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I'm interested in what the A&E doctors on the list do with the patient on warfarin who has a minor head injury with no loss of consciousness and GCS 15. Do you admit them all? Having read, Saab M, Gray A, Hodgkinson D, Irfan M. Warfarin and the apparent minor head injury. J Accid Emerg Med 1996; 13: 208-9. The suggestion is that they should all get admitted. Of the two patients presented in the paper, the first one presented with increasing headache 2 days after the head injury (INR 2.5) and the second one died despite being admitted (INR 4.2 not reversed). Incidently the authors quoted an increased risk of intracranial haematoma if the INR is over 2. Hylek EM, Singer DE. Risk factors for intracranial hemorrhage in outpatients taking warfarin. Ann Intern Med 1994; 120: 897-902. But when I read the paper p901 it actually refers to a Prothrombin Ratio of 2 and "... our PTR threshold of 2.0 corresponds to an INR range of 3.7 to 4.3". Increased age was also another risk factor for subdurals. The paper really wasn't looking at head injury though. The latter paper was an 11 year study managing warfarin doses for 8,000 patients. They found 44 subdurals only 3 of these were from "trivial" head injuries. The study excluded patients who had lost consciousness. So most were spontaneous bleeds. They also had 77 intracerebral bleeds. The physicians are putting more of the geriatric population on warfarin, so it's becoming an increasing problem. I don't have a short stay ward. Well, what do you do? Ray McGlone A&E Consultant Royal Lancaster Infirmary / Westmorland General Hospital