In the Emergency Department (ED) lower leg immobilisation after injury is a necessary treatment but is also a known risk factor for the development of venous thromboembolism (VTE). This accounts for approximately 2% of all VTE cases which are potentially preventable with early pharmacological thromboprophylaxis.
Inclusion Criteria (must fit ALL):
- 16 years or over
- Isolated lower limb injury that will be treated in a rigid splint or cast, OR will be non-weight bearing; (Exclude patient with MT shoe who can weight bear)
- Not already anti-coagulated
- Being discharged
Contraindications – D/W Haematologist
- Known Haemophilia or other bleeding disorder
- Known Thrombocytopaenia or previous heparin induced thrombocytopaenia
- Cerebral haemorrhage within 3 months
- Severe hypertension systolic >200 or diastolic >120 mmHg
- Active peptic ulcer or history of varices or upper GI bleed <2 weeks
- Major trauma or Head Injury or Surgery to the eye or nervous system <4 weeks
- Hypersensitivity to Rivaroxaban OR Tinzaparin
- Clinical judgement that risks outweigh benefit
Tests
- A baseline renal function and full blood count should be documented.
- (This must have been taken within the last 3 months)
- Document Creatinine Clearance in note (Cr-Cl) Use MDCalc- LINK HERE
- Suspected Haemophilia – FBC & Clotting screen
- If abnormal D/W Haematologist
- Suspected Thrombocytopenia – FBC
- If Plt’s <75 D/W Haematologist
- Pregnancy/Breastfeeding – use Tinzaparin (rivaroxaban contraindicate)
Prophylaxis
- Rivaroxaban 10mg OD 14 day – if Cr-Cl >15ml/min
- Tinzaparin* SC OD (if Ortho think operation required) 14 day + Sharps bin
- <50kg / Frail or CrCl <20 – Tinzaparin 3500units daily SC
- 50-109kg – Tinzaparin 4500units daily SC
- 110- 149kg – Tinzaparin 7000units daily SC
- 150kg or Over – Tinzaparin 9000units twice daily SC
*If CrCL<20ml/min one Enoxaparain 20mg SC once daily
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The first dose and TTO of anticoagulant will be given to the patient in the ED.
