Dear Ray and all,
These are the very patients my wee publication was about. It seems that each
ED gets a small cluster of them and they seem to do badly. Is it the fault of
the background disease, the warfarin, delay in diagnosis or delay or refusal
to treat aggressively?
My past training included 2.5 yrs as Neurosurgical reg. These patients were
infrequent in our unit as well but they seemed to do badly when we messed with
them ( no EBM). We were standalone without direct access to haematology.
I think the only way to really deal with the problem is to get a team approach
with ED, Haematology and Neurosurgery all working together to see if aggressive
clottology control plus neurosurgery before the patient progresses to the terminal
state and see if this gives a better outcome. Of course it should be a randomised
national or international controlled trial to get power. Imagine the politics
to get all these on board!
What do the Americans do does anyone know?
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
>>
>>
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>
>
>
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