Journal of Emergencies, Trauma, and Shock

EDITORIAL
Year
: 2021  |  Volume : 14  |  Issue : 3  |  Page : 121--122

What's new in emergencies, trauma, and shock: Head Injury in anticoagulated patients – an enigma


Vivek Chauhan 
 Department of Medicine, IGMC, Shimla, Himachal Pradesh, India

Correspondence Address:
Vivek Chauhan
Department of Medicine, IGMC, Shimla, Himachal Pradesh
India




How to cite this article:
Chauhan V. What's new in emergencies, trauma, and shock: Head Injury in anticoagulated patients – an enigma.J Emerg Trauma Shock 2021;14:121-122


How to cite this URL:
Chauhan V. What's new in emergencies, trauma, and shock: Head Injury in anticoagulated patients – an enigma. J Emerg Trauma Shock [serial online] 2021 [cited 2021 Nov 27 ];14:121-122
Available from: https://www.onlinejets.org/text.asp?2021/14/3/121/327086


Full Text



The current issue of the Journal of Emergencies, Trauma, and Shock features an article on intracranial hemorrhage (ICH) in head injury patients on warfarin or direct oral anticoagulants (DOAC). In this article, the patients on warfarin had a higher rate of ICH compared to DOAC, however, the rate of delayed ICH was comparable between the two.[1]

There is sparse and conflicting evidence directing the outcomes and management of head injury in patients anticoagulated with DOAC.[2] DOAC have become the new standard anticoagulants replacing the Vitamin K antagonists (VKA) in clinical practice worldwide. Research on the outcomes of such patients of traumatic brain injury (TBI) becomes important to guide the management practices. The guidelines recommend immediate computed tomography (CT) of the brain in suspected or known TBI in those having potential or known intake of anticoagulants.[3] The risk of ICH appears to be higher with VKA as compared to the antiplatelets and DOAC.[3] The guidelines are based on the systematic reviews of the available literature, but we need to take the results of these systematic reviews with a pinch of salt because the studies they included were very heterogeneous in the nature of their study designs and inclusion and exclusion criteria.[2]

Based on the evidence available, a repeat CT is needed only in those patients having documented ICH in the initial CT or those with normal initial CT who deteriorate during observation or after discharge or those who cannot be examined neurologically due to intubation, sedation, or dementia.[2],[3],[4]

Anticoagulated patients with minor head injury are mostly elders who suffer a ground-level fall leading to a minor head injury.[2] They make the bulk of emergency department (ED) referrals for assessment and observation. Physicians in ED should be clear in their approach to such patients. Most systematic reviews on these patients suggest that if initial CT head does not show ICH, the patients with minor head injury do not need a routine repeat CT to rule out delayed ICH irrespective of whether they were taking warfarin, DOAC, or antiplatelets.[2],[4],[5],[6] Other factors such as age and brain atrophy may be more important factors for delayed ICH than the choice of anticoagulant used.[4]

ED physicians may encounter patients with unknown history of medication intake. In such patients, the platelet function tests are recommended to confirm or rule out platelet inhibitor intake.[3] Thrombin time or dilute thrombin time is recommended to rule out dabigatran intake and anti-activated factor-X activity to rule out apixaban intake.[3]

In patients with ICH after TBI, reversal of VKA is recommended using four-factor prothrombin complex concentrate (PCC) and role of Vitamin K is adjunctive.[3] PCC is also recommended in TBI if laboratory testing of anti-Xa activity is unavailable for patients on apixaban, edoxaban, or rivaroxaban.[3] Idarucizumab is recommended in the absence of laboratory testing of thrombin time to reverse the effect of dabigatran. But wherever available, laboratory testing should guide the use of reversal agents for DOAC. Low-molecular-weight heparin should be started 24 h after injury in a clinically and radiologically stable TBI in those needing anticoagulation for underlying illnesses.[3]

The definition of minor head injury is not uniform among the published studies. Glasgow Coma Scale (GCS) of 13–15, GCS of 14–15, and GCS of 15 with loss of consciousness, amnesia, or deterioration are some of the criteria used to define minor head injury by various investigators. Similarly, the inclusion criteria used were variable, e.g., patient age >55, only the patients brought by emergency medical services, patients having ground-level falls only, or patients having any kind of head injury.[2] The outcome measures were, however, comparable among most studies that included death, disability, neurosurgery, or readmission within 1 month.[2]

It is also prudent to study the limitations of the available systematic reviews on this topic. Any further research on the anticoagulated patients with head injury should include uniform definitions inclusion and follow-up criteria, and outcome measures so that they are all inclusive and generalizable to the wide spectrum of head injuries. Also, most published research is retrospective chart reviews which limits the level of evidence generated on this topic. Therefore, future studies need to be multicentric and prospective in design to be more meaningful and informative.

Comparison between VKA and DOAC has been the central theme of most recent studies. Since DOAC have replaced VKA in clinical practice, we need newer research ideas focused on DOAC.

Reversal of anticoagulation and antiplatelets also needs further research. There is insufficient evidence on the role of desmopressin, platelet transfusion, or tranexamic acid in reversing the effect of antiplatelet drugs.[3]

To conclude, the management of TBI in anticoagulated patients needs multicentric prospectively done research focusing on key areas of management. In the absence of good quality large prospective studies, the available evidence is conflicting in many areas of TBI in anticoagulated patients.

References

1Hughes PG, Alter SM, Greaves SW, Mazer BA, Solano JJ, Shih RD, et al. Acute and delayed intracranial hemorrhage in head-injured patients on warfarin versus direct oral anticoagulant therapy. J Emerg Trauma Shock 2021;14:123-7.
2Fuller G, Sabir L, Evans R, Bradbury D, Kuczawski M, Mason SM. Risk of significant traumatic brain injury in adults with minor head injury taking direct oral anticoagulants: A cohort study and updated meta-analysis. Emerg Med J 2020;37:666.
3Wiegele M, Schöchl H, Haushofer A, Ortler M, Leitgeb J, Kwasny O, et al. Diagnostic and therapeutic approach in adult patients with traumatic brain injury receiving oral anticoagulant therapy: An Austrian interdisciplinary consensus statement. Crit Care 2019;23:62.
4Huang GS, Dunham CM, Chance EA, Hileman BM. Detecting delayed intracranial hemorrhage with repeat head imaging in trauma patients on antithrombotics with no hemorrhage on the initial image: A retrospective chart review and meta-analysis. Am J Surg 2020;220:55-61.
5Chauny JM, Marquis M, Bernard F, Williamson D, Albert M, Laroche M, et al. Risk of delayed intracranial hemorrhage in anticoagulated patients with mild traumatic brain injury: Systematic review and meta-analysis. J Emerg Med 2016;51:519-28.
6Puzio TJ, Murphy PB, Kregel HR, Ellis RC, Holder T, Wandling MW, et al. Delayed intracranial hemorrhage after blunt head trauma while on direct oral anticoagulant: Systematic review and meta-analysis. J Am Coll Surg 2021;232:1007-16.e5.