Rapid warfarin reversal in anticoagulated patients with traumatic intracranial hemorrhage reduces hemorrhage progression and mortality
Rapid warfarin reversal in anticoagulated patients with traumatic intracranial hemorrhage reduces hemorrhage progression and mortality
复制标题
DOI：
10.1097/01.ta.0000189067.16368.83
复制
发表时间：
2005-11-01
影响因子：
--
通讯作者：
Janczyk, RJ
中科院分区：
文献类型：
--
作者：
Ivascu, FA;Howells, GA;Janczyk, RJ
背景：我们机构的一项前瞻性队列研究表明，华法林抗凝创伤患者持续颅内出血（ICH）的死亡率为48%，而非抗凝患者的死亡率为10%。尽管抗凝逆转，仍有40%的患者表现出脑出血进展，导致65%的死亡率。这些患者中有71%最初表现为格拉斯哥昏迷评分（GCS）评分>= 14和“轻度”ICH。我们假设脑出血的早期诊断和快速抗凝逆转可以降低脑出血的进展率和死亡率。方法：所有已知或怀疑有头部外伤的抗凝患者均进入香豆素治疗方案。该方案确保了记录在案的脑出血患者的立即分类和医生评估、头部计算机断层扫描（CT）扫描和新鲜冷冻血浆给药。结果：纳入方案的82例患者中有19例（23%）被记录为脑出血。19例患者中16例（84%）表现为GCS， >= 14。脑出血治疗患者的中位国际标准化比值（INR）为2.7，非脑出血患者为2.5 （p = 0.546）。方案患者开始华法林逆转的平均时间为1.9小时，而方案前患者为4.3小时（p < 0.001）。19例ICH患者中有2例（10%）死亡。然而，两名患者在损伤后10小时出现bbb10，并伴有严重的脑出血。10%的死亡率明显低于之前观察到的48%的死亡率（p < 0.001），并且现在与未使用抗凝治疗的类似损伤患者的死亡率一致。结论：抗凝创伤患者的初始GCS和INR均不能可靠地识别脑出血患者。通过快速头部CT扫描快速确认脑出血，并及时用新鲜冷冻血浆逆转华法林抗凝，可减少脑出血进展，降低死亡率。
Background: A prospective cohort study at our institution demonstrated a 48% mortality rate in warfarin anticoagulated trauma patients sustaining intracranial hemorrhage (ICH) compared with a 10% mortality rate in nonanticoagulated patients. Forty percent of patients demonstrated progression of their ICH, despite anticoagulation reversal, with a resultant 65% mortality rate. Seventy-one percent of these patients initially presented with a Glasgow Coma Scale (GCS) score >= 14 and a 'minor' ICH. We postulated that early diagnosis of ICH and rapid anticoagulation reversal would reduce ICH progression rates and mortality.Methods: All anticoagulated patients with known or suspected head trauma were entered into the Coumadin protocol. The protocol ensured immediate triage and physician evaluation, head computed tomography (CT) scan, and fresh frozen plasma administration in patients with documented ICH.Results: Eighty-two patients were entered into the protocol with ICH documented in 19 (23%). Sixteen of 19 patients (84%) presented with GCS >= 14. Median international normalized ratio (INR) for treated patients with ICH was 2.7 versus 2.5 for patients without ICH (p = 0.546). Mean time to initiate warfarin reversal was 1.9 hours for protocol patients versus 4.3 hours for preprotocol patients (p < 0.001). Two of 19 (10%) protocol patients with ICH died. However, both patients presented >10 hours after injury with a severe ICH. This 10% mortality rate is significantly less than the 48% mortality rate seen previously (p < 0.001) and is now consistent with that observed in similarly injured patients not on anticoagulation.Conclusion: Neither the initial GCS nor INR in anticoagulated trauma patients reliably identifies patients with ICH. Rapid confirmation of ICH with expedited head CT scan combined with prompt reversal of warfarin anticoagulation with fresh frozen plasma decreases ICH progression and reduces mortality.