Evaluation of a protocol for early detection of delayed brain hemorrhage in head injured patients on warfarin
In 2007, Essentia Health St. Mary’s Medical Center (SMMC), a Level II trauma center in northeastern Minnesota, implemented a protocol for patients who presented with blunt head trauma and were receiving warfarin for anticoagulation. The purpose of this study was to determine the incidence and risk factors of early delayed, warfarin-associated intracranial hemorrhage (ICH).
Adult patients with signs and symptoms of head injury on warfarin who were admitted by protocol to SMMC between March 2007 and June 2015 were included. Patients were observed for neurologic change and received a follow-up head CT scan within 24 h after an initial negative scan.
Among the 232 episodes of care studied, there were 204 patients. The average age was 71; 51% of patients were female. Most patients presented with Glasgow Coma Scale score of 15 and had signs of head trauma. The majority of patients (63%) had a therapeutic International Normalized Ratio (INR) for their indicated condition, but 19% of patients had a supratherapeutic INR and 19% had a subtherapeutic INR. The incidence of early delayed ICH was 1.7%; none of these cases required operative intervention or were fatal.
For patients who were anticoagulated with warfarin and had sustained minor traumatic brain injury, implementation of our protocol showed low incidence of early delayed ICH in the first 24 h. We believe withholding warfarin for several days and careful follow-up regarding its resumption is warranted, especially in the setting of supratherapeutic INR.
KeywordsTraumatic brain injury Warfarin Delayed hemorrhage
The project was funded in part by a Grant from Essentia Health Duluth Clinic Foundation.
JLH assisted with data collection, data analysis, and manuscript preparation. TAW assisted with literature search and manuscript preparation. PC assisted with the data analysis, interpretation, and manuscript preparation. CAM acquired funding, supervised staff, and assisted with manuscript preparation. MME assisted with data collection. SDE conceived the study, assisted with data collection and interpretation, and manuscript preparation. All authors reviewed and approved the final manuscript.
Compliance with ethical standards
Conflict of interest
No conflicts of interests to declare: this research was funded in part by a Grant from Essentia Health Duluth Clinic Foundation.
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