Warfarin-Associated Intracerebral Hemorrhage Is Inadequately Treated at Community Emergency Departments

Liotta, Eric M.; Garg, Rajeev; Temes, Richard E.; John, Sayona; Lee, Vivien; Bleck, Thomas P.; Prabhakaran, Shyam

doi:10.1161/strokeaha.112.664540

Cited by 21 publications

(15 citation statements)

References 10 publications

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“…The results showed a numerically lower inhospital mortality rate among patients in the early-reversal group relative to the other patients (30% versus 39%, p = 0.72). 27 The observed trend of reduced mortality risk with earlier INR reversal parallels results from our study (i.e., lower inhospital mortality among patients with ICH whose INR was corrected to a value of ≤1.5); however, our findings were significant at the 95% confidence level.…”

Section: Discussionsupporting

confidence: 87%

Use of blood products in patients with anticoagulant-related major bleeding: An analysis of inhospital outcomes

Menzin¹,

Sussman²,

Nichols³

et al. 2014

American Journal of Health-System Pharmacy

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Section: Discussionsupporting

confidence: 87%

Use of blood products in patients with anticoagulant-related major bleeding: An analysis of inhospital outcomes

Menzin¹,

Sussman²,

Nichols³

et al. 2014

American Journal of Health-System Pharmacy

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“…An initial mild presentation or nonspecific symptomatology can potentially contribute to both diagnostic and therapeutic delays, despite clear guidelines recommending rapid INR correction. The 4.45-hour treatment delay in our traditional ED referral cohort is remarkably consistent with a 4.48-hour delay to PCC treatment recently published in an independent WAICH cohort derived from 24 community EDs [17]. In these settings, a stroke prenotification system geared toward high sensitivity and the presence of a dedicated stroke team upon patient arrival can help expedite the diagnosis and facilitate treatment.…”

Section: Discussionsupporting

confidence: 83%

“…Analogous to ischemic stroke, rapid intervention is crucial and may lead to better outcomes [17,18]. Unlike patients with ischemic stroke, patients with WAICH present heterogeneously, with symptoms ranging from headache to coma.…”

Section: Discussionmentioning

confidence: 99%

Stroke Prenotification Is Associated with Shorter Treatment Times for Warfarin-Associated Intracerebral Hemorrhage

et al. 2013

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Background: Warfarin-associated intracerebral hemorrhage (WAICH) is a devastating disease with increasing incidence. In this setting, treatment with prothrombin complex concentrates (PCC) is essential to correct coagulopathy. Yet despite the availability of coagulopathy correction strategies, significant treatment delays can occur in emergency departments (EDs), which may be overcome using stroke prenotification strategies. To explore this, we compared arrival-to-treatment times with PCC for WAICH between two different stroke response systems that used the same international normalized ratio (INR) correction protocol. Methods: We established a registry of consecutive patients presenting with WAICH and treated with PCC presenting to two Canadian tertiary-care academic stroke centers: one with a stroke prenotification system, and one with a traditional ED assessment, treatment and referral system. In this comparative cohort design, we defined the WAICH diagnosis time as the earliest time point where both INR and CT were available. We compared median times from arrival to treatment, as well as arrival to diagnosis, and diagnosis to treatment. Results: Between 2008 and 2010, we collected data from 123 consecutive patients with intracranial hemorrhage who received PCC for INR correction (79 from ED referral, and 44 prenotification). Onset-to-arrival times, demographics, Glasgow Coma Scale scores, and baseline INR were similar between the two systems. Arrival-to-treatment times were significantly shorter in the prenotification system as compared to the traditional ED referral system (135 vs. 267 min; p = 0.001), which was driven by both decreased arrival-to-diagnosis time (49 vs. 117 min; p = 0.006), as well as decreased diagnosis-to-treatment time (56 vs. 112 min; p < 0.001). Arrival-to-scan times and arrival-to-INR times were similarly shorter in the prenotification system (68 vs. 118 min and 20.5 vs. 47 min, respectively). Conclusion: Stroke prenotification was associated with shorter arrival-to-treatment times for emergent INR correction in patients with WAICH, which was driven by both faster diagnosis and treatment. Our results are consistent with those seen in ischemic stroke, suggesting that prenotification systems present an opportunity to optimize acute intracerebral hemorrhage therapy.

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“…This is particularly important as antithrombotics influence the risk of traumatic hematoma expansion, and urgent surgical intervention, requiring assessment and treatment of coagulopathy, may be warranted. 32,40 Although individual rapid-TEG parameters failed to identify those patients at risk for hematoma expansion in a study of 279 patients with isolated TBI, the composite coagulopathy score, which was heavily weighted by rapid-TEG parameters, was associated with increased odds of expansion (OR 1.81, 95% CI 1.09-3.01; p = 0.021).…”

Section: 2660mentioning

confidence: 99%

Neurosurgical applications of viscoelastic hemostatic assays

Kvint¹,

Schuster²,

Kumar

2017

Neurosurgical Focus

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Patients taking antithrombotic agents are very common in neurosurgical practice. The perioperative management of these patients can be extremely challenging especially as newer agents, with poorly defined laboratory monitoring and reversal strategies, become more prevalent. This is especially true with emergent cases in which rapid reversal of anticoagulation is required and the patient’s exact medical history is not available. With an aging patient population and the associated increase in diseases such as atrial fibrillation, it is expected that the use of these agents will continue to rise in coming years. Furthermore, thromboembolic complications such as deep venous thrombosis, pulmonary embolism, and myocardial infarction are common complications of major surgery. These trends, in conjunction with a growing understanding of the hemostatic process and its contribution to the pathophysiology of disease, stress the importance of the complete evaluation of a patient’s hemostatic profile in guiding management decisions. Viscoelastic hemostatic assays (VHAs), such as thromboelastography and rotational thromboelastometry, are global assessments of coagulation that account for the cellular and plasma components of coagulation. This FDA-approved technology has been available for decades and has been widely used in cardiac surgery and liver transplantation. Although VHAs were cumbersome in the past, advances in software and design have made them more accurate, reliable, and accessible to the neurosurgeon. VHAs have demonstrated utility in guiding intraoperative blood product transfusion, identifying coagulopathy in trauma, and managing postoperative thromboprophylaxis. The first half of this review aims to evaluate and assess VHAs, while the latter half seeks to appraise the evidence supporting their use in neurosurgical populations.

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Warfarin-Associated Intracerebral Hemorrhage Is Inadequately Treated at Community Emergency Departments

Cited by 21 publications

References 10 publications

Use of blood products in patients with anticoagulant-related major bleeding: An analysis of inhospital outcomes

Use of blood products in patients with anticoagulant-related major bleeding: An analysis of inhospital outcomes

Stroke Prenotification Is Associated with Shorter Treatment Times for Warfarin-Associated Intracerebral Hemorrhage

Neurosurgical applications of viscoelastic hemostatic assays

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