Just had a similar conversation with a local haematologist. I think it's a question of scale across the Bay we have 40-60 haemophiliacs etc, but probably 6,000 people on Warfarin.
Had another case no trauma, spontanteous intracerebral bleed obeying commands, eyes open spontaneously but dysphasic. 3 cm left frontoparietal haematoma. On warfarin INR 1.9. FFP given, but unfortunately she died. Neurosurgeons advised medical treatment..
Does anyone have experience of using prothrombin complex?
Ray McGlone
----- Original Message -----
From: Robert Spykerman
To: [log in to unmask]
Sent: Thursday, January 31, 2002 7:41 AM
Subject: Re: Warfarin and Minor Head Injuries
On a similar vein, are there any guidelines on CT patients on anticoagulants? I think the general consensus on hemophiliacs is that they should all be scanned (again, I can't quote any evidence, just the advice I'd been given by my haem colleagues).
Personally I scan all warfarin patients. I can't say I've ever found a bleed yet in a minor head injury in anyone on warfarin, but then maybe off the top of my head, I've only scanned oh, perhaps 3-4 patients that fit your criteria below in the past year.
I think I recall one spectacular bleed (subdural) involving a head injury and warfarin, but this guy would have been scanned anyway even if he wasn't on warfarin.
Hmmm... what about other haemostatically challenged patients? I am told that one's bleeding time (i.e. platelet function) is not significantly altered till your platelets dip below 50 x 10^9/l...
How about the alcoholic patient with liver failure with a PT of say, 23 secs and a platelet count of 75x10^9/l with a minor head injury and is otherwise well (and sober)?
Another question: would you or I recognize such a patient without bloodwork? Some of these guys with compensated liver failure can look extremely 'normal' and yet have a PT that's off by 4-5 secs...
And chronic alcoholics with no liver failure are also at risk of having lower platelet counts.... Although certainly never in my experience below 50....
Excuse me I am rather giddy from a long shift.
Robert Spykerman
Reg, ED, Cork University Hospital
----- Original Message -----
From: Ray McGlone
To: [log in to unmask]
Sent: Wednesday, January 30, 2002 9:40 PM
Subject: Warfarin and Minor Head Injuries
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
