ABSTRACT
A 50-year-old obese motorcyclist is admitted to the emergency department hypotensive and is emergently taken to the operating room for damage control surgery for a Grade 4 liver laceration and expected large volume resuscitation. In addition to the liver laceration, he is found to have the following injuries: bilateral femur fractures and pulmonary contusions, pelvic fracture, and a small intracerebral hematoma. Immediately postop, the patient is transferred to the surgical intensive care unit (SICU) for stabilization, optimization of his mechanical ventilation requirements, and aggressive correction of his metabolic disturbances in preparation for definitive fascial closure and fixation of his pelvis and femur fractures. Pharmacologic deep vein thrombosis prophylaxis is withheld secondary to the small intracerebral hematoma (ICH) documented on head computed tomography (CT). The patient is started on mechanical sequential compression devices (SCDs) for primary prevention of venous thromboembolism (VTE). On post-operative day (POD) 10, the patient develops acute respiratory distress manifested by hypoxemia, tachypnea, and hemoptysis. A pulmonary embolus is diagnosed on spiral CT and subsequently a deep vein thrombus is discovered in the patient’s proximal left femoral vein by duplex ultrasound. The patient is initiated on a weight-based enoxaparin regimen. After several days of combination anticoagulant therapy, the patient is successfully bridged to warfarin treatment. On POD 20, the patient was on trach collar for 24 h and is subsequently transferred to a ward bed. The patient is discharged to a rehabilitation facility 5 days later with a plan to continue warfarin for the next 3 months.
