Lower extremity hemorrhage in spinal cord injured patients receiving therapeutic anticoagulation

Six episodes of lower extremity hemorrhage occurred in five spinal cord injured patients receiving therapeutic anticoagulation. Factors contributing to hemorrhage included excessive anticoagulation in two episodes and soft tissue trauma during vigorous range of motion (ROM) exercises in three. The three episodes without clinical evidence of trauma were initially misdiagnosed as recurrent deep venous thrombosis. Ecchymoses developed in three episodes, but were delayed in appearance in two. Noninvasive vascular tests yielded false positive results in two out of three cases. Venograms performed in four episodes were negative for thrombosis. Based on this experience, the initial investigation of lower extremity swelling in this setting should include: a search for evidence of trauma, analysis of medications for coagulation-related interactions, leg x-rays, and early determination of hemoglobin, prothrombin or partial thromboplastin time, and platelet count. If there is any question of acute thrombosis, a venogram, rather than noninvasive vascular studies, must be performed. All persons involved in the care of these patients should be aware of the increased risk of bleeding and should perform ROM exercises of weak or paralyzed extremities with caution.