head injury on coumadin

[saintsfan180]

Quick question for board review and practice:

I'm sure this varies some by facility. We would always scan these people (head trauma on coumadin) where I trained and send them out if negative. I'm doing HippoEM and they imply that they should be admitted for obs. Are you guys admitting a head injury on coumadin for obs, with a normal neuro exam, and with a reasonable INR (therapeutic)? If so, how bad does the injury have to be? A bump vs +LOC or what?

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[xaelia]

The preponderance of evidence suggests delayed bleeds are probably on the order of 1% or less, and some occur >24 hours after onset. Any observation protocol would be quite low yield.

Send 'em home with return precautions and document the discussion.

 

[WilcoWorld]

I do not routinely admit for Obs, and I almost always discharge the types of patients you describe.

If the initial head CT is negative and the clinical picture is not strongly suggestive then I tell the patient/family about the possibility of a delayed bleed and ask if they're comfortable/able to return if new or worsening symptoms develop. In my experience >95% of the time people want to go home.

Delayed bleeds are real, and even admitting for 23 hour Obs will still miss some of them. I think where you're going to get burned is if you don't think about it and/or you don't discuss it with the patient & family before discharge (and, of course, document that conversation).

 

[gro2001]

Quick question for board review and practice:

I'm sure this varies some by facility. We would always scan these people (head trauma on coumadin) where I trained and send them out if negative. I'm doing HippoEM and they imply that they should be admitted for obs. Are you guys admitting a head injury on coumadin for obs, with a normal neuro exam, and with a reasonable INR (therapeutic)? If so, how bad does the injury have to be? A bump vs +LOC or what?

This is a controversial topic, without a ton of great literature to back it up. I think someone on FULL ANTICOAGULATION (whether it is therapeutic coumadin, full dose lovenox, or some of em novel anticoagulants) who has anything more than a tiny bump on the old noggin needs a initial CT head and EITHER a repeat CT head somewhere 6-12 hours down the line OR 24 hours or so of close observation. However, the observation does not necessarily need to be in the hospital. A very dedicated and reliable companion/spouse who will check on them diligently and bring them back at the earliest sign of deterioration is often acceptable. If home obs is not an option (no reliable companion, or the person's baseline might make it difficult to detect early signs of deterioration, or there are transport issues, etc) or the unjury is a little more severe, I tend to either keep them for a bit and rescan them in the ER or admit them for observation to trauma depending on a host of other factors: patient preference, ER census, trauma service census, time of day, any other semi bull**** reason to admit (did someone say chest pain?), bad vibes, etc. Significantly super therapeutic or legit head trauma on full anticoagulation probably need to be admitted.

 

[link2swim06]

At my hospital these pts will generally get sent home with return precautions after a neg CT.

 

[RustedFox]

This is a controversial topic, without a ton of great literature to back it up. I think someone on FULL ANTICOAGULATION (whether it is therapeutic coumadin, full dose lovenox, or some of em novel anticoagulants) who has anything more than a tiny bump on the old noggin needs a initial CT head and EITHER a repeat CT head somewhere 6-12 hours down the line OR 24 hours or so of close observation. However, the observation does not necessarily need to be in the hospital. A very dedicated and reliable companion/spouse who will check on them diligently and bring them back at the earliest sign of deterioration is often acceptable. If home obs is not an option (no reliable companion, or the person's baseline might make it difficult to detect early signs of deterioration, or there are transport issues, etc) or the unjury is a little more severe, I tend to either keep them for a bit and rescan them in the ER or admit them for observation to trauma depending on a host of other factors: patient preference, ER census, trauma service census, time of day, any other semi bull**** reason to admit (did someone say chest pain?), bad vibes, etc. Significantly super therapeutic or legit head trauma on full anticoagulation probably need to be admitted.

If I did this down here on the gulf coast, there would never be an empty bed in the hospital. Ever.

 

[GeneralVeers]

If I did this down here on the gulf coast, there would never be an empty bed in the hospital. Ever.

Agreed with RustedFox. Most of them I send home. If they are on Coumadin I'll get an INR to document that they are not supra-therapeutic and send them out with head injury instructions.

