Presentation

Classic presentation

• Patients on anticoagulation who fall may have no immediate sequelae of an intracranial hemorrhage (ICH). Symptoms can develop over days or even weeks.
  
  
  
  • The most common presentation of intracranial hemorrhage is an insidious onset of headache, light-headedness, nausea, and vomiting.
    
  • Emergency physicians must maintain a high level of suspicion for intracranial bleeding in patients on anticoagulation, even in the absence of trauma, and particularly in those patients with a supratherapeutic INR.
  
  
• Patients on anticoagulation (and antiplatelet therapy in particular) also commonly present with gastrointestinal bleeding.
  
• Other patients may have less critical sources of bleeding but may present with insufficient hemostasis, as with epistaxis or superficial lacerations.

Critical presentation

• Patients with more significant head trauma can present acutely with altered mental status and obtundation, or with abnormal neurological findings such as hemiplegia, cranial nerve deficits, or seizures.
  
• Patients may also present in shock from life-threatening bleeds such as gastrointestinal bleeds, massive hemoptysis, epistaxis, or internal bleeding from trauma.

Diagnosis and evaluation

• Imaging
  
  
  
  • In anticoagulated patients with altered mental status or possible head trauma, a non-contrast computed tomography (CT) is key in identifying intracranial hemorrhage.
    
  • Acute intracranial hemorrhages will appear bright on CT while chronic hemorrhages will appear dark.
    
  • Anticoagulated patients with head trauma, no loss of consciousness, and a negative initial head imaging should be observed for at least 6 hours (the exact number of hours is controversial) from the onset of the trauma. A repeat CT scan after this observation period is also controversial.
    
  • Those with large intracranial hemorrhages (greater than 30 mL), midline shift, or extension into the ventricles have particularly poor prognoses.
    
    
    
    • The Intracerebral Hemorrhage Score is a clinical tool that can help predict prognosis. It uses GCS, age, ICH volume, location, and intraventricular extension to help determine prognosis and estimate mortality.
  
  
• Laboratory tests
  
  
  
  • All patients with serious bleeding should receive a complete blood count, electrolyte levels, renal function testing, coagulation tests (PT/INR/aPTT), and type and cross-match.
    
  • For ED patients on warfarin, PT/INR is crucial to assess the degree of hypercoagulability.
    
  • There is no readily available laboratory test that can identify ED patients on dabigatran. The aPTT test is the most sensitive in determining the presence of the anticoagulant effect of dabigatran, but can often be normal depending on the timing of the test.
    
  • ED patients treated with heparin can be monitored using the aPTT or heparin activity level.
    
  • The aPTT test is not reliable for ED patients on enoxaparin and an anti-Xa activity level should be obtained instead. This test is not readily available everywhere, however, and may be difficult to interpret depending on the timing of the patient’s last dose of enoxaparin.

Critical management

• Initial management should start with the ABCs. Undertake airway management for patients with suspected intracranial hemorrhage who are not protecting their airway.
  
• Obtain adequate intravascular access with two large-bore intravenous lines for possible massive transfusion of blood products.
  
• Patients on warfarin
  
  
  
  • All patients with serious or life-threatening bleeding should receive vitamin K 10 mg IV for sustained reversal of warfarin-induced anticoagulation.
    
    
    
    • While there are concerns about IV vitamin K-induced anaphylaxis, more recent literature suggests the incidence to be similar to that of anaphylaxis with penicillin, and slow administration (over 1 hour) may further decrease this risk.
    
    
  • If available, prothrombin complex concentrates (PCCs) have been shown to result in faster correction of INR and require less total volume of infusion than fresh frozen plasma.
    
  • In institutions where PCC is not available, these patients should receive fresh frozen plasma, initially dosed at 10–15 mL/kg. This may be difficult in patients with medical comorbidities such as heart failure.
  
  
• Patients on dabigatran
  
  
  
  • No research study to date has been able to show reversibility of dabigatran.
    
  • If available and clinically feasible, dialysis can remove approximately 60% of dabigatran at 2 hours.
    
  • Additional studies are still pending on the efficacy of PCC and recombinant factor VIIa in reversing dabigatran.
  
  
• Patients on heparin
  
  
  
  • Heparin can be reversed emergently in patients with serious bleeding through the use of protamine sulfate at a ratio of 1 mg protamine sulfate/100 units heparin.
    
  • This may need to be titrated further in patients on subcutaneous heparin as its absorption will be slower.
  
  
• Patients on enoxaparin
  
  
  
  • Although protamine sulfate does not reverse the anti-Xa activity of enoxaparin, its administration at a ratio of 1 mg/mg of enoxaparin may reduce clinical bleeding.
  
  
• Patients on antiplatelet medications
  
  
  
  • For critical bleeding, platelet transfusion may be beneficial, as antiplatelet medicines frequently irreversibly inactivate platelets.
    
  • Desmopressin (DDAVP) can be also administered to these patients as it enhances platelet adhesion to the vessel walls, and increases factor VIII and von Willebrand factor (vWF).

Sudden deterioration

• Deterioration in these patients usually occurs because of worsening intracranial bleed or from hemorrhage and anemia.
  
  
  
  • For patients with suspected or confirmed ICH, a neurosurgical consult should be obtained immediately for drainage and/or craniotomy in the operating room.
    
  • Patients that are continuing to hemorrhage should be aggressively reversed and transfused with packed red blood cells. A surgical consultation may also be needed to help control the source of bleeding.

Pressor of choice: Patients on anticoagulants presenting in shock will need to be aggressively resuscitated with blood products. Infusion of crystalloids and use of pressors such as phenylephrine and norepinephrine can be initiated as a temporizing measure.

References

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