Warfarin toxicity in the emergency department: recommendations for management.
OBJECTIVE
To examine patients who presented to a hospital emergency department with evidence of warfarin toxicity, and to review the available published literature to determine what guidelines are available for management of this problem.


METHODS
A retrospective analysis of all adult patients who presented to The Geelong Hospital Emergency Department between 1 January 1996 and 30 June 1998 with international normalized ratio > 6 due to warfarin toxicity.


RESULTS
A total of 84 patients with international normalized ratio > 6 were included in the study. The average age was 68.3 years. Fifty-three per cent were women. The international normalized ratio was between 6 and 10 in 33 patients (39%), and greater than 10 in 51 patients (61%). Major bleeding occurred in 16.7% of patients, minor bleeding in 17.8%. Sixty-five per cent had no bleeding. Seven patients died, four of those with bleeding. Patients with an international normalized ratio > 10 were more likely to receive fresh frozen plasma (77.6% vs 28.6%; P < 0.001) and in greater amounts (3.0 units vs 0.8 units; P < 0.001) than those with an international normalized ratio of 6-10. There were also more episodes of major bleeding, although not significant. Patients with major bleeding were older (mean 75.4 years vs 67.5 years; P = 0.04), more likely to be admitted (P = 0.046), were more often given fresh frozen plasma (P = 0.003) and in greater amounts (3.28 units vs 2.0 units; P = 0.02).


CONCLUSIONS
Warfarin toxicity is a common problem, and variation in management is not surprising considering the lack of consensus in the literature on this topic. Current recommendations are summarized and a simple flowchart for management of this problem is provided.
Cruickshank
J
J
Emergency Department, The Geelong Hospital, Victoria, Australia. jaycen.cruickshank@health.wa.gov.au
Ragg
M
M
Eddey
D
D
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D000925:Anticoagulants / Q000506:poisoning*; D004638:Emergency Treatment; D005260:Female; D006470:Hemorrhage / Q000139:chemically induced / Q000453:epidemiology / Q000628:therapy; D006801:Humans; D008297:Male; D008875:Middle Aged; D010949:Plasma; D011041:Poisoning / Q000453:epidemiology / Q000401:mortality / Q000628:therapy; D017410:Practice Guidelines as Topic; D012189:Retrospective Studies; D012307:Risk Factors; D014739:Victoria / Q000453:epidemiology; D014812:Vitamin K / Q000627:therapeutic use; D014859:Warfarin / Q000506:poisoning*
D000925:Anticoagulants; D014812:Vitamin K; D014859:Warfarin