title: A protocol for the rapid normalization of INR in trauma patients with intracranial hemorrhage on prescribed warfarin therapy.
abstract: Trauma patients on prescribed warfarin therapy sustaining intracranial hemorrhage can be difficult to manage. Rapid normalization of coagulopathy is imperative to operative intervention and may affect outcomes. To identify and expedite warfarin reversal, we designed a protocol to administer a prothrombin complex concentrate. A Proplex T protocol was instituted in May 2004. It dictated that trauma patients with an International Normalized Ratio (INR) greater than 1.5, history of prescribed warfarin therapy, and intracranial hemorrhage on CT scan receive a prothrombin complex concentrate for reversal of their coagulopathy. Neither the protocol nor the factor concentrate was validated for use in this subset of trauma patients; therefore, adherence to the protocol and use of the factor concentrate was not mandatory. Patients not administered the prothrombin complex concentrate received vitamin K and fresh-frozen plasma. The protocol resulted in an increased number of patients receiving Proplex T (54.3% vs 35.4%, P = 0.047). Protocol patients had improved times to normalization of INR (331.3 vs 737.8 minutes, P = 0.048), number of patients with reversal of coagulopathy (73.2% vs 50.9%, P = 0.026), and time to operative intervention (222.6 vs 351.3 minutes, P = 0.045) compared with control subjects. There were no differences in intensive care unit (ICU) days, hospital days, or mortality. The Proplex T protocol increased the number of patients who received prothrombin complex concentrate, provided rapid normalization of INR, and improved time to operative intervention.
authors.affiliation: Department of Surgery, Section of Trauma Services, Christiana Care Hospital and Health Center, Newark, Delaware 19718, USA. mkalina@hotmail.com
authors.forename: Michael
authors.initials: M
authors.lastname: Kalina
authors.forename: Glen
authors.initials: G
authors.lastname: Tinkoff
authors.forename: Adebayo
authors.initials: A
authors.lastname: Gbadebo
authors.forename: Paula
authors.initials: P
authors.lastname: Veneri
authors.forename: Gerard
authors.initials: G
authors.lastname: Fulda
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000627:therapeutic use*; D001777:Blood Coagulation; D001779:Blood Coagulation Factors / Q000008:administration & dosage*; D002985:Clinical Protocols; D015331:Cohort Studies; D005260:Female; D006801:Humans; D019934:International Normalized Ratio; D020198:Intracranial Hemorrhage, Traumatic / Q000097:blood* / Q000000981:diagnostic imaging / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014859:Warfarin / Q000627:therapeutic use*
chemical_list: D000925:Anticoagulants; D001779:Blood Coagulation Factors; C025667:prothrombin complex concentrates; D014859:Warfarin