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Increasing use of warfarin for stroke prevention in elderly
Less studied than warfarin-related non- traumatic ICH
Progression of hematoma common, even when initially small
Progression increases mortality risk
Reversal seems to decrease progression
No randomized trials
What’s the smallest amount of traumatic intracranial hemorrhage that doesn’t need to be reversed? Location specific ?
Warfarin and TBI Ivascu Journal of Trauma 2005
FFP REVERSAL PROTOCAL INR corrected within 24 hours (< 1.4) – Shorter median time to FFP initiation (90 v. 210 min) – 12 of 69 (17%) not reversed by 24 hours This experience neither unique nor acceptable Logistics of FFP or reversal agent itself?
In patients with life-threatening bleeding “hold warfarin therapy and give FFP, PCC, or rVIIa supplemented with vitamin K (10 mg by slow IV infusion). Repeat, if necessary, depending on INR (Grade 1c).”
Methods: We performed a 2-year (2005-2006) retrospective study of adult blunt trauma patients with traumatic brain injury who presented coagulopathic (international normalized ratio [INR] >1.3) and required emergent craniotomy. We compared patients who did (rFVIIa group) and did not (no-rFVIIa group) receive rFVIIa to correct coagulopathy before craniotomy .
Brown et al. Recombinant Factor VIIa for the Correction of Coagulopathy Before Emergent Craniotomy in Blunt Trauma Patients. Journal of Trauma-Injury Infection & Critical Care,2010
METHODS: The clinical and laboratory features of a prospectively followed up case-series of 15 patients with traumatic ICB (mainly isolated SDHs) and coagulopathy (INR) >1.3 treated with rFVIIa in our institution are presented, along with a review of the literature regarding the role of rFVIIa in neurosurgical patients with ICB.
RESULTS: All 15 patients suffered a SDH (4 of 15 had a combined ICB) and coagulopathy (mean INR, 2.34 +/- 0.83; thrombocytopenia rate, 20%), which was attributed to anticoagulants in 46.7%. The mean INR decreased to 1.5 +/- 0.14 after standard therapy and 0.92 +/- 0.1 after rFVIIa therapy.
METHODS: nine patients with coagulopathy requiring urgent neurosurgical intervention were reviewed retrospectively. Each patient was given a dose ranging from 40 to 90 microg/kg of rFVIIa before undergoing surgery. Pre-rFVIIa coagulation and post-rFVIIa coagulation parameters were obtained. Once correction of the coagulopathy was verified, each patient underwent the appropriate neurosurgical procedure. 20 minutes after infusion of the medication showed normalization of values.
METHODS: The trauma registry was used to identify patients with severe TBI who were admitted during a 4-year period and were coagulopathic at admission (international normalized ratio, INR >/=1.4) and required a neurosurgical procedure.