Reversing INR in patients on warfarin who have sustained a mild head injury
Date First Published:
July 4, 2011
Last Updated:
July 4, 2011
Report by:
Andrew Skinner, ED SHO (Croydon University Hospital)
Search checked by:
Oliver Spencer, Croydon University Hospital
Three-Part Question:
Do [adults with a mild head injury] [on warfarin] benefit from [INR reversal]
Clinical Scenario:
A 78 year old man on warfarin for AF presents to the ED with a head injury following a mechanical fall. There was no LOC, nausea or vomiting, amnesia or visual disturbances and neurological examination was normal. He did however sustain a laceration to his occiput, which required suturing. Despite not fulfilling NICE criteria he underwent a CT head, which was unremarkable besides an old infarct.
The gentleman was admitted for observation and 10hrs later dropped his GCS to 4/15. Repeat CT demonstrated a large subdural haematoma. He subsequently died 14hrs later.
In hindsight, should his INR have been reversed regardless of its value to help prevent delayed bleeding?
The gentleman was admitted for observation and 10hrs later dropped his GCS to 4/15. Repeat CT demonstrated a large subdural haematoma. He subsequently died 14hrs later.
In hindsight, should his INR have been reversed regardless of its value to help prevent delayed bleeding?
Search Strategy:
Medline 2001-2011 using OVID interface.
Search Details:
(("craniocerebral trauma"[MeSH Terms] OR ("craniocerebral"[All Fields] AND "trauma"[All Fields]) OR "craniocerebral trauma"[All Fields] OR ("head"[All Fields] AND "injury"[All Fields]) OR "head injury"[All Fields]) AND ("warfarin"[MeSH Terms] OR "warfarin"[All Fields])) AND ("2001/07/07"[PDat] : "2011/07/04"[PDat])
Outcome:
No papers were found to address this issue.
Author Commentary:
It is well known that patients with a coagulopathy such as those on warfarin who have an intracranial haemorrhage benefit from rapid INR reversal.
There is a theoretical benefit of decreasing the risk of delayed intracranial haemorrhage by reversing the INR of patients on warfarin after sustaining a relatively 'minor' head injury and having a normal CT head.
This theoretical benefit will have to be balanced against the reason for anticoagulation.
There is a theoretical benefit of decreasing the risk of delayed intracranial haemorrhage by reversing the INR of patients on warfarin after sustaining a relatively 'minor' head injury and having a normal CT head.
This theoretical benefit will have to be balanced against the reason for anticoagulation.
Bottom Line:
Further work is needed to address this question.
Clinicians should have a low threshold for obtaining a CT head on these type of patients- solely following NICE will miss some intracranial haemorrhages.
A period of close observation for these patients is also important.
Clinicians should have a low threshold for obtaining a CT head on these type of patients- solely following NICE will miss some intracranial haemorrhages.
A period of close observation for these patients is also important.