title: Dabigatran bleed risk with closed head injuries: are we prepared?
abstract: OBJECTIVE
  The direct thrombin inhibitor dabigatran has recently been approved in the US as an alternative to warfarin. The lack of guidelines, protocols, and an established specific antidote to reverse the anticoagulation effect of dabigatran potentially increases the rates of morbidity and mortality in patients with closed head injury (CHI). Confronted with this new problem, the authors reviewed their initial clinical experience.
  
  
  METHODS
  The authors retrospectively reviewed all cases of adult patients (age ≥ 18 years) who sustained CHI secondary to ground-level falls and who presented to the authors' provisional regional Level I trauma center between February 2011 and May 2011. The authors divided these patients into 3 groups based on anticoagulant therapy: dabigatran, warfarin, and no anticoagulants.
  
  
  RESULTS
  Between February 2011 and May 2011, CHIs from ground-level falls were sustained by 5 patients while on dabigatran, by 15 patients on warfarin, and by 25 patients who were not on anticoagulants. The treatment of the patients on dabigatran at the authors' institution had great diversity. Repeat CT scans obtained during reversal showed 4 of 5 patients with new or expanded hemorrhages in the dabigatran group, whereas the warfarin group had 3 of 15 (p = 0.03). The overall mortality rate for patients sustaining CHI on dabigatran was 2 (40%) of 5, whereas that of the warfarin group was 0 (0%) of 15 (p = 0.05).
  
  
  CONCLUSIONS
  It is critical for physicians involved in the care of patients with CHI on dabigatran to be aware of an elevated mortality rate if no treatment protocol or guideline is in place. The authors will soon implement a reversal management protocol for patients with CHI on dabigatran at their institution in an attempt to improve efficacy and safety in their treatment approach.
authors: Delray Medical Center/Provisional Level I Trauma Center, Delray Beach, Florida, USA. michaelwparra@yahoo.com
authors: Michael W
authors: MW
authors: Parra
authors: Lloyd
authors: L
authors: Zucker
authors: Eric S
authors: ES
authors: Johnson
authors: Diane
authors: D
authors: Gullett
authors: Cristina
authors: C
authors: Avila
authors: Zachary A
authors: ZA
authors: Wichner
authors: Candace R
authors: CR
authors: Kokaram
mesh_terms: D000058:Accidental Falls; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000009:adverse effects* / Q000494:pharmacology; D001562:Benzimidazoles / Q000009:adverse effects* / Q000494:pharmacology; D020202:Cerebral Hemorrhage, Traumatic / Q000188:drug therapy* / Q000209:etiology / Q000401:mortality; D002985:Clinical Protocols / Q000592:standards; D006259:Craniocerebral Trauma / Q000150:complications / Q000188:drug therapy* / Q000401:mortality; D000069604:Dabigatran; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014859:Warfarin / Q000009:adverse effects* / Q000494:pharmacology; D055815:Young Adult; D015091:beta-Alanine / Q000009:adverse effects / Q000031:analogs & derivatives* / Q000494:pharmacology
chemical_list: D000925:Anticoagulants; D001562:Benzimidazoles; D015091:beta-Alanine; D014859:Warfarin; D000069604:Dabigatran