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Wed Jul 8 19:11:32 BST 2009

If she's on Coumadin for the traditional indication -- a-fib -- we have a very low threshold for reversal.  The rate of thrombotic consequences in un-anticoagulated AF is about six per cent per year, which is significantly lower than that of evolving brain hemorrhage among anticoagulated patients with mechanical risk and neurologic symptoms.  Indeed, we've developed a system-wide policy for expediting reversal in interhospital transfers: the referring hospital types the patient and calls the trauma center with the result.  The trauma center prepares the plasma while the patient is en route, and confirms the type before administration.  That way we cut out the 40-minute thaw time on either side of the transfer.

(Applies to unstable, multi-system, or neuro trauma; if the warfarin is for a mechanical valve, then it's a trauma surgeon's call).

As for clopidogrel, well, we mostly try to discourage its prescription.  Drug-eluting stents, much to our surprise and consternation, comprise a only fraction of the cases who get Plavix, owing mostly to an aggressive marketing strategy in north America ("Mom, your leg cramps are worrying me.  Talk to your doctor about Plavix.  I don't want to you die.").  The pills should come with a complimentary helmet.

A stable patient is a very lucky patient.  If they're sick, the options are pretty thin.  We've had cases which neurosurgery simply wouldn't touch; and as far as I pretend to understand it, platelets are not much help.  Clopidogrel might be one of the excuses to use rFVII(a).  And / or prayer.  

In either case, if the patient's not admitted to a trauma surgeon, it goes to performance review.  There are certainly cases in this category that pass the straight-face test (little or no true injury, admit for obs or to investigate the cause of the crash/fall, usually have a consult on record); but they all get a close look.  

Agree of course that repeat CT's are not very helpful if the patient is clinically unchanged.  But we still do them to make everybody more confident in discharge.  Old habits.

Pret Bjorn, RN
Bangor, ME USA

________________________________

From: trauma-list-bounces at trauma.org on behalf of Sise, Mike MD
Sent: Wed 7/8/2009 9:30 AM
To: trauma-list at trauma.org
Subject: Elederly falls on Coumadin or Plavix

Colleagues,

82 year old woman on Warfarin (Coumadin) 5.0 mg per day trips on a rug, falls striking her forehead. She is brought to the Emergency Department by her daughter who she lives with. She is amnestic for the event and has a superficial forehead abrasion. Her physical examination is normal, her head CT scan is also normal, and her INR is 3.0. Should she have been made a trauma patient? Do you admit her for observation? Do you schedule a repeat head CT scan and if so, how many hours later?

75 year old man on Clopidogrel (Plavix) 75 mg daily for recent placement of a drug eluding coronary stent is in a moderate speed MVC and complains of left shoulder and arm pain. He has an A-C separation but an otherwise negative workup including head CT and torso CT and EKG. Should he be admitted for observation? Should he have a repeat head CT scan and if so, when?

Mike Sise
San Diego

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Elederly falls on Coumadin or Plavix