — LMWH prophylaxis within 24-72 h of injury after haemostasis + IPC adjunct; therapeutic LMWH for confirmed VTE; ~8-12-week prophylaxis duration; routine IVC filter NOT recommended (Consortium for Spinal Cord Medicine; ACCP/CHEST 2021)" by default fallback (first axis)
  • enoxaparin (prophylactic)
    first line
    lmwh
    40 mg SC daily (renal/weight-adjusted; 30 mg SC daily if CrCl <30), start 24-72 h post-injury once haemostasis secured • SC • daily for ~8-12 weeks (longer if persistently immobile/complete motor injury)
    triggers: acute_sci_prophylaxis_initiation, haemostasis_secured_no_active_bleeding
    Consortium for Spinal Cord Medicine CPG + ACCP/CHEST 2021 — LMWH is the prophylactic agent of choice in acute SCI; early initiation captures the day 7-14 risk peak
    rxcui 67108
  • enoxaparin (therapeutic)
    first line
    lmwh
    1 mg/kg SC BID (1 mg/kg SC daily if CrCl <30) • SC • BID for confirmed VTE; ≥3 months then reassess
    triggers: confirmed_sci_dvt_or_pe, treatment_dose_anticoagulation_indicated
    ASH 2020 (PMID 33007077); ACCP/CHEST 2021 — therapeutic LMWH for confirmed VTE; predictable SC absorption; reconcile timing with spinal-surgery bleeding window
    rxcui 67108
  • Intermittent pneumatic compression (IPC)
    add on
    mechanical_prophylaxis
    Apply from admission; sole modality if pharmacologic prophylaxis contraindicated • N/A • continuous while immobile
    triggers: sci_admission, pharmacologic_prophylaxis_contraindicated_bridge
    PVA CPG — IPC is a recommended adjunct from admission and the bridge when bleeding risk precludes LMWH; add LMWH as soon as bleeding risk acceptable
  • dabigatran / apixaban / rivaroxaban (treatment, selected stable patients)
    second line
    doac
    standard DOAC VTE-treatment regimen once spinal-surgery bleeding window passed and no contraindication • PO • per agent
    triggers: stable_sci_patient_confirmed_vte_no_contraindication_post_surgical_window
    ACCP/CHEST 2021 — DOACs acceptable for VTE treatment in stable patients; defer until surgical bleeding risk acceptable; avoid in significant renal impairment / drug interactions
    rxcui 1037045
  • warfarin
    second line
    vitamin_k_antagonist
    5 mg PO daily, target INR 2-3 after LMWH bridge • PO • daily; overlap LMWH ≥5 d and until INR ≥2 for ≥24 h
    triggers: long_term_oral_ac_preferred_after_bridge, doac_unsuitable
    ACCP/CHEST 2021 standard alternative for long-term oral AC after LMWH bridge
    rxcui 11289
  • heparin (UFH)
    comorbidity specific
    unfractionated_heparin
    prophylactic 5000 U SC q8-12h, or therapeutic weight-based IV with aPTT/anti-Xa • SC/IV • per indication
    triggers: severe_renal_impairment_crcl_below_15, peri_operative_reversibility_required
    Preferred when reversibility/short half-life needed around spinal surgery or in severe renal impairment; serial platelets for HIT
    rxcui 235473
  • AVOID routine IVC filter for primary prophylaxis
    contraindication substitute
    do_not_use
    AVOID prophylactic IVC filter; reserve retrievable filter for proven proximal VTE + absolute ongoing AC contraindication, and remove when AC feasible • N/A • N/A
    triggers: sci_primary_vte_prevention_decision, proven_vte_with_absolute_ac_contraindication
    PVA CPG reverses older routine-filter practice; PREPIC2 (PMID 25919526) — filters do not reduce recurrent VTE/mortality when AC is possible and add long-term complications
  • AVOID treatment-dose AC across an unsecured spinal column / active bleed
    contraindication substitute
    do_not_use
    Defer therapeutic AC until haemostasis secured + spinal stabilisation timeline allows; use IPC bridge • N/A • N/A
    triggers: active_bleeding, unstable_or_unsecured_spinal_column, recent_neurosurgery_within_bleeding_window
    Spinal epidural haematoma risk; reconcile AC timing with neurosurgery before therapeutic dosing

outpatient playbook — drug actions (3)

  1. 1. curtail prophylaxis after the high-risk window if mobilising
    rxcui 67108
    stop prophylactic LMWH at ~8-12 weeks if adequately mobile; continue if persistently immobile/complete motor injury • SC • reassess at window end
    trigger: End of high-risk prophylaxis window
    PVA CPG — duration tied to ongoing immobility risk
  2. 2. reassess treated-VTE AC duration
    rxcui 11289
    stop after ≥3 months if provoking factor (acute SCI immobility) resolved; extend if unprovoked/persistent risk • PO • reassess at 3 months
    trigger: Completed minimum treatment course
    ACCP/CHEST 2021 provoked-vs-persistent-risk framework
  3. 3. switch to LMWH if pregnancy
    rxcui 67108
    enoxaparin 1 mg/kg SC BID antepartum + 6 weeks postpartum • SC • BID
    trigger: Pregnancy in SCI woman with VTE history
    ASH 2018 pregnancy; warfarin teratogenic, DOAC unsafe in pregnancy

