Patient on Coumadin Therapy Sustains a Massive Subdural Hematoma With Brain Herniation

Case Overview

This case involves a female patient who fell and sustained a blow to the head. The patient was on Coumadin therapy for atrial fibrillation. When she arrived at the emergency room, CT head imaging showed an evolving subdural hematoma. The patient needed to be transferred to a tertiary care center for further treatment, but, in transit, the patient was never given vitamin K or fresh frozen plasma to reverse the effects of the anticoagulation. The patient’s bleed progressed rapidly before surgical intervention could be attempted. The patient suffered from brain herniation and death due to a massive hematoma.

Questions to the Emergency Medicine expert and their responses

What is the accepted management procedure for a patient with a minor head injury who is receiving anticoagulants?

For patients receiving warfarin who've suffered a minor head injury, an initial CT scan needs to be performed. That should be followed by twenty-four-hours of observation, and a second CT scan, which will identify most occurrences of delayed bleeding. An initial international normalized ratio greater than three suggests higher risk. In this patient's case, the head CT was indicative for a major bleed, therefore more advanced measures should have been initiated. These could include vitamin K and fresh frozen plasma as reversal agents to attempt to stop the bleed from progressing.

About the expert

This multiple board certified doctor has remained in active practice for more than 20 years. As a former director of a paramedic training program and as a current director of an Emergency Medicine program that handles a high volume of emergency cases similar to that described in this case, this expert is highly qualified to review all aspects of any emergency medical case.