A 76-year-old man came to the emergency department after slipping on the ice and hitting his head. He believed he was briefly unconscious, but he was able to stand on his own and walk. He remembered losing his balance and then finding himself on his side on the ice. generic Levofloxacin online

He arrived at the hospital 30 minutes later accompanied by his son. He stated that, other than a headache, he felt fine. His medications included hydrochlorothiazide, acetaminophen, and 4 mg of warfarin daily for chronic atrial fibrillation. buy Omnicef 300 mg

His son stated that he seemed somewhat confused about important dates. Half an hour later, he was noted to be only opening his eyes to the sound of a voice and to be confused as to date and place.

QUESTIONS
What are the key management issues for patients taking warfarin who have sustained head injuries? What is the recommended approach for reversing the effects of warfarin in the setting of acute intracranial hemorrhage?

Warfarin is being prescribed to an increasing number of people with atrial fibrillation, prosthetic heart valves, and thromboembolic disease, conditions that are seen more and more frequently in our aging population. With age also comes an increased incidence of falls and other mishaps that result in blunt head injuries. It is not surprising, then, that the number of patients taking warfarin who present with head trauma is increasing.
There is about an 8- to 12-fold increase in the frequency of spontaneous intracranial hemorrhage among patients taking warfarin. Patients using warfarin are thought to have a similarly increased risk of intracranial hemorrhage as a result of blunt injury to the head. The usual bleeding pattern is intracerebral rather than epidural or subdural. The prognosis of patients taking warfarin who present with intracranial hemorrhage is generally poor, with a mortality rate of approximately two out of three. buy Strattera 25 mg

Headache is the most common warning symptom. Patients appearing alert and oriented can quickly become confused and then obtunded. Intracranial bleeding must be recognized and reversal of anticoagulation initiated. Steps must be taken quickly to identify the nature of the injury and prevent irreversible brain damage from continued intracranial hemorrhage. Celecoxib 200 mg online

Initial assessment
Patients at risk must be identified by triage staff upon arrival in the emergency department and be monitored. A detailed history and examination should include determination of Glasgow coma scale score (GCSS). A detailed neurologic examination must be carried out, with attention to features that indicate a focal deficit.

Family members or witnesses can be particularly helpful and can aid in evaluating the nature of the mishap. They can also often detect subtle alterations in thinking and behaviour, which might be early indications of brain injury. Buy canadian Sumatriptan

A careful evaluation of the cervical spine and examination for associated injuries must be included in the assessment. Initial investigations should include a complete blood count, international normalized ratio (INR), and partial thromboplastin time. The cause of the fall must be established, and further investigations might be indicated in that regard. Skelaxin 400 mg online

Some patients taking warfarin do not require computed tomography scans after head injury. The availability of equipment and the individual features of each presentation must be considered. With patients taking warfarin, however, the threshold for ordering CT scans of the head and for admitting and monitoring them is substantially lower than for other patients. buy generic Carisoprodol

Therapy
Any suggestion of an adverse intracranial process warrants initiation of focused therapy to reverse anticoagulation. Progressive confusion, decline in the GCSS, or any new focal neurologic deficit indicate the need for rapid reversal of the effects of warfarin. The decision to reverse anticoagulation might precede completion of imaging studies. Locating and ascertaining the nature of the hemorrhage by CT scan might need to follow reversal of anticoagulation, and empiric reversal of anticoagulation might be required before the INR is known. canadian pharmacy Tramadol

Administration of fresh-frozen plasma is the recommended method for rapid reversal of the effects of warfarin. There are other approaches, but they are either ineffective or impractical in this special setting.
Warfarin depletes vitamin K-dependent clotting factors II, VII, IX, and X. Frozen plasma, which can be thawed and administered in about 20 minutes, will effectively replace these depleted factors immediately. Normalizing a patient’s clotting profile requires 8 to 10 mL/kg of frozen plasma, which corresponds to two to three units of plasma because each unit contains 200 to 280 mL. buy Levaquin 500 mg

Frozen plasma, which contains no platelets, has replaced stored plasma, which was deficient in factors V and VIII. Frozen plasma can be given without major concerns regarding antibody (ABO) compatibility. In cases where ABO sensitivity is of concern, ABO-typed plasma can be given. Testing for serologic compatibility is not required before administration. Administration of frozen plasma carries no risk of transmitting infectious agents or of serious volume or osmotic overload. buy omnicef antibiotics

When there is less urgency, vitamin K can be administered to correct factors depleted by warfarin, but the process is slow. Vitamin K can be given orally or parenterally at a dose of 1 to 10 mg. The INR is a measure of vitamin K-dependent factor levels. Some normalization of a prolonged INR can be expected 2 hours after administration of vitamin K. Hemorrhage is usually controlled in 3 to 8 hours, and normalization of the INR is expected in 12 to 18 hours. canadian pharmacy Levaquin

In conclusion, recognition that patients taking warfarin are at high risk of bleeding is important for all members of the emergency team. Rapid identification of features suggestive of intracranial bleeding and prompt reversal of anticoagulation can save lives. Celebrex arthritis

ANSWERS
Patients taking warfarin have a high risk of intracranial hemorrhage with catastrophic results following head injury. Initial signs and symptoms can be subtle. Any clinical evidence of intracranial bleeding requires prompt administration of 8 to 10 mL/kg of frozen plasma and definitive imaging as part of overall management.