Warfarin Institute of America
Dedicated to Your Health
IF SOMEONE TAKING WARFARIN HITS HIS/HER HEAD
ANY HEAD INJURY, NO MATTER HOW SLIGHT IT MIGHT SEEM AT THE TIME, IS CAUSE FOR CONCERN WHEN A PERSON IS TAKING WARFARIN. THIS DOES NOT MEAN THAN AN AMBULANCE RIDE TO THE HOSPITAL IS ALWAYS NECESSARY. IN FACT, IT MAY TAKE UP TO A WEEK FOR THERE BE ANY INDICATION OF A BRAIN INJURY. IT IS POSSIBLE TO HAVE TESTS DONE TOO SOON AFTER THE INJURY WHICH CAN LEAD TO A FALSE SENSE OF SECURITY. CLOSE OBSERVATION FOR A LONG PERIOD OF TIME MAY BE NECESSARY. DO NOT OVERLOOK THE FACT THAT A BRAIN INJURY MAY CAUSE THE INJURED PERSON TO DEVELOP POOR JUDGMENT CAUSING THEM TO NOT RELATE THEIR CONDITION TO SIGNIFICANT OTHERS.
I believe that the above statement can be backed-up by reports in the medical literature. Hylek and Singer studied the records of 121 people hospitalized for bleeding in the head. 77 of these had bleeding in the brain which was fatal 46% of the time 44 had bleeding in the area between the skull and the brain (subdural bleeding). This was fatal 20% of the time. The symptoms that caused the person to be admitted to the hospital included headache, nausea and vomiting, unresponsiveness, paralysis on one side of the body, inability to communicate and confusion. The people who had bleeding into the brain were usually hospitalized sooner (78% within 24 hours) after symptoms developed than were those who had subdural bleeding (27% took 3 to 7 days and 21% were not hospitalized until more than a week after symptoms developed). Besides the 46% who died from bleeds into the brain, another 45% left the hospital with some type of neurological problem. Only 9% of these patients were normal at the time of discharge. For those with subdural bleeding, 59% left the hospital with some type of neurological problem while 20% were normal at that time.
Mina et al. studied the records of 380 patients who were taking anticoagulants (aspirin and many other medications in addition to warfarin) who were admitted with trauma. They had a dramatic finding that 60% of people who were anticoagulated when they fell down stairs died. They concluded that people who were anticoagulated, even with aspirin alone, were four to five times more likely to die from a head injury than were people not taking anticoagulants.
There have been some controversies as to how much risk people are at if the suffer a head injury and are taking warfarin. A study by Li et al. found these people are at moderate or higher risk of suffering an intracranial (inside the head) injury. They recommend that there should be a CT scan done on all patients who are taking warfarin and suffer head trauma.
One of my patients was shopping for clothes at Wal-Mart. An article of clothing fell off its hanger. She bent down to pick it up and hit her face on the rack sticking out from the wall. She went to the Emergency Room the next day after it happened because her entire face was bruised. No internal bleeding was found. After one week she noticed that she was having trouble seeing and went back to the ER. This time a small bleed into the subdural area was noted. She had evidently been bleeding very slightly over the course of one week. Her INR at the time was 2.7, so she was not overdosed on warfarin.
How do you decide if an injury is serious enough to require emergency evaluation. Several studies have categorized patients as high, moderate and low risk. Anyone who has an altered state of consciousness, an obvious skull wound, who does not remember what caused the head injury, seizures, vomiting, or if the cause of the injury is unknown should seek emergency treatment. If the emergency treatment findings are negative, do not be lulled into a false sense of security. Many of these people were not admitted to the hospital for more than a week after the injury. I recently saw this happen to one of my long-term patients. She fell and hit her head quite hard. Her daughter called me and asked my advice. The family decided that since she seemed to have not been harmed they would simply watch her at home. After several days she began talking nonsense. The family took her to the emergency room. Because of her advanced age (88) and the large amount of blood in her head, it was decided that she was unlikely to survive surgery. Her doctors and family both feared that the end was near. However, she recovered and was able to return home at nearly her usual state of health. However, the warfarin was not re-started.
I have been an expert witness in a murder trial where the guilt or innocence of the accused turned on whether or not the deceased merely fell and hit his head, or was he pushed down a flight of stairs or was he hit over the head. Whether or not a person taking warfarin is safe after hitting his/her head is probably the most difficult decision there is to make concerning this drug.
References:
Hylek EM et al. Risk factors for intracranial hemorrhage in outpatients taking warfarin. Ann Int Med 1994;120:897-902.
Mina AA et al. Intracranial complications or pre-injury anticoagulation in trauma patients with head injury. J Trauma 2002;53:668-672.
Li J et al. Mild head injury, anticoagulants, and risk of intracramial injury. Lancet 2001;357:771-772.
If you are in doubt, have it checked out. DO NOT SEND ME AN E-MAIL ASKING MY OPINION AS TO WHETHER OR NOT AN INJURY IS SERIOUS ENOUGH TO BE TREATED!!!
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Last updated January 1, 2006