Learning points from the presentation and discussion:
* Decision instruments and an ACEP clinical policy exist to assist in the determination of whether a patient with a minor head injury requires imaging in the ED. These guidelines exclude anticoagulated patients, however, and the threshold to image the brain of head-injured patients who are anticoagulated should be low.
* Head-injured patients who are anticoagulated are at risk for delayed intracranial bleeding after a negative head CT. Options for managing this risk include a period of ED observation, admission to the hospital, and discharge with strict precautions/supervision (with or without a scheduled return visit). These strategies may or may not be combined with a repeat head CT. The duration of increased risk is not known but is thought to be somewhere between 24-72 hours, though delayed bleeds have presented even later than this.
* Intracranial bleeding with coagulopathy is a medical and surgical emergency that is both immediately life-threatening and responsive to ED therapies. These therapies should not wait for consultant collaboration and, where suspicion of ICH is sufficient, initiation of these therapies should not wait until confirmation of ICH.
* For patients with life-threatening bleeding on warfarin: administer vitamin K 10mg IV over 10 minutes and prothrombin complex concentrate. Dosing of PCC is not firmly established and can be based on both weight and INR, but 50 units/kg is a reasonable starting point in an emergency. An alternative is FFP, which should be administered at a dose of 15 ml/kg. At Sinai, a unit of FFP contains anywhere between 150 and 350 cc FFP; assume 200 cc for estimation purposes. FFP is blood type-specific; the blood bank needs to know the patient’s blood type but does not need a blood sample to cross-match.
* PCC reverses INR much more quickly than FFP, is easier to handle, and does not have the volume concerns of FFP. However, it is much more expensive than FFP and is associated with more thrombotic complications than FFP. In patients who are at particular risk of thrombosis, or when bleeding is not life-threatening, consider the benefit:harm between the two options.
* For patients with life-threatening bleeding on unfractionated heparin, stop the heparin infusion. Then administer protamine at a dose of 1 mg/100 u heparin given within the past 30 minutes, .75 mg/100 u heparin given 30-60 minutes ago, .5 mg/100 u heparin given 60-120 minutes ago, and .3 mg/100 u heparin given more than 2 hours ago.
* For patients with life-threatening bleeding on low molecular weight heparin, protamine is only partially effective (consider this before administering LMWH in a patient more likely to bleed - unfractionated heparin may be a better choice). The dose of protamine is 1 mg IV per 1 mg LMWH given in the last 10 hours. If LMWH is causing life-threatening bleeding unresponsive to protamine, consider activated Factor VII.
* For patients with life-threatening bleeding on plavix or aspirin, administer DDAVP at a dose of .3 mcg/kg with 6 units of platelets.
* For patients with life-threatening bleeding and liver failure with INR > 1.2, administer vitamin K 10 mg IV along with either PCC or FFP.
* For patients with life-threatening bleeding and renal disease associated with platelet dysfunction, administer DDAVP at a dose of 20 mcg. FFP or cryoprecipitate may also be used for additional procoagulant effect if necessary.
* For patients with life-threatening bleeding and thrombocytopenia, transfuse platelets to a level of at least 50,000.
