An increasing number of people are taking anticoagulants for the prophylaxis of thromboembolic disease. This may cause problems when they attend hospital following trauma. Patients may also develop spontaneous bleeding that may have similar effects to bleeding after an injury.
This article discusses the risks of bleeding (especially in head injury); the risks of stopping anticoagulation; how anticoagulation should be reversed and how anticoagulation should affect the approach to the head-injured patient.
Aienta C, Caroli M, Balbi S.1997. Management of head injured patients in the emergency department: a practical protocol. Surg Neurol48: 213-219.
2.
Black PR, Flowers MJ, Saleh M.1997. Acute carpal tunnel syndrome as a complication of oral anticoagulant therapy. J Hand Surg (Br)22B: 50-51.
3.
British Committee for Standards in Haematology (BCSH). 1998. Guidelines on oral anticoagulation: third edition. British Journal of Haematology101: 374-387.
4.
Brown J, Li J, Levine M, Rosen M.2000. Do anticoagulated patients with minor head injury need head CT? Results from the COSH [antiCOagulation and the Study of Head injury] phase I trial. Acad Emerg Med7: 495-495.
Checketts MR, Wildsmith JAW.2003. Preoperative considerations. In: Wildsmith JAW, Armitage EN, McClure JH eds. Principles and practice of regional anaesthesia, 3rd edn. Philadelphia: Churchill Livingstone, 77-90.
7.
Evans G, Luddington R, Baglin T.2001. Beriplex P/N reverses severe Warfarin-induced over-anticoagulation immediately and completely in patients presenting with major bleeding. BJ Haem115: 998-1001.
8.
Fabbri A, Servadei F, Marchesini Get al. 2004. Which type of observation for patients with high-risk mild head injury and negative computerised tomography? Europ J Emerg Med11: 65-69.
9.
Ferrera PC, Bartfield JM.1999. Outcomes of anticoagulated trauma patients. Am J Emerg Med17: 154-156.
10.
Garra G, Nashed AH, Capobianco L.1999. Minor head trauma in anticoagulated patients. Acad Emerg Med6: 121-124.
11.
Hart RG, Boop BS, Anderson DC.1995. Oral anticoagulants and intracranial haemorrhage. Facts and hypotheses. Stroke26: 1471-1477.
12.
Hay SM, Allen MJ, Barnes MR.1992. Acute compartment syndrome resulting from anticoagulant treatment. BMJ305: 1474-1475.
13.
Haydel MJ, Preston CA, Mills TJet al. 2000. Indications for computed tomography in patients with minor head injury. New Eng J Med343: 100-105.
14.
Hylek EM, Singer DE.1994. Risk factors for intracranial haemorrhage in outpatients taking warfarin. Ann Intern Med120: 897-902.
15.
Jeret JS, Mandell M, Anziska Bet al. 1993. Clinical predictors of abnormality disclosed by computed tomography after mild head trauma. Neurosurgery32: 9-16.
16.
Karni A, Holtzman R, Bass Tet al. 2001. Traumatic head injury in the anticoagulated elderly patient: a lethal combination. Am Surg67: 1098-1100.
17.
Kearon C, Hirsh J.1997. Management of anticoagulation before and after elective surgery. New Eng J Med336: 1506-1511.
18.
Keogh IJ, Rowley H, Russell J.2002. Critical airway compromise caused by neck haematoma. Clin Otolarygol27: 245-245.
19.
Landenfeld CS, Beyth RJ.1993. Anticoagulant related bleeding: clinical epidemiology, prediction and prevention. Am J Med95: 392-393.
20.
Lavoie A, Ratte S, Clas Det al. 2004. Preinjury warfarin use among elderly patients with closed head injuries in a trauma center. J Trauma56: 802-807.
21.
Lee ST, Liu TN, Wong CWet al. 1995. Relative risk of deterioration after mild closed head injury. Acta Neurochir (Wien)135: 136-140.
22.
Li J, Brown J, Levine M.2001. Mild head injury, anticoagulants and risk of intracranial injury. Lancet357: 771-772.
23.
Lin J, Hanigan WC, Tarantino M, Wang J.2003. The use of recombinant activated factor VII to reverse warfarin-induced anticoagulation in patients with hemorrhages in the central nervous system: preliminary findings. J Neurosurg98(4): 737-740.
24.
Makris M, Greaves M, Phillips WSet al. 1997. Emergency oral anticoagulant reversal: the relative efficacy of infusions of fresh frozen plasma and clotting factor concentrate on correction of the coagulopathy. Thromb Haemostat77: 477-480.
25.
Mathiesen T, Benediktsdottie K, Johnsson H, Lindqvisst M, von Holst H.1995. Intracranial traumatic and non-traumatic haemorrhagic complications of warfarin treatment. Acta Neurologica Scandinavica91: 208-214.
26.
Miller EC, Holmes JF, Derlet R.1997. Utilising clinical factors to reduce head CT scan ordering for minor head trauma patients. J Emerg Med15: 453-457.
27.
Mina AA, Knipfer JF, Park DY, Bair HA, Howells GA, Bendick PJ.2002. Intracranial complications of prein-jury anticoagulation in trauma patients with head injury. J Trauma53: 668-672.
28.
Mina AA, Bair HA, Howells GA, Bendick PJ.2003. Complications of preinjury warfarin use in the trauma patient. J Trauma54: 842-847.
29.
National Institute for Clinical Excellence (NICE)2003. Head injury: triage, assessment, investigation and early management of head injury in infants, children and adults. Clinical guideline 4. Developed by the National Collaborating Centre for Acute Care. London: National Institute of Clinical Excellence, 2003.
30.
Prasad SS, O’Malley M, Machani B, Shackleford IM.2003. A case report of a spinal epidural haematoma associated with warfarin therapy. Ann Roy Coll Surg Engl85: 277-278.
31.
Radberg JA, Olsson JE, Radberg CT.1991. Prognostic parameters in spontaneous intracerebral hematomas with special reference to anticoagulant treatment. Stroke22: 571-576.
32.
Reynolds FD, Dietz PA, Higgins DH, Whitaker TS.2003. Time to deterioration of the elderly, anticoagulated, minor head injury patient who presents without evidence of neurological abnormality. J Trauma54: 492-496.
33.
Saab M, Gray A, Hodgkinson D, Irfan M.1996. Warfarin and the apparent minor head injury. J Accid Emerg Med13: 208-209.
34.
Sjöblom L, Hårdemark H-G, Lindgren Aet al. 2001. Management and prognostic features of intracerebral hemorrrhage during anticoagulant therapy. Stroke42: 2567-2574.
35.
Stein J, Viramontes BE, Kerrigan DC.1995. Fall related injuries in anticoagulated stroke patients during inpatient rehabilitation. Arch Phys Med Rehab76: 840-843.
36.
Stein SC, Ross SE.1992. Mild head injury: a plea for routine early CT scanning. J Trauma33: 11-13.
37.
Thumboo J, O’Duffy JD.1998. A prospective study of the safety of joint and soft tissue aspirations and injections in patients taking warfarin. Arthritis Rheum41: 736-739.