 

[MSUSpartan642]

Agreed with RustedFox. Most of them I send home. If they are on Coumadin I'll get an INR to document that they are not supra-therapeutic and send them out with head injury instructions.

If the patients on Coumadin are supra-therapeutic do you consider placing them in obs then? Specific cut off for the INR (3.0,3.5, etc.)? Just curious

 

[RustedFox]

If the patients on Coumadin are supra-therapeutic do you consider placing them in obs then? Specific cut off for the INR (3.0,3.5, etc.)? Just curious

No. They go home. Back to their ECF/ALF, with head injury instructions.

Seriously, the number of seniors on whatever variety of anticoagulants here is staggering (*). Furthermore, you have to consider aspirin/plavix on the spectrum of "anticoagulants". Every time some old fattie on ASA/plav falls while golfing - do you consider obs ? Hell no.

(*) - WARNING: THREAD HIJACK: The number of bluehairs on NOACs is huge; but its brilliant at the same time. I regularly see men and women in their 90s who are fully functional, mobile, happy, mentally sharp, and (often) living with a modest amount of assistance. I had a 107 year old female last month who told me about the day she was working in a Chicago office building in the roaring 20s when she heard gunshots ring out a block or so away. You guessed it; it was the "St. Valentine's Day Massacre". She also asked me what I thought about the upcoming baseball postseason, and was near-insistent that she got home in time for the game. Totally with it. I left the shift totally stunned. I want to be like her. I have an 87 year-old volunteer at my hospital who demands a hug-and-kiss from me every shift, and who can't wait to show me pics of her great-grandchildren on her smartphone... after she complains that Facebook has changed the format... again.

Think about it. The year is 2015. If more and more seniors are living into their 90s... (and living well)... think about what will happen in the year 2035.

When I was an intern... acute endovascular stroke intervention was a fairy tale. Six years later, I transfer old folks left and right to my nearest neurointerventional facility... and the suits at my shop are wondering how they can build one here.

When I'm 160, I'll still be trolling interns on SDN.

 

[southerndoc]

The preponderance of evidence suggests delayed bleeds are probably on the order of 1% or less, and some occur >24 hours after onset. Any observation protocol would be quite low yield.

Send 'em home with return precautions and document the discussion.

One study found a 6% delayed bleed risk within 24 hours for INR >3.

The largest study (over 1,000 patients) found it to be a little over 0.5% for delayed bleed in warfarin. They followed patients up for 2 weeks.

Most people don't realize the risk of intracranial bleeds is higher in clopidogrel patients (12%) than warfarin patients (5%).

Both of these studies were published in Annals a few years ago.

Speaking of which, BI is really shooting itself in the wallet by making Praxbind so expensive. They should give that stuff away dirt cheap to ER's, ambulances, etc. By having a specific agent that will nearly completely reverse Pradaxa within 4 hours (80% within 40 minutes), they could sell Pradaxa like crazy since people would want something that could be reversed easily. No other anticoagulant can be so easily reversed now.

 

[WilcoWorld]

One study found a 6% delayed bleed risk within 24 hours for INR >3.

The largest study (over 1,000 patients) found it to be a little over 0.5% for delayed bleed in warfarin. They followed patients up for 2 weeks.

Most people don't realize the risk of intracranial bleeds is higher in clopidogrel patients (12%) than warfarin patients (5%).

Both of these studies were published in Annals a few years ago.

Speaking of which, BI is really shooting itself in the wallet by making Praxbind so expensive. They should give that stuff away dirt cheap to ER's, ambulances, etc. By having a specific agent that will nearly completely reverse Pradaxa within 4 hours (80% within 40 minutes), they could sell Pradaxa like crazy since people would want something that could be reversed easily. No other anticoagulant can be so easily reversed now.

Right!? It almost seems like there should be a law preventing a drug company from holding the patent for the only antidote to its own drug...

 

[WilcoWorld]

No. They go home. Back to their ECF/ALF, with head injury instructions.

Seriously, the number of seniors on whatever variety of anticoagulants here is staggering (*). Furthermore, you have to consider aspirin/plavix on the spectrum of "anticoagulants". Every time some old fattie on ASA/plav falls while golfing - do you consider obs ? Hell no.

