----- Original Message -----
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 -----
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