By Allison Sarff Luu, MD
IN THIS BLOG POST, WE WILL GO THROUGH AN EASY ALGORITHM THAT CAN BE APPLIED TO ALL PATIENTS WITH INTRACRANIAL HEMORRHAGE, AND SPECIFICS ON ANTI-COAGULATION REVERSAL.
A 77 yo M was BIBA after a ground level fall. He arrives well-appearing with a scrape on his forehead. He states that he just tripped while he was jogging. Other than a headache, he has no acute complaints.
VS: 98.7 P 75 BP 174/107 RR 12 98% RA GCS 15
Then he tells you “By the way, I take Warfarin”
Now you’re worried. You rush him to the CT scanner, and low and behold, his CT is NEGATIVE! You’re out of the woods… or so you thought.
The nurse calls you back after about 4hrs and tells you your patient is unresponsive. At this point you rush him to the CT scanner again and you find this:
How did this happen? Did I miss something? In these moments of panic as a physician, it’s nice to have a mnemonic to help you through. When you see a massive head bleed, you should think: BRAINS
- B lood pressure control
- R everse Coagulopathy
- A BC’s
- I CP Control
- N eurosurgery
- S eizure prophylaxis
Blood pressure control
Generally, avoid hypotension!
- Keep MAP > 80
- Generally SBP 140-160
PCC or Kcentra was FDA approved in the US in 2013. It consists of a combination of clotting factors II, VII, IX, and X as well as protein C and S prepared from FFP (fresh frozen plasma). There is no risk for infection or TRALI as there is with FFP and it is much faster to obtain when compared with FFP. It also consists of less fluid so it is great for patients in whom you are concerned about fluid overload.
This part you know, protect your patient’s airway. Does your patient have a gag reflex? If the answer is no, intubate. Is their GCS < 8 in a trauma? Intubate.
Much of this is controversial so talk it over with your neurosurgeon but in general, here are the things to consider:
- Hypertonic saline (3% saline or NaBicarb)
- Hyperventilate (if the patient is near-herniation)
- Give Mannitol
- Elevate the head of the bed >30 degrees (not controversial, just do it. Decreases ICP and protects against aspiration in your intubated patient)
Your definitive management lies here. Get your specialist on board for a possible surgical procedure. They will be happy you reversed the anticoagulation already.
General indications for neurosurgery include a GCS < 8 in:
- Epidural Hematoma
- Subdural Hematoma
- Penetrating injury
- Depressed skull fracture
The Incidence of post-traumatic seizures in the 1st week is about 6-10% but may be as high as 30%
1st line: Phenytoin
2nd line: Keppra
Now lets circle back to our patient. What happened in this case is a phenomenon known as a Delayed Bleed
Definition: Bleeding that occurs anytime after an initial negative head CT.
The 2002 European guideline on mild TBI recommended that all anticoagulated head-injured patients be admitted and receive 2 CT scans, one initially and a second after 24 hours. This guideline was based off of 2 case reports.
Why would a delayed bleed occur?
Think back to the basics of clot formation with me for a minute. It tends to occur in 3 stages:
Once you have formed the clot, you need to STABILIZE it. This is where fibrin comes in. Fibrin is made in the anticoagulation cascade. I know you tried to forget this immediately after learning it for your boards, but its actually pretty important! Here’s a closer look:
I added in some detail about where each of our anticoagulation medications block this cascade to ultimately block the formation of fibrin!
Because fibrin stabilizes an already formed clot, a delayed bleed is not so far-fetched if you’re missing fibrin. The clot forms immediately due to factors such as platelets, but keeping it in place is something that occurs over the long-term.
When should you worry about a delayed bleed?
With the data we have now, we know they occur in <1% of all minor head injuries on warfarin, with varying INRs (sometimes a normal INR).
They also occur at various times (4hrs or up to 8 days after injury) and are thus almost impossible to predict or prevent.
Particular things to be cautious about include:
- Patients > 60 years old
- Patients on warfarin or –xabans/Dabigatran
- Patients with poor social circumstance/live alone and won’t be able to return immediately to the ED if they were to decline
Watch Dr. Luu lecture on this topic:
For more reading, please check out the following articles:
- Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and preinjury warfarin or clopidogrel use. Nishijima DK, Offerman SR, Ballard DW, Vinson DR, Chettipally UK, Rauchwerger AS, Reed ME, Holmes JF; Clinical Research in Emergency Services and Treatment (CREST) Network. Ann Emerg Med. 2012 Jun;59(6):460-8.e1-7. doi: 10.1016/j.annemergmed.2012.04.007.
- Routine repeat head CT may not be indicated in patients on anticoagulant/antiplatelet therapy following mild traumatic brain injury. McCammack KC, Sadler C, Guo Y, Ramaswamy RS, Farid N. West J Emerg Med. 2015 Jan;16(1):43-9. doi: 10.5811/westjem.2014.10.19488. Epub 2014 Dec 1.
- The value of sequential computed tomography scanning in anticoagulated patients suffering from minor head injury. Kaen A, Jimenez-Roldan L, Arrese I, Delgado MA, Lopez PG, Alday R, Alen JF, Lagares A, Lobato RD. J Trauma. 2010 Apr;68(4):895-8. doi: 10.1097/TA.0b013e3181b28a76.
- Management of minor head injury in patients receiving oral anticoagulant therapy: a prospective study of a 24-hour observation protocol. Menditto VG, Lucci M, Polonara S, Pomponio G, Gabrielli A. Ann Emerg Med. 2012 Jun;59(6):451-5. doi: 10.1016/j.annemergmed.2011.12.003. Epub 2012 Jan 14.