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Understanding the management of patients with head injury taking warfarin: who should we scan and when? Lessons from the AHEAD study
  1. Suzanne M Mason1,2,
  2. Rachel Evans1,2,
  3. Maxine Kuczawski1
  1. 1Centre for Urgent and Emergency Care Research, School of Health and Related Research, University of Sheffield, Sheffield, UK
  2. 2Northern General Hospital, Sheffield Teaching Hospitals, Sheffield, UK
  1. Correspondence to Dr Rachel Evans, Centre for Urgent and Emergency Care Research, School of Health and Related Research, University of Sheffield, Sheffield S10 2TN, UK; r.j.evans{at}sheffield.ac.uk

Abstract

Anticoagulated patients represent an important and increasing proportion of the patients with head trauma attending the ED, but there is no international consensus for their appropriate investigation and management. International guidelines vary and are largely based on a small number of studies, which provide poor-quality evidence for the management of patients taking warfarin. This article provides an overview of the clinical research evidence for CT scanning head-injured patients taking warfarin and a discussion of interpretation of risk and acceptable risk. We aim to provide shop floor clinicians with an understanding of the limitations of the evidence in this field and the limitations of applying ‘one-size-fits-all’ guidelines to individual patients. There is good evidence for a more selective scanning approach to patients with head injuries taking warfarin than is currently recommended by most guidelines. Specifically, patients without any head injury–related symptoms and GCS score 15 have a reduced risk of adverse outcome and may not need to be scanned. We argue that there is evidence to support an individualised approach to decision to CT scan in mild head injuries on warfarin and that clinicians should feel able to discuss risks with patients and sometimes decide not to scan.

  • emergency department management
  • imaging, Ct/mri
  • trauma, head
  • research, clinical
  • guidelines

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Footnotes

  • Contributors SMM was responsible for the conception of the work and devising the angle which it promotes. She also reviewed draft copies of the article and gave final approval of the main document. RE was responsible for summarising and critiquing the literature, drafting the article and re-drafting following comments. She also did the majority of writing the article and gives approval for the final copy of the article. She managed the submission and comments for the article. MK was responsible for managing the initial AHEAD study and providing the data for the article. She also reviewed and commented on drafts of the article including giving approval for the final copy after comments. All authors gave final approval to the version submitted for publication.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent None required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement There are further data available from the AHEAD study, which are currently being analysed. These data items include the CT findings and the mechanisms of injury of the patients involved. We aim to publish these findings separately in due course. There are no further unpublished data specifically relating to this review article.

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