Characteristics, management and outcomes of adults with major trauma taking pre-injury warfarin in a Western Australian population from 2000 to 2005: a population-based cohort study.
OBJECTIVE
To describe the characteristics, management and outcomes of patients with major trauma who were taking warfarin; explore the use of rapid anticoagulation reversal; and assess the effect of reversal on outcomes.


METHODS
Retrospective cohort analysis of prospective data extracted from the trauma registries and patient charts of the two adult trauma referral hospitals with neurosurgical units in Western Australia, 2000 to 2005. Inclusion criteria were: major trauma (injury severity score > 15); first international normalised ratio (INR) after injury > 1.4; and documented (in registry or chart) warfarin use.


RESULTS
Eighty patients were identified. Their mean age was 76.8 years. Forty-six were men; 34 were transferred from another hospital; 28 died; and the functional outcomes of 58 were worse at discharge from hospital than before injury. Intracranial haemorrhage (ICH) occurred in 62, of whom 25 died; the difference in mortality between those with ICH and those without ICH was insignificant. Warfarin reversal started 17.4 hours (mean) after injury and the documented period between injury and completion of reversal was 54.2 hours (mean). Multiple logistic regression models, controlling for age, sex, on-scene Glasgow Coma Scale (GCS), initial INR and progressive ICH, showed no independent survival benefit for rapid reversal. Factors associated with mortality were age (22% increase per year [95% CI, 17%-34%]) and progressive ICH on computed tomography scan (24 of the 36 patients with progressive ICH died v one of the 26 patients with stable ICH died). Every point increase in on-scene GCS > 8 increased survival likelihood by 215% (95% CI, 119%-388%).


CONCLUSIONS
Patients with major trauma taking warfarin at the time of injury have high mortality rates, poor functional outcomes and long delays to initiation and completion of anticoagulation reversal. Rapid, appropriate warfarin reversal was rarely performed and was not independently associated with survival. Age, low on-scene GCS and progressive ICH were strongly associated with mortality, but presenting INR, ICH v no ICH, and sex were not.
Mountain
David
D
Department of Emergency Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia. david.mountain@health.wa.gov.au
Sistenich
Vera
V
Jacobs
Ian G
IG
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000009:adverse effects* / Q000037:antagonists & inhibitors; D001779:Blood Coagulation Factors / Q000627:therapeutic use; D015984:Causality; D015331:Cohort Studies; D005169:Factor VIII / Q000627:therapeutic use; D005260:Female; D005340:Fibrinogen / Q000627:therapeutic use; D006470:Hemorrhage / Q000150:complications* / Q000188:drug therapy / Q000401:mortality; D006801:Humans; D020300:Intracranial Hemorrhages / Q000150:complications / Q000188:drug therapy / Q000401:mortality; D008297:Male; D008875:Middle Aged; D010949:Plasma; D012042:Registries; D016896:Treatment Outcome; D014812:Vitamin K / Q000627:therapeutic use; D014859:Warfarin / Q000009:adverse effects* / Q000037:antagonists & inhibitors; D014904:Western Australia / Q000453:epidemiology; D014947:Wounds and Injuries / Q000150:complications* / Q000401:mortality
D000925:Anticoagulants; D001779:Blood Coagulation Factors; C026912:cryoprecipitate coagulum; D014812:Vitamin K; C025667:prothrombin complex concentrates; D014859:Warfarin; D005169:Factor VIII; D005340:Fibrinogen