(*) - WARNING: THREAD HIJACK: The number of bluehairs on NOACs is huge; but its brilliant at the same time. I regularly see men and women in their 90s who are fully functional, mobile, happy, mentally sharp, and (often) living with a modest amount of assistance. I had a 107 year old female last month who told me about the day she was working in a Chicago office building in the roaring 20s when she heard gunshots ring out a block or so away. You guessed it; it was the "St. Valentine's Day Massacre". She also asked me what I thought about the upcoming baseball postseason, and was near-insistent that she got home in time for the game. Totally with it. I left the shift totally stunned. I want to be like her. I have an 87 year-old volunteer at my hospital who demands a hug-and-kiss from me every shift, and who can't wait to show me pics of her great-grandchildren on her smartphone... after she complains that Facebook has changed the format... again.

Think about it. The year is 2015. If more and more seniors are living into their 90s... (and living well)... think about what will happen in the year 2035.

When I was an intern... acute endovascular stroke intervention was a fairy tale. Six years later, I transfer old folks left and right to my nearest neurointerventional facility... and the suits at my shop are wondering how they can build one here.

When I'm 160, I'll still be trolling interns on SDN.

Better plan your retirement accordingly...

 

[RustedFox]

Better plan your retirement accordingly...

Retirement ? Lol.

 

[emergentmd]

Trauma center we are associated with has protocol for admit/obs on coumadin with INR greater than 1.5 I believe or on the new Xarelto like meds.

I explain to pt and offer admission and document that they don't want to stay. I find it absurd to admit all head trauma on Xarelto.

 

[turkeyjerky]

One study found a 6% delayed bleed risk within 24 hours for INR >3.

The largest study (over 1,000 patients) found it to be a little over 0.5% for delayed bleed in warfarin. They followed patients up for 2 weeks.

Most people don't realize the risk of intracranial bleeds is higher in clopidogrel patients (12%) than warfarin patients (5%).

Both of these studies were published in Annals a few years ago.

I think that study had a major selection bias which inflated the rate of bleeds in patients takin clopidogrel--I dont think most people scan every tiny bump on the noggin for these patients, while they certainly do in patients on warfarin.

And the rate of delayed bleeds in clopidogrel is very low, so obs'ing these patients is clearly superfluous.

I strongly consider obs'ing patients w/ a super therapeutic INR.

 

[ccfccp]

Agreed with most. I discuss the risk of delayed bleed, document well, and discharge with close follow up instructions. Might consider obs if lives alone with no family. I will sometimes offer obs, but most want to go home. This is in a completely asymptomatic patient. A whiff of a neurologic complaint will get you an obs admission.

 

[TheBlueBlazer]

As mentioned before, the risk of delayed bleed is probably even lower than the published data, and that echoes our experience at our place. That said, if someone has a big external whack and shows up early after their injury, we tend to hold onto them overnight, especially if they're one of those old folks with some extra room in the ol' coconut. Low-energy injury, reliable and able to be well-observed at home though, no need to keep them.

 

[Birdstrike]

Quick question for board review and practice:

I'm sure this varies some by facility. We would always scan these people (head trauma on coumadin) where I trained and send them out if negative. I'm doing HippoEM and they imply that they should be admitted for obs. Are you guys admitting a head injury on coumadin for obs, with a normal neuro exam, and with a reasonable INR (therapeutic)? If so, how bad does the injury have to be? A bump vs +LOC or what?

This is one where you'll see Trauma teams admit all these and community EM physicians admit practically none of these, unless there's some clinical reason to do so. Ct scanners nowadays are pretty darn good, and with a completely normal exam in the ED........you're going to admit? Okay, whatever. If your admitting teams will take these, then okay I guess, pretty seems like over kill. I don't recall every having one of these delayed bleeds after a negative CT. I've picked up several subclinical head bleeds in patients with normal exams and no loc that where an anticoagulant was their only risk factor, but admit ALL head bonks on coumadin despite, negative CT and normal exam? Hmm....I'm a pretty intense CYA doctor, and this one seems like over kill. Just saying'

And by the way, "Hello again, SDN EM." Seems like its been forever since I've been on here...