Guideline: How To Manage Bleeding In The Anticoagulated Patient
Over the past year, I’ve written about bleeding problems in trauma patients caused or exacerbated by the various anticoagulants now on the market. The field of available drugs keeps growing, and the number of ways to keep blood in liquid form is increasing.
Here’s a link to a set of guidelines for approaching and treating patients who are taking these medications and then develop problematic bleeding. There are few good studies that have actually analyzed the efficacy of these methods, but it’s what we have to work with now.
If you have any additional maneuvers that you think should be included, please comment or email. And feel free to implement some studies to find the real best practices.
Link: Guideline for bleeding in patients taking anticoagulants
When Can Your Trauma Patient Stop Taking Warfarin?
I admit it. I read trauma and surgery literature, not medical literature. Imagine my surprise when a fellow physician (internist) told me that there is an objective system for helping us figure out whether anticoagulation is needed for atrial fibrillation. “CHADS2” he said. Am I the last trauma surgeon on earth to hear about this?
CHADS2 is a validated scoring system for predicting stroke risk in people with atrial fibrillation. There are 5 components as follows:
- C - congestive heart failure - 1 point
- H - hypertension (treated or untreated) - 1 point
- A - age >= 75 - 1 point
- D - diabetes mellitus - 1 point
- S2 - history of stroke or TIA - 2 points
Stroke risk is directly correlated to the number of points scored. So based on that the recommendations are:
- Score = 0: low risk, no therapy needed or just take aspirin
- Score = 1: moderate risk, aspirin or oral anticoagulant
- Score >= 2: moderate to high risk, take oral anticoagulant
Bottom line: Evaluate every trauma patient on anticoagulation to see if they really need to keep taking it. If it’s for a one-time episode of DVT or PE that happened years ago, they should be able to stop. If it’s for a-fib, check their CHADS2 score and work with their primary care provider to see if they could take aspirin or nothing. Factor in a history of frequent falls or car crashes as well.
Reference: Selecting patients with atrial fibrillation for anticoagulation: stroke risk stratification in patients taking aspirin. Circulation 110 (16): 2287–92, 2004.
How To Manage TBI In Patients On Warfarin
We all know that the combination of traumatic brain injury (TBI) and warfarin can be dangerous. Here at Regions, we developed a reversal protocol a few years ago. However, we found that just having a list of preferred “antidotes” to give was not enough. The time factor is very important, and we found that we needed to ensure prompt use of these medications when indicated.
So we added features that ensured timely response and reversal. You can download the protocol by clicking the image above or the link at the bottom of this post.
First, we recognized that any patient with a known or suspected TBI who was taking warfarin was at risk. If the initial GCS was <14, then a full trauma team activation is called. This gives the patient priority lab processing and immediate access to the CT scan. In addition, 2 units of thawed plasma are administered while in the resuscitation room. If the head CT is negative, plasma is stopped.
For patients with a GCS of 14 or 15, a “Code RED” is called, ensuring that an ED physician sees the patient immediately. A point of care INR is drawn and the patient is sent for stat head CT. If the head CT is negative with INR>2.5, the patient is admitted for observation and a repeat head CT is obtained 12 hours later. We have seen patients develop delayed hemorrhage when they have high INR.
We apply a restrictive set of criteria to determine if a patient may go home from the ED, which causes us to admit most for observation. And if they do have a positive CT, we use the algoritm listed below for comprehensive management and reversal.
Bottom line: Patients with any head trauma and an elevated INR are a walking time bomb. They need prompt assessment and reversal of their anticoagulation if indicated. Feel free to share your protocols here as well by posting a comment.
Download the full protocol; click here.
Anticoagulation Reversal In Trauma
I’ve previously written about reversing specific agents that may interfere with clotting in trauma patients. Today I’m going to provide a reference sheet to help you reverse any of the common agents that your trauma patients may be taking.
This reference is a work in progress and will change as new drugs are introduced. I’ll update it as revisions are made. And as always, comments and suggestions are welcome!
Click here to download the reference sheet.
Thanks to Colleen Morton MD from Regions Hospital for sharing this draft