Venous Thromboembolism Prophylaxis in Trauma and Critically Ill Patients: A State-of-the-Art Evidence-Based Review

State-of -the Art Review

Venous Thromboembolism Prophylaxis in Trauma and Critically Ill Patients: A State-of-the-Art Evidence-Based Review

Belinda De Simone^1-2, Fausto Catena^1-3*, Rifat Latifi^4*,

• Department of Emergency Minimally Invasive Surgery, Trauma Hub Center, Bufalini Hospital, AUSL Romagna, Cesena, Italy
• Department of Theoretical and Applied Sciences, eCampus University, 22060 Novedrate (CO), Italy.
• Department of Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40126 Bologna Italy
• The University of Arizona, Tucson, Arizona and Tucson Medical Center, Tucson, Arizona

Corresponding Author:

Belinda De Simone, MD

Department of Emergency Minimally Invasive Surgery, Trauma Hub Center

Bufalini Hospital, AUSL Romagna

Viale Giovanni Ghirotti, 286, 47521 Cesena FC, Italy

[email protected]

___________________________

Abstract

Background:
Venous thromboembolism (VTE), comprising deep vein thrombosis (DVT) and pulmonary embolism (PE), is one of the most frequent and preventable causes of morbidity and mortality in trauma and critically ill patients. These populations present multiple overlapping risk factors, including endothelial injury, venous stasis, systemic inflammation, and prolonged immobilization that create a uniquely high-risk setting. Despite decades of research, variability in practice persists, and the optimal prophylaxis strategy remains debated. The aim of this state-of-the-art review is to provide an updated, evidence-based review of effective thrombo-prophylaxis strategies in trauma and critically ill patients.

Methods:
We performed a state-of-the-art narrative review based on PubMed, Embase, and Cochrane searches (1990–August 2025), complemented by guideline repositories and expert consensus reports. Priority was given to randomized controlled trials, multicenter registries, systematic reviews, and international guideline statements. The review focuses on pharmacologic and mechanical prophylaxis, management of special populations, barriers to implementation, and future directions including anti-Xa–guided dosing, biomarkers, and artificial intelligence (AI).

Results:
Low molecular weight heparin (LMWH) has emerged as the pharmacologic gold standard, demonstrating superior efficacy and safety compared to unfractionated heparin (UFH). Early initiation (24–48 hours for most patients, and 24–72 hours post-stable imaging in traumatic brain injury) reduces VTE without significantly increasing bleeding risk. Mechanical prophylaxis remains essential when anticoagulation is contraindicated, and combined strategies (LMWH + intermittent pneumatic compression) provide synergistic benefit. Prophylactic inferior vena cava filters, once widely used, are no longer recommended except in rare cases of absolute contraindication to anticoagulation. Special populations such as spinal cord injury, pelvic fractures, burns, pregnancy, obesity, and cancer require tailored protocols.

Conclusion:
VTE prevention in trauma and critical illness patient is evolving from a uniform, protocol-driven approach to a precision-based model. Anti-Xa–guided dosing, biomarker-informed prophylaxis, AI-driven risk prediction, extended post-discharge strategies, and digital health monitoring represent promising innovations.

Keywords: Venous thromboembolism, deep vein thrombosis, pulmonary embolism, trauma, critical illness, thromboprophylaxis, low molecular weight heparin, mechanical prophylaxis, artificial intelligence, precision medicine.