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Treatment of Trauma Patients With Intracranial Hemorrhage on Preinjury Warfarin

Ivascu, Felicia A. MD; Janczyk, Randy J. MD; Junn, Fredrick S. MD; Bair, Holly A. BSN; Bendick, Phillip J. PhD; Howells, Greg A. MD

The Journal of Trauma: Injury, Infection, and Critical Care: August 2006 - Volume 61 - Issue 2 - p 318-321
doi: 10.1097/01.ta.0000223944.25922.91
Original Articles

Background: Preinjury warfarin anticoagulation has been shown to increase the mortality of traumatic intracranial hemorrhage. We have evaluated the impact on patient mortality of the rapid triage of patients at risk for warfarin associated traumatic intracranial hemorrhage.

Methods: A “Coumadin Protocol” was implemented in January, 2001 in the Emergency Department that expedited triage of anticoagulated trauma patients to immediate physician evaluation. Patient outcomes during a 2 year period were compared with a matched control group of similarly injured, anticoagulated patients who were treated before protocol initiation.

Results: Thirty-five patients were treated after implementation of the Coumadin Protocol. Mean time until warfarin reversal was 4.3 ± 4.4 hours, and there was a 37% mortality. Twenty-two control patients had a mean time to reversal of 4.2 ± 2.9 hours, with a 45% mortality (p = 0.610). Ten protocol patients were shown to have intracranial hemorrhage progression by computed tomography (CT) scan, with a 60% mortality rate. Seventeen patients had follow-up CT scan and showed no progression; only one of these patients (6%) died (p = 0.004). Hemorrhage severity based on the initial CT scan did not predict mortality or hemorrhagic progression.

Conclusions: We conclude from these data that a trauma center protocol for rapid identification of intracranial bleeding without a concomitant therapeutic protocol does not improve survival in head injured patients on preinjury warfarin.

From the Division of Trauma Surgery (F.A.I., R.J.J., H.A.B., P.J.B., G.A.H.) and the Division of Neurosurgery (F.S.J.), William Beaumont Hospital, Royal Oak, Michigan.

Submitted for publication July 13, 2004.

Accepted for publication April 12, 2006.

Address for Reprints: Randy J. Janczyk, MD, Division of Trauma Surgery, William Beaumont Hospital, 3601 W. Thirteen Mile Road, Royal Oak, MI 48073; email:

© 2006 by Lippincott Williams & Wilkins