The East guidelines state:
“Patients receiving warfarin with a posttraumatic intracranial
hemorrhage should receive initiation of therapy to correct their international
normalized ratio (INR) toward a normal range (e.g., <1.6× normal) within 2
hours of admission.”
What protocols should be implemented to ensure adequate and
timely correction of anticoagulation in patients with intracranial hemorrhage?
Ivascu et al developed a protocol in which all warfarin anticoagulated trauma
patients at risk for intracranial injury were expedited through the triage
process to a treatment area for immediate physician evaluation; however, this
protocol did not improve mortality because time to correction of anticoagulation
did not change. Ivascu et al then
created a second protocol that focused on timely reversal of anticoagulation. See protocol below.
Ivascu et al then compared this new treatment protocol with the
previous identification protocol and historical controls. They found that initiation of reversal of
anticoagulation occurred 2 hours sooner in the treatment protocol vs the
identification protocol. In fact, in the
treatment protocol, the time for complete reversal of the INR to less than 1.6
occurred approximately 1 hour before the identification protocol/historical
reference group even began initiation of therapy. By reversing the INR quickly in patients on
anticoagulation with ICH, the treatment protocol decreased mortality by 30%.
In conclusion, protocols should be instituted for rapid reversal
of anticoagulation in patients on anticoagulation and head bleeds. In this particular study, a significant
mortality benefit was achieved by initiating anticoagulation reversal within 2
hours of presentation.
from Dr. John Cull
No comments:
Post a Comment