A growing number of adults, usually elderly, are taking Coumadin (warfarin) to manage chronic medical conditions or deep venous thrombosis. While warfarin is a very useful drug for these problems, it is notoriously difficult to maintain tight control of INR. If an individual on warfarin is involved in a fall or vehicular crash, bleeding complications can become life-threatening. A recent Journal of Trauma article shows that mortality more than doubles in elderly patient who are admitted awake after just falling from standing.
The key is to rapidly reverse an elevated INR. Vitamin K can be used to increase biological activity of several clotting factors, but this occurs over several hours. Plasma is also used, but there are several considerations. Many hospitals have only frozen plasma, and there may be a delay of 30 to 45 minutes to thaw it. Multiple units may need to be transfused in order to normalize higher INRs, which may cause volume overload in elderly patients with cardiovascular disease.
More recently, activated Factor VII (NovoSeven) has been used to aid rapid reversal of the INR. NovoSeven is FDA approved for only the following uses:
- Bleeding or surgery in hemophiliacs
- Bleeding or surgery in congenital Factor VII deficiency
Use of NovoSeven for rapid reversal of warfarin is an off-label use, and physicians must weigh the risks and benefits prior to use. It is also very costly, about $7000 per vial. To download a printable copy of our protocol, click here.
PROTOCOL – PATIENTS ON WARFARIN WITH HEAD INJURY AND ABNORMAL CT SCAN
Check INR. Goal INR is 1.2-1.4
If > 1.4
- Give Vitamin K 10 mg IV
- Transfuse thawed plasma 15ml/kg (4-6 units)
- Consider NovoSeven Weight <= 100kg – give 2mg IV
Repeat INR at 2hrs, 4hrs, 12hrs and 24 hrs after NovoSeven administration.
If INR increases to > 1.4, repeat plasma transfusion as needed.
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Reference: J Trauma. 2009 Jun;66(6):1518-22; discussion 1523-4.
NOTE: This guideline is based on protocols in use at the Regions Hospital Level I Adult and Pediatric Trauma Centers. As with any potent drugs or procedures, undesired side-effects may occur. The individual physician prescribing these medications or procedures is solely responsible for the safety of his or her individual patient.