Warfarinised traumatic contusion with borderline GCS at a district hospital
A 71-year-old man is brought to a district hospital 90 minutes after a 2-metre fall from a ladder. Initial GCS was 14; it is now 13 (E3 V4 M6). He takes warfarin for a metallic mitral valve, and his INR is 3.2. Non-contrast CT shows a left frontal contusion measuring 18 mL, a 4 mm acute subdural haematoma, no midline shift, and no basal cistern effacement. Platelets are 110