Ray,
I'm never quite sure what our neurosurgeons want! Either a patient is too
well for surgery or too sick...you just can't win. I can't even claim its
an agist thing as we have the same problem with young people. Maybe they
have reached a fatalistic attitude and feel there is no point in trying, who
knows?
As far as finding out which patients are on warfarin I agree it can be very
difficult, especially as many elderly patients have no idea what tablets
they take. I have taken to recording a negative drug history; ie Patient
NOT on warfarin in all my elderly patients and encourage the SHOs to do the
same.
At the other end of the chronological scale, I have been dealing with a
toddler who is on long term warfarin treatment! Now we all know how often
kids fall over and bang their heads! Pretty soon he'll be jumping off the
bed, falling off his bike etc etc. It would be impractical to check his INR
on each presentation (and he DOES attend every time), or do regular CTs and
his mum won't let him stay in for observation! For the moment we are
pragmatic and let him go with instructions to his mum to return if he has
any problems. The local haematologists aren't terribly sure what to do
either...any ideas!
Simon McCormick
----- Original Message -----
From: Ray McGlone <[log in to unmask]>
To: <[log in to unmask]>
Sent: 09 February 2002 10:29
Subject: Re: Warfarin and minor head injury
> My mailing on warfarin and minor head injury was initiated that week
because
> we had two patients attend in the space of 48 hrs.
>
> The first was an 80 yr old female who fell hitting her forehead with no
loss
> of consciousness. Discharged with head injury advice with fit husband.
> Returned 14 hrs later with deteriorating GCS. CT scan showed subdural ?
> acute on chronic. INR was 2.1. Neurosurgeons decided not to intervene in
> view of GCS < 8, by then. She had been put on Warfarin well over a decade
> previously because of 2 DVT's. The 1st being related to post surgery.
>
> The second was a 75 yr old female in AF. Presented with Right arm paresis
> and expressive dysphasia, but was alert. CT showed 3 cm intracerebral
> haematoma in left fronto-parietal area (near surafce of brain). INR was
1.9
> and this was reversed with fresh frozen plasma and Vitamin K.
Neurosurgeons
> did not accept her because she was alert. Died later that day.
>
> As my father is also in AF and on warfarin so these two cases certainly
> concentrate the mind!
>
> A useful paper on guidelines on oral anticoagulation was published in the
> British Journal of Haematology 1998 101 374-387. The new drug to
potentially
> replace warfarin is called Melagatran (?spelling) but it's still going
> through clinical trials. My haematologist colleague is digging out the
paper
> on it for me and I'll pass on the reference.
>
> Our juniors don't always ask about warfarin especially if the head injury
is
> "minimal". Our local haematology dept have a database for the patients on
> warfarin (standalone) so I'm getting our reception staff to put the names
on
> our computer system so it is printed on the card when they attend. Yes,
> haematology had to print out the list and the reception staff manually
input
> the data!!!!!
>
> Regards
>
> Ray McGlone
> A&E Lancaster
> ----- Original Message -----
> From: "Dunn Matthew Dr. (RJC) ACCIDENT & EMERGENCY - SwarkHosp-TR"
> <[log in to unmask]>
> To: <[log in to unmask]>
> Sent: Monday, February 04, 2002 9:20 AM
> Subject: Re: Warfarin and minor head injury
>
>
> > > -----Original Message-----
> > > From: Andrew Webster [mailto:[log in to unmask]]
> >
> > > It may be recommended but on what evidence? seeing an
> > > emergency physician
> > > with no real interest, or skills in long term head injury follow up is
> >
> > The lack of evidence for routine minor head injury follow up is because
> > nobody is doing the studies because nobody is following up the patients.
> > We'd have to start doing it on a large scale before we could say with
any
> > certainty that we shouldn't be doing it. Maybe the majority of EPs
haven't
> > the interest or skills, but some do. Even if each hospital couldn't
offer
> > it, you'd probably be able to get a couple of emergency physicians
within
> > the region prepared to offer a regional minor head injuries follow up
> > service.
> >
> > > going to be of no real benefit to the patient or the doctor,
> >
> > Maybe not the patient; but for the doctor, plenty of scope for research
> > papers, discretionary points and medicolegal work.
> >
> > Matt Dunn
> >
> >
> > This email has been scanned for viruses by NAI AVD however we are unable
> to
> > accept responsibility for any damage caused by the contents.
> > The opinions expressed in this email represent the views of the sender,
> not
> > South Warwickshire General Hospitals NHS Trust unless explicitly stated.
> > If you have received this email in error, please notify the sender.
> >
>
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