Podcast #113 - Gotta Scan 'Em All: Intracranial Bleeding Risk in Anticoagulation
What happens when you have someone who is anticoagulated fall and have minor head trauma? They are talking to you, they appear neurologically intact, and they feel like they can go home. Do you let them or do you still encourage a CT scan of their head? There is a recent paper that may change your practice.
The British Journal of Haematology published a paper on the "Incidence of intracranial bleeding in anticoagulated patients with minor head injury: a systematic review and meta-analysis of prospective studies" by Minhas et al.
The risk of intracranial hemorrhage (ICH) after minor head injury using five studies that met their criteria (after over 10,000) they found that these studies with mostly a low risk of bias had 4080 potential patients. Approximately 98% of patients were taking vitamin K antagonists (warfarin). In addition to warfarin other patients such as those on NOACs or LMWH. Of the included patients, 8.9% of them had ICH. Even scarier, when the authors performed random effects analysis and sensitivity analysis generated higher estimates of the incidence at up to 10.9% total (about 1 in 9 patients).
This should absolutely scare us. Some people incorrectly try to use rule out criteria like the Canadian CT Head Injury/Trauma Rule. However, these decision aids remind us to exclude those on anticoagulation and for good reason. They have not been studied in a way that demonstrates how to safely rule out these patients.
At this time, we must consider any patient who is anticoagulated (given that we are aware as there is always a potential for limitations in knowing they are on anticoagulants) to need a head CT. Although they may not all need it emergently, they should get it as soon as possible to avoid downstream complications.
Check out other #FOAMed publications on this topic including JournalFeed andEM Lit of Note. Also, organizations such as the CDC and NICE.
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