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Acute traumatic or non-traumatic SCI within the first ~3 months — prophylaxis-decision pathway triggered (VTE risk among the highest of any condition); New unilateral lower-limb swelling/warmth in an SCI patient — DVT despite absent pain (sensory level abolishes the classic symptom); Unexplained tachypnoea, hypoxaemia, tachycardia or new autonomic dysreflexia in an SCI patient — occult pulmonary embolism until excluded.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Spinal-cord-injury DVT/VTE (highest-risk; LMWH within 24-72 h, IPC adjunct, no routine IVC filter)** (cardio.dvt.spinal-cord-injury.v1).
Scope: 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

No severity triggers fired against current inputs.

Plan

Regimen axis: **SCI VTE — LMWH prophylaxis within 24-72 h of injury after haemostasis + IPC adjunct; therapeutic LMWH for confirmed VTE; ~8-12-week prophylaxis duration; routine IVC filter NOT recommended (Consortium for Spinal Cord Medicine; ACCP/CHEST 2021)**.
1. enoxaparin (prophylactic) 40 mg SC daily (renal/weight-adjusted; 30 mg SC daily if CrCl <30), start 24-72 h post-injury once haemostasis secured SC daily for ~8-12 weeks (longer if persistently immobile/complete motor injury) (lmwh, first line) — Consortium for Spinal Cord Medicine CPG + ACCP/CHEST 2021 — LMWH is the prophylactic agent of choice in acute SCI; early initiation captures the day 7-14 risk peak
2. enoxaparin (therapeutic) 1 mg/kg SC BID (1 mg/kg SC daily if CrCl <30) SC BID for confirmed VTE; ≥3 months then reassess (lmwh, first line) — ASH 2020 (PMID 33007077); ACCP/CHEST 2021 — therapeutic LMWH for confirmed VTE; predictable SC absorption; reconcile timing with spinal-surgery bleeding window
3. Intermittent pneumatic compression (IPC) Apply from admission; sole modality if pharmacologic prophylaxis contraindicated N/A continuous while immobile (mechanical_prophylaxis, add on) — PVA CPG — IPC is a recommended adjunct from admission and the bridge when bleeding risk precludes LMWH; add LMWH as soon as bleeding risk acceptable
4. dabigatran / apixaban / rivaroxaban (treatment, selected stable patients) standard DOAC VTE-treatment regimen once spinal-surgery bleeding window passed and no contraindication PO per agent (doac, second line) — ACCP/CHEST 2021 — DOACs acceptable for VTE treatment in stable patients; defer until surgical bleeding risk acceptable; avoid in significant renal impairment / drug interactions
5. warfarin 5 mg PO daily, target INR 2-3 after LMWH bridge PO daily; overlap LMWH ≥5 d and until INR ≥2 for ≥24 h (vitamin_k_antagonist, second line) — ACCP/CHEST 2021 standard alternative for long-term oral AC after LMWH bridge
6. heparin (UFH) prophylactic 5000 U SC q8-12h, or therapeutic weight-based IV with aPTT/anti-Xa SC/IV per indication (unfractionated_heparin, comorbidity specific) — Preferred when reversibility/short half-life needed around spinal surgery or in severe renal impairment; serial platelets for HIT
7. AVOID routine IVC filter for primary prophylaxis AVOID prophylactic IVC filter; reserve retrievable filter for proven proximal VTE + absolute ongoing AC contraindication, and remove when AC feasible N/A N/A (do_not_use, contraindication substitute) — PVA CPG reverses older routine-filter practice; PREPIC2 (PMID 25919526) — filters do not reduce recurrent VTE/mortality when AC is possible and add long-term complications
8. AVOID treatment-dose AC across an unsecured spinal column / active bleed Defer therapeutic AC until haemostasis secured + spinal stabilisation timeline allows; use IPC bridge N/A N/A (do_not_use, contraindication substitute) — Spinal epidural haematoma risk; reconcile AC timing with neurosurgery before therapeutic dosing

Setting playbook (outpatient) — Longitudinal SCI care: complete/curtail prophylaxis or treatment per evolving mobility and risk, PTS surveillance, ensure filter removal, reproductive planning for women, integrate with the autonomic-dysreflexia chronic plan
9. curtail prophylaxis after the high-risk window if mobilising stop prophylactic LMWH at ~8-12 weeks if adequately mobile; continue if persistently immobile/complete motor injury SC reassess at window end — End of high-risk prophylaxis window (PVA CPG — duration tied to ongoing immobility risk)
10. reassess treated-VTE AC duration stop after ≥3 months if provoking factor (acute SCI immobility) resolved; extend if unprovoked/persistent risk PO reassess at 3 months — Completed minimum treatment course (ACCP/CHEST 2021 provoked-vs-persistent-risk framework)
11. switch to LMWH if pregnancy enoxaparin 1 mg/kg SC BID antepartum + 6 weeks postpartum SC BID — Pregnancy in SCI woman with VTE history (ASH 2018 pregnancy; warfarin teratogenic, DOAC unsafe in pregnancy)

