Effectiveness of low-molecular-weight heparin versus unfractionated heparin for venous thromboembolism prophylaxis after firearm-related penetrating brain injury

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OBJECTIVE: Venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism, is a major source of morbidity and mortality following firearm-related penetrating brain injury (PBI). Standard pharmacological prophylaxis against VTE includes the use of low-molecular-weight heparin (LMWH) or unfractionated heparin (UH). However, the comparative effectiveness of LMWH versus UH to prevent VTE in this population remains unclear. METHODS: A retrospective analysis was conducted using data from the Trauma Quality Improvement Program (2017-2019) to evaluate the effectiveness of LMWH versus UH in patients with PBI. Adult patients (age ≥ 16 years) with an isolated firearm-related PBI treated at a level I or II trauma center were included. The primary outcome was the occurrence of VTE. Secondary outcomes were the need for late neurosurgical decompression and in-hospital mortality. Hierarchical logistic regression models were used to evaluate the association between prophylaxis type and the outcomes, adjusting for patient baseline and injury characteristics, as well as timing of VTE prophylaxis initiation. Effect modification was evaluated to determine whether the observed associations varied between types of early neurosurgical intervention: craniotomy/craniectomy, intracranial monitor/drain placement, or no intervention. RESULTS: Among 2012 patients with isolated firearm-related PBI, LMWH was associated with 51% decreased odds of VTE compared with UH (OR 0.49, 95% CI 0.32-0.77) after risk adjustment. Subgroup analysis showed that LMWH, compared with UH, was associated with reduced odds of VTE in patients who underwent early craniotomy/craniectomy (OR 0.42, 95% CI 0.23-0.74) or no intervention (OR 0.41, 95% CI 0.21-0.79). The type of pharmacological VTE prophylaxis was not associated with the occurrence of late neurosurgical decompression or in-hospital mortality. CONCLUSIONS: In patients with firearm-related PBI, LMWH appears to be significantly more effective at preventing VTE compared with UH, without increasing the risk of neurosurgical intervention. These findings support the use of LMWH as the preferred agent for VTE prophylaxis after PBI.

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