Delayed Intracranial Hemorrhage After Blunt Trauma: Are Patients on Preinjury Anticoagulants and Prescription Antiplatelet Agents at Risk?

Peck, Kimberly A.; Sise, C. Beth; Shackford, Steven R.; Sise, Michael J.; Calvo, Richard Y.; Sack, Daniel I.; Walker, Sarah; Schechter, Mark S.

doi:10.1097/ta.0b013e31823b9ce1

Cited by 61 publications

(67 citation statements)

References 13 publications

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“…Two studies reported separate results of patients on warfarin and clopidogrel, from which only patients on warfarin were included for this analysis. 12,15 The five studies qualitatively had substantial heterogeneity with noted differences in location, design, and population characteristics ( Table 1). The prospective observational study by Nishijima et al 15 had the largest sample size and showed a prevalence of 6 (95% confidence interval [CI], 2Y15) cases of delayed intracranial hemorrhage per 1,000 patients.…”

Section: Resultsmentioning

confidence: 98%

Delayed intracranial hemorrhage in the anticoagulated patient

Miller

Lieberman

Nahab

et al. 2015

Journal of Trauma and Acute Care Surgery

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Section: Resultsmentioning

confidence: 98%

Delayed intracranial hemorrhage in the anticoagulated patient

Miller

Lieberman

Nahab

et al. 2015

Journal of Trauma and Acute Care Surgery

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“…However, the pre-injury use of APAs did not affect morbidity and mortality in retrospective studies in patients with pelvic fractures [412] or general trauma without brain injury [413], but did have an effect in patients with hip fractures [409]. On the contrary, even mild head trauma (GCS 14 to 15) while on APAs is associated with a high incidence of intracranial hemorrhage (ICH) [414-416], and a risk of delayed ICH in this group of patients mandates a longer period of observation [417,418]. Moreover, observational studies found a five-fold increase in traumatic ICH in patients on APAs [419].…”

Section: Resultsmentioning

confidence: 99%

Management of bleeding and coagulopathy following major trauma: an updated European guideline

Bouillon²,

et al. 2013

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IntroductionEvidence-based recommendations are needed to guide the acute management of the bleeding trauma patient. When these recommendations are implemented patient outcomes may be improved.MethodsThe multidisciplinary Task Force for Advanced Bleeding Care in Trauma was formed in 2005 with the aim of developing a guideline for the management of bleeding following severe injury. This document represents an updated version of the guideline published by the group in 2007 and updated in 2010. Recommendations were formulated using a nominal group process, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) hierarchy of evidence and based on a systematic review of published literature.ResultsKey changes encompassed in this version of the guideline include new recommendations on the appropriate use of vasopressors and inotropic agents, and reflect an awareness of the growing number of patients in the population at large treated with antiplatelet agents and/or oral anticoagulants. The current guideline also includes recommendations and a discussion of thromboprophylactic strategies for all patients following traumatic injury. The most significant addition is a new section that discusses the need for every institution to develop, implement and adhere to an evidence-based clinical protocol to manage traumatically injured patients. The remaining recommendations have been re-evaluated and graded based on literature published since the last edition of the guideline. Consideration was also given to changes in clinical practice that have taken place during this time period as a result of both new evidence and changes in the general availability of relevant agents and technologies.ConclusionsA comprehensive, multidisciplinary approach to trauma care and mechanisms with which to ensure that established protocols are consistently implemented will ensure a uniform and high standard of care across Europe and beyond.Please see related letter by Morel et alhttp://ccforum.com/content/17/4/442

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“…The 0.5% rate of delayed development of ICH is similar to previously published reports. 11,20 There are a number of reasons that the use of plasma to reverse warfarin anticoagulation may be ineffective. According to the results of a systematic review of 80 randomized clinical trials, the current guidelines for the administration of FFP are largely empirical.…”

Section: Discussionmentioning

confidence: 99%

“…10 Traumatic brain injury in anticoagulated patients occurs not only acutely but can also develop more slowly and be identified in a delayed fashion. 11,12 Aggressive reversal of anticoagulation has been shown to improve outcome after traumatic intracranial hemorrhage (ICH). 13 Options for reversal of anticoagulation include infusion of fresh frozen plasma (FFP), administration of vitamin K, and use of coagulation factors.…”

Section: Introductionmentioning

confidence: 99%

Prophylactic Fresh Frozen Plasma Infusion is Ineffective in Reversing Warfarin Anticoagulation and Preventing Delayed Intracranial Hemorrhage After Falls

Reddy

Sharma

Grotts

et al. 2015

The Neurohospitalist

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Background: Elderly patients, with considerable fall risk, are increasingly anticoagulated to prevent thromboembolic disease. We hypothesized that a policy of prophylactic fresh frozen plasma (FFP) infusion in patients having falls would reverse vitamin K antagonists (VKAs) and that reversal would decrease delayed intracranial hemorrhage (ICH). Methods: A retrospective review of patients with trauma admitted to a level 2 community trauma center was performed from January 2010 until November 2012. Inclusion criteria were: ground level fall (GLF) with suspected head trauma, on VKA, an international normalized ratio (INR) of >1.5, and a negative head computed tomography (CT). Patients were transfused with FFP to a goal INR of <1.5 while observed. Patients were classified as reversed (REV) if the lowest INR achieved within 4 to 24 hours after initial INR was <1.5 or unreversed (NREV) if lowest INR achieved was >1.5. Chi-square and logistic regression were performed. Results: A total of 194 patients met the criteria. In all, 43 (22%) patients were able to be REV, and 151 (78%) patients remained NREV. Unreversed patients were male and younger (P < .05). There was no difference in mean FFP received. Unreversed patients had a higher initial INR of 3.0 compared to REV patients (2.5; P ¼ .018). One patient developed a delayed ICH and belonged to the REV group. Conclusion: The incidence of delayed hemorrhage was 0.5%. A strategy of prophylactic FFP infusion was ineffective in VKA reversal. We recommend against prophylactic infusion of FFP during a period of observation for patients on VKA with suspected head trauma and a negative initial CT.

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Delayed Intracranial Hemorrhage After Blunt Trauma: Are Patients on Preinjury Anticoagulants and Prescription Antiplatelet Agents at Risk?

Cited by 61 publications

References 13 publications

Delayed intracranial hemorrhage in the anticoagulated patient

Delayed intracranial hemorrhage in the anticoagulated patient

Management of bleeding and coagulopathy following major trauma: an updated European guideline

Prophylactic Fresh Frozen Plasma Infusion is Ineffective in Reversing Warfarin Anticoagulation and Preventing Delayed Intracranial Hemorrhage After Falls

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