One particular hazard of head injury in the anticoagulated patient is "delayed" neurologic deterioration. At presentation the patient may have a relatively normal Glasgow Coma Score, only to deteriorate several hours later due to development of an intracranial hematoma.
Recommendations for patients with a history of coumadin therapy and head injury:
(1) The INR (International Normalized Ratio) should be measured in all of these patients.
(2) Most patients should have a head CT scan performed, including patients (a) with a Glasgow Coma Score of 13 or 14, or (b) GCS 15 and supratherapeutic INR.
(3) The patient should be admitted for neurologic observation if the INR is elevated (supratherapeutic) OR if there is a traumatic abnormality seen on CT scan.
(4) Short-term reversal of anticoagulation should be considered if the patient is admitted, especially if the INR is supratherapeutic.
(5) A repeat CT scan should be considered (a) 12-18 hours after admission or (b) if there is any signs of neurologic worsening, no matter how subtle.
(6) Consideration should be taken of any condition that could potentiate the level of anticoagulation (liver disease, vitamin K deficiency, protein malnutrition, etc.)
It would appear that the only patients who are receiving coumadin and who have had a head injury who can be released with some degree of confidence should have all of the following:
(1) INR < 1.5
(2) Glasgow Coma Score 15
(3) no other coagulopathy
(4) no abnormality seen on head CT scan
