Warfarin Patient Requiring Urgent Extraction

Do not extract today.

Reasoning:

• The patient has a mechanical mitral valve - he is at high thrombotic risk if anticoagulation is interrupted or reversed.
• His INR of 3.4 is within his therapeutic range (target 2.5-3.5) but sits at the upper end. For a simple extraction, an INR up to ~4.0 is often acceptable in primary care provided local haemostatic measures are available and the INR is measured close to the procedure.
• However, the INR is 3 days old and there is no same-day testing available. You cannot confirm the current value, and a rising INR in an elderly patient on warfarin is plausible.
• You also lack access to reversal agents, and the patient is hypertensive.

Immediate management:

1. Do not stop or alter warfarin - coordinate with his cardiologist/anticoagulation clinic.
2. Arrange same-day or next-day INR and proceed once confirmed ≤4.0 with a plan for local haemostasis (sutures, haemostatic agent, tranexamic acid mouthwash).
3. Control pain with paracetamol; avoid NSAIDs and aspirin.
4. If urgent and INR confirmed safe, extract with atraumatic technique, sutures, and pressure; consider tranexamic acid 4.8% mouthwash 10 ml four times daily for 2-3 days.
5. Give written post-operative bleeding instructions and an emergency contact.
6. Optimise BP before elective care.

Explanation to patient:

• His mechanical mitral valve means his blood is prone to forming clots on the valve. Warfarin keeps his INR in a narrow window (2.5-3.5). If we reverse it or stop it, even briefly, he is at risk of stroke, valve thrombosis, or systemic embolism - these can be catastrophic and irreversible.
• For most simple dental extractions, current guidance (e.g. SDCEP, UK) supports continuing warfarin with a confirmed INR and good local haemostasis, rather than interrupting therapy.
• The evidence shows that local measures (sutures, haemostatic packing, tranexamic acid rinse) control bleeding in the vast majority of patients with INR within range, without systemic reversal.

Alternative plan:

• Confirm INR same-day.
• If ≤4.0: proceed with local haemostasis.
• If >4.0: defer and liaise with the anticoagulation clinic to adjust the dose - not to reverse acutely unless there is major bleeding.
• Never give vitamin K or FFP for a routine dental extraction.

Stepwise management of post-extraction bleeding on warfarin:

1. Assess - ABC, vital signs, estimate blood loss, check for haematoma or airway compromise. Most dental bleeding is venous/oozing and not life-threatening.
2. Local measures first:
   • Remove loose clot, identify bleeding point.
   • Apply pressure with gauze for 10-20 minutes.
   • Suture the socket if not already closed; consider a haemostatic agent (oxidised cellulose, collagen plug, fibrin sealant).
   • Tranexamic acid 4.8% mouthwash 10 ml for 2 minutes, four times daily for 2-3 days - do not swallow.
3. Check INR urgently - if markedly supratherapeutic (>5-6) or bleeding persists despite local measures, refer to emergency department for assessment and possible reversal.
4. Do not stop warfarin yourself; liaise with the anticoagulation team.
5. Analgesia: paracetamol only; avoid NSAIDs.
6. Document and give written advice; review next day.

Key exam point: local measures resolve the majority; systemic reversal is reserved for uncontrolled bleeding or supratherapeutic INR with clinical bleeding.