Hit head, on blood thinner-wife wants CT Will Davies June 2014
Selection of Adults with Head Injury for CT Scan Early management of head injury: summary of updated NICE guidance. Hodgkinson S, Pollit V, Sharpin C, Lecky F, BMJ 2014; 348
Case 72 year old male Fell at home whilst trying to throw his walking stick at the dog Tripped over tie Hit head on lino floor Witnessed by wife Unconscious for 30 sec Well since
History Seen by resident in ED A bit cross as he has had to come to hospital at his wife s insistence. Denies headache. No vomiting or visual disturbance. A bit vague, but wife says he gets like that sometimes when he is cross, probably the hospital.
PMHx. Dhx. Etc. Atrial fibrillation NSTEMI 5 years ago with normal angio 6 months ago Warfarin 2mg OD (INR 2.1 2 days ago stable for last 18 months) Aspirin 100mg OD Ex smoker NKDA
Examination Unremarkable GCS 15/15 PERLA CNS intact Gait abnormal, likely due to TKR No haematoma on scalp
You are Asked to Review Wife wants a CT as she has a brother who died from a stroke 2 years ago. 1. Do you do the CT? 2. Do you admit for observation? 3. Do you do both?
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Thank You
Is there any evidence to support this stance?
What are blood thinners? Warfarin Direct thrombin inhibitors and factor Xa inhibitors (dabigatran and rivaroxaban) Heparins
A coagulopathy (clotting or bleeding disorder) is an impairment of the blood s ability to clot. Therefore, every patient on anti-platelet agents is coagulopathic. Very small amounts of additional intracranial bleeding may result in catastrophic consequences to the patient. Clopidogrel and aspirin inhibit platelet function for at least 5 days after discontinuation of the drug. Aspirin doubles the bleeding time and clopidogrel is considered to be equally effective, if not more potent. Many of the new anti-platelet agents have similar effects on the coagulation system (1) 1. Brunton L, Chabner B, Knollman B. Goodman & Gildman s. The Pharmacological Basis of Therapeutics. 12th Edition. McGraw-Hill; 2011
Are there any Rules? New Orleans Criteria, NEXUS II, and the Canadian CT Head Rule All specifically exclude older patients (>60 years in the New Orleans Criteria, >65 years in the Canadian rule and NEXUS II). These guidelines should not be used to assess older patients.
Newer Rules? 22 Jan 2014, NICE Head Injury Guideline Update (1) 1. Early management of head injury: summary of updated NICE guidance. Hodgkinson S, Pollit V, Sharpin C, Lecky F, BMJ 2014; 348
Why Delay up to 8 Hours? That isn t how I see it
Is There a Clinically Significant Cohort of Delayed Bleeders? Yes Management of Minor Head Injury in Patients Receiving Oral Anticoagulant Therapy: A Prospective Study of a 24-Hour Observation Protocol. Vincenzo G. Menditto et al. Ann Emerg Med.2012;59:451-455. 97 consecutive patients. Ten refused the second CT scan and were well during 30-day follow-up. Repeated CT scanning in the remaining 87 patients revealed a new haemorrhage lesion in 5 (6%), with 3 subsequently hospitalized and 1 receiving craniotomy. Two patients discharged after completing the study protocol with 2 negative CT scan results were admitted 2 and 8 days later with symptomatic subdural hematomas; neither received surgery. Two of the 5 patients with delayed bleeding at 24 hours had an initial international normalized ratio greater than 3.0, as did both patients with delayed bleeding beyond 24 hours. The relative risk of delayed haemorrhage with an initial international normalized ratio greater than 3.0 was 14 (95% confidence interval 4 to 49).
What About Antiplatelet Agents? An observational cohort multicenter study (1) reported immediate traumatic intracranial haemorrhage or contusion >65 years of age with a history of trauma above the clavicles. Clopidogrel 24 of 217 patients (11.1% 95% CI 7.2 to 16). This is a much higher incidence that the 33 of 594 patients (5.6%), who were taking warfarin. The majority did not have loss of consciousness or amnesia at anytime and 6 out of 33 patients with an initial GCS of 15, had intracranial hematomas without evidence of trauma above the clavicles 1.Immediate and delayed traumatic intracranial haemorrhage in patients with head trauma and pre-injury warfarin or clopidogrel. Nishijima D et al. Ann Emerg Med. 2012;59(6):460-8
What About Antiplatelet Agents? Fabbri et al (1) reported that patients with GCS 14-15, who were on clopidogrel, not only had an increased incidence of TICH, but also had a two-fold risk for deterioration within 7 days, when the number of lesions was <2, at the first CT scan (6.90% versus 3.70%, RR 1.86, 95% CI 1.06 to 3.30; P = 0.032). The risk further increased when the number of lesions was 3 (34.8% versus 10.4% not treated; RR 3.34, 95% CI 1.74 to 6.40, P = 0.003). The lesions included traumatic subarachnoid haemorrhage, subdural and epidural haematoma, intra-cerebral haemorrhage/contusion, depressed skull fracture and intra-ventricular haemorrhage. 1. Antiplatelet therapy and the outcome of subjects with intracranial injury: the Italian SIMEU study. Fabbri A et al. Critical Care. 2013,17
So the Risk of Bleeding is High What about the risks associated with the CT?
Radiation Risk of CT head From: Radiation Dose Associated With Common Computed Tomography Examinations and the Associated Lifetime Attributable Risk of Cancer! Arch Intern Med. 2009;169(22):2078-2086. doi:10.1001/archinternmed.2009.427" Figure Legend:! Median Effective Radiation Dose (IQR, Minimum and Maximum) for Each Type of CT Study" " Date of download: 4/20/2014" Copyright 2014 American Medical Association. All rights reserved."
From: Radiation Dose Associated With Common Computed Tomography Examinations and the Associated Lifetime Attributable Risk of Cancer! Arch Intern Med. 2009;169(22):2078-2086. doi:10.1001/archinternmed.2009.427" Figure Legend:! Estimated Number of Patients Undergoing Computed Tomography (CT) That Would Lead to the Development of 1 Radiation-Induced Cancer, by Type of CT Examination and Age at the Time of Exposure, Based on the Median and Interquartile Radiation Dose Observed" " Date of download: 4/20/2014" Copyright 2014 American Medical Association. All rights reserved."
Take Home Message CT head all patients on blood thinners with an injury above the clavicles. Good evidence to suggest 24hrs admission with 2 hourly neuro obs and repeat CT prior to discharge. Watch this space!
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