Anticoagulated Trauma Patient

Anticoagulants should be reversed immediately if TBI or significant bleeding is even POSSIBLE.

Warfarin and novel oral anticoagulants (NOACs) have been shown to increase the severity of head injury and increase mortality rate. Mortality of trauma patients with head injury while on warfarin ranges from 33% to 50%.  Furthermore, it has been reported that the head injured patients on warfarin have an increased risk of mortality from 2-fold to 4-fold, when compared with non-anti-coagulated patients with similar degrees of head injury.

As part of the trauma workup, one should always obtain an adequate history, which includes a list of current home medications. Early identification of warfarin use has been shown to reduce mortality on patients with intracranial hemorrhage from 48% to 9%. In the same study, mean time to warfarin reversal (normal coagulation profile) was 1.7 hours in the early identification group compared to 4.3 hours.

Another important aspect of the anti-coagulated patient is the decreased reliability of their neurological exam. It has been shown that GCS of 15 and no loss of consciousness does not reliably rule out intracranial pathology after trauma. Indeed, one study reported two anti- coagulated patients with no loss of consciousness that eventually died from consequence of intracranial hemorrhage. Therefore, all patients with known warfarin or NOAC use should have a CT scan of the head as part of their trauma workup regardless of their mental status.

If ICH is known or strongly suspected OR significant bleeding is suspected at any site (eg, see MTP activation criteria as indicators of hemorrhage), use reversal guideline incorporating aPCCs’ to achieve rapid effect (see Oral Anticoagulants in Trauma and Surgery Guideline- http://uktraumaprotocol.blogspot.com/2013/07/anticoagulants-in-trauma-and-surgery.html).

If active bleeding is not suspected based upon exam, mechanism is not significant AND neuro exam is satisfactory, reversal of warfarin may be initiated by administration of FFP (15-30cc/kg).

In all patients receiving reversal therapy for warfarin, vitamin K is indicated.

Repeat head CT is indicated at some point prior to discharge in all patients using systemic anticoagulants on admission.

In patients taking anticoagulants on admission for afib and/or prior DVT/PE, consider having patient remain off of therapeutic anticoagulation until at least 2 weeks after injury, to be determined on follow-up with PCP or SGB using input from Neurosurgery.

In patients on anticoagulants for cardiac valvular disease, stroke or life threatening thrombotic/thromboembolic disease, consider consulting the Anticoagulation Consult Service, PharmD and/or PCP or cardiologist to determine optimal timing and dose of anticoagulation, with input from Neurosurgery.

If therapeutic anticoagulants are restarted [including warfarin, therapeutic LMWH and novel oral anticoagulants such as the direct thrombin inhibitor (Pradaxa) and factor Xa inhibitors], patients should undergo repeat head CT immediately prior to starting and should be monitored in the hospital for 48-72 hours after anticoagulants are therapeutic. 

Lavoie A, Ratte S, Clas D, Demers J, Moore L, Martin M, Bergeron E. Preinjury warfarin use among elderly patients with closed head injuries in a trauma center. J Trauma. 2004 Apr;56(4):802-7.
Mina AA, Bair HA, Howells GA, Bendick PJ. Complications of preinjury warfarin use in the trauma patient. Trauma. 2003 May;54(5):842-7.
Janczyk et al. Rapid warfarin reversal in anticoagulated trauma patients with intracranial hemorrhage reduces hemorrhage progression and mortality. Abstract presented at AAST annual meeting, September 30, 2004.
Alahmadi H, et al. The Natural History of Brain Contusion:  An Analysis of Radiological and Clinical Progression. J Neurosurgery.  2010;112:1139-1145.
Itshayek E et al. Delayed Posttraumatic Acute Subdural Hematoma in Elderly Patients on Anticoagulation. Neurosurgery. 2006;58:851-855.