Case 22: Warfarin Woe

A 73 year old man is brought to the ED by his neighbor after a witnessed trip & ground fall over a hose in his back yard. It was a ground level fall and he hit the right side of his head against a knee-high brick wall in the garden. There was no loss of consciousness and he felt fine prior to tripping. He has a mild headache, but no other injuries. He talkes HCTZ, omeprazole and warfarin. His exam is normal except for a small contusion over his right ear.

His labs are normal except for an INR of 2.4. His head CT is normal. He feels fine and wants to go home. Where’s the mystery you ask? The mystery is to answer these question: 1.) What is the “standard of care” for such a presentation. 2.) What is optimal care for such a presentation, i.e. under what circumstances should there be consideration for FFP? for Vitamin K? for admission?

Before answering, check out my Coagulation Cascade and the location of action of Coumadin. Please submit any comments for improvements.

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ANSWER: Even though the CT is normal. This patient is at high risk for DELAYED CNS bleeding. Admission should be considered most strongly if there is no one at home to observe this patient. FFP only lasts 6 hours, so it is not needed. There are no good data for vitamin K use in a case like this, but it should be considered when the risks of stroke from coumadin reversal are low, such as in a patient with no prior CVA’s or who is on Coumadin for DVT/PE prophylaxis. See below for more.

CASE OUTCOME: This patient went home.  He didn’t answer the door when the neighbor came over the next morning so 911 was called.  On arrival to the ED the patient was deeply comatose.  He was intubated and a repeat CT scan showed a huge subdural hematoma.  The CT from the prior evening was reviewed - normal.  Because of the grim prognosis, supportive care was withdrawn and the patient expired.

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MANAGEMENT OF ELEVATED INR WITHOUT BLEEDING

from

“QUICK ESSENTIALS: EMERGENCY MEDICINE“

ELEVATED INR TREATMENT: WITHOUT SIGNIFICANT BLEEDING:
Head trauma: Observe 6 hours in ED even if CT negative. consider repeat CT. Consider prophylactic vitamin K if risks of reversal low (i.e. no prior CVA or not in A-fib)
Dispo: Always have recheck in 24h. Never d/c alone to home. supervision or admit
Vitamin K: Onset 2-12hours. Coumadin Resistance: 10mg:10days, 1mg:1d.   Works by activating an alternative quinone reductase.
Note: In significant head trauma consider being more aggressive with treatment

INR            Risk of Event in 48 hours      TREATMENT if no active bleeding*
INR<5         <1:1000                                        Hold coumadin (see next chart), ū home
INR:5-9       intermediate                                2.5mg po vitamin K, rarely admission
INR:9-20     >1:100                                         5mg po vitamin K, consider admission
INR>20        High risk                                      10mg vitamin K IVPB and admission
* If bleeding present, treatment is more aggressive. See next section

Dispo: Consider admisison if INR>10,  bad head trauma even if CT neg, lives alone.

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