Non-pharmacologic actions:
- Mobility optimisation
- Compression therapy if PTS
- AD chronic-plan integration
- Annual reproductive counselling for women
- Patient carries VTE/AC card

AVOID / contraindication checks:
- Defer_pharmacologic_prophylaxis_until_haemostasis_secured_then_start_24_to_72h
- No_treatment_dose_ac_across_unsecured_spinal_column_or_active_bleed (spinal epidural haematoma risk)
- Lmwh_renal_dose_reduction_below_crcl_30 (FDA label)
- Serial_platelets_for_hit_surveillance_days_4_to_14_on_heparins
- Warfarin_avoid_pregnancy_use_lmwh (ASH 2018 pregnancy)
- Decision:lmwh_is_prophylactic_agent_of_choice_in_acute_sci (PVA CPG)
- Decision:ipc_adjunct_from_admission_and_bridge_when_pharmacologic_contraindicated
- Decision:prophylaxis_duration_8_to_12_weeks_longer_if_persistently_immobile
- Decision:no_routine_ivc_filter_for_primary_prophylaxis (PVA CPG; PREPIC2)
- Decision:retrievable_filter_only_for_proven_proximal_vte_with_absolute_ac_contraindication_and_remove_when_ac_feasible
- Decision:reconcile_ac_timing_with_spinal_surgery_window
- Decision:new_dvt_pe_is_an_autonomic_dysreflexia_trigger_coordinate_with_ad_plan

Monitoring

Regimen monitoring:
- serial platelet count days 4 to 14 on heparins (HIT 4T + anti-PF4 if drop)
- haemoglobin and bleeding surveillance especially post surgery
- renal function for lmwh dose during acute aki recovery
- surveillance compression us per unit protocol (clinical signs unreliable in SCI)
- pe vigilance unexplained tachypnoea desaturation or new autonomic dysreflexia
- villalta pts score at 3 6 12 months for treated proximal vte
- ivc filter retrieval tracking when ac becomes feasible

Setting (outpatient) monitoring:
- Periodic review tied to mobility
- Annual PTS check for treated proximal DVT
- Confirm filter removed

Follow-up plan: 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)
- Close-out criterion: prophylaxis/treatment duration plan + filter-removal + rehab co-management documented

Monitoring phase: 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

Disposition

Current setting: outpatient — Longitudinal SCI care: complete/curtail prophylaxis or treatment per evolving mobility and risk, PTS surveillance, ensure filter removal, reproductive planning for women, integrate with the autonomic-dysreflexia chronic plan

Disposition criteria:
- Indefinite SCI longitudinal co-management; VTE risk persists while immobile and integrates with the autonomic-dysreflexia plan

Escalation triggers (move to higher acuity):
- Recurrent VTE → extend/escalate AC + haematology
- Pregnancy → LMWH switch
- Major bleed → reverse + reassess intensity

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [SEVERE] SCI patient with PE causing hypotension (relative to the low SCI baseline), RV strain, or hypoxaemia — clinical detection is unreliable in SCI so presentation is often late and severe; a new PE can also precipitate autonomic dysreflexia
- [SEVERE] Objectively confirmed proximal DVT/PE in an SCI patient with an absolute, ongoing contraindication to anticoagulation — the only accepted indication for an IVC filter (retrievable, to be removed when AC feasible)
- [SEVERE] Platelet fall ≥50% (or to <100k) on days 4-14 of heparin/LMWH exposure with new or extending thrombosis — HIT in a patient already at maximal VTE risk

Citations

- Consortium for Spinal Cord Medicine — Prevention of VTE in SCI (PVA CPG) + ACCP/CHEST 2021 + ASH 2020 VTE Treatment [PMID:34352295](https://pubmed.ncbi.nlm.nih.gov/34352295/)
- Cited evidence (PMID 33007077) [PMID:33007077](https://pubmed.ncbi.nlm.nih.gov/33007077/)
- Cited evidence (PMID 31794602) [PMID:31794602](https://pubmed.ncbi.nlm.nih.gov/31794602/)
- Cited evidence (PMID 27733851) [PMID:27733851](https://pubmed.ncbi.nlm.nih.gov/27733851/)
- Cited evidence (PMID 27922832) [PMID:27922832](https://pubmed.ncbi.nlm.nih.gov/27922832/)

Last reconciled with current guidelines: 2026-05-15.
References
  • Consortium for Spinal Cord Medicine — Prevention of VTE in SCI (PVA CPG) + ACCP/CHEST 2021 + ASH 2020 VTE Treatment — PMID:34352295
  • Cited evidence (PMID 33007077) — PMID:33007077
  • Cited evidence (PMID 31794602) — PMID:31794602
  • Cited evidence (PMID 27733851) — PMID:27733851
  • Cited evidence (PMID 27922832) — PMID:27922832