The toddler scenario is certainly a difficult one with no easy solution.
Probably best to get the child seen by or discussed with a middle grade or
consultant on each visit. A senior pragmatic approach is better than a
junior one, as the child is at risk.

Ray McGlone
Lancaster A&E


----- Original Message -----
From: "Simon McCormick" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Saturday, February 09, 2002 11:40 AM
Subject: Re: Warfarin and minor head injury


> 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.
> > >
> >