Approaches to emergency management of head injury in patients on anticoagulant therapy: a review and a care protocol

Hidalgo Natera A, Salido Mota M

This review attempts to address controversial issues in the emergency management of

minor to moderately severe head injuries in patients on anticoagulant therapy, a group

not usually discussed in clinical guidelines. We pose questions that have not been fully

answered regarding the care of asymptomatic patients. We also propose an evidencebased care protocol encompassing early detection of intracranial hemorrhage (ICH) and the timing of reversal of anticoagulant therapy to reduce complications and mortality. PubMed and the Cochrane Library were searched using a free-text strategy for the terms brain injuries, coumarin, or craniocerebral trauma. The end date for the search was June 2013. The articles included had varied designs and results: 11 found an association between head injury in patients on anticoagulants and risk of ICH whereas 3 found no association; 13 linked anticoagulants in head injury patients to increased mortality

whereas 3 did not; 11 supported use of emergency computed tomography (CT) whereas

2 did not; and 8 favored use of follow-up CT whereas 13 did not. Most proposed reversal

of anticoagulation to treat ICH. We found no definitive, multidisciplinary, consensus-based

care protocol in the literature. We concluded that the combination of head injury,

advanced age, and anticoagulation has potentially serious consequences. The consensus

regarding use of CT to guide the emergency management of head injury in

anticoagulated patients is stronger than for the use of CT for follow-up. Reversal of

anticoagulant therapy seems to be more appropriate when ICH is detected. There is

growing support for the use of prothrombin complex rather than fresh frozen plasma or

recombinant activated factor VII. Evidence for guiding the management of head injury

patients on therapeutic anticoagulation is limited.

Hidalgo Natera A, Salido Mota M