Anti coagulated head injuries

In 2014 NICE updated their guidelines on Head Injury: assessment and early management. This included specific guidance for those patients on warfarinScreen Shot 2016-08-27 at 12.27.56

Guidance regarding the ongoing observation of these patients is not contained within the guideline but as with much of Emergency Medicine variation between departments and regions vary in the threshold to admit patients with a normal CT head due to concerns of these patients developing a delayed bleed.

A recent systematic review and meta analysis on the topic has just been published and we thought it would be worth a look.

Risk of Delayed Intracranial Hemorrhage in Anticoagulated Patients with Mild Traumatic Brain Injury: Systematic Review and Meta-Analysis. Chauny JM. J Emerg Med. Jul 26 2016

The paper gives an interesting take on the risk we are dealing with following a normal scan in presentation to the ED and whilst the papers contained may not be the strongest level of evidence the meta-analysis is probably the best we have to go on at present.

Enjoy and we’d love to hear any of your thoughts.


  • Francoise says:

    Thanks for this podcast. Do the papers specify their advice re altering/omitting warfarin doses or giving vitamin K to the patients even if their CT is normal? Our local haematologists are suggesting we give Vit K Before Ct to any patient on warfarin we are concerned has a bleed after TBI.

  • Mattias says:

    Is there any way I can download this podcast without having Itunes?

  • David Hindle says:

    Thanks for the review. There has been a paper in the last few years (perhaps included in the Meta Analysis?), that showed the risk of delayed ICH was higher if the patient’s INR > 3. So I think a combination of factors can be used to help make this decision: mechanism, how much outward sign of trauma there is, INR > 3 or not, does patient live alone or have reliable family members available to watch the patient carefully for signs of delayed bleed. Using all this have a discussion with the patient and family as you stated in the podcast.
    In addition, another paper has recently suggested that patient’s taking Clopidogrel have a higher incidence of delayed ICH than those on Warfarin. So a careful review of their medications is needed, and if a patient is taking Clopidogrel and Warfarin, be more concerned.

    • Simon Laing says:

      Thanks David, do you have the reference for the INR paper? I heard Su Mason present the findings from the AHEAD study which found the opposite (I.e. No correlation with INR and bleeding rate).

      Thanks for the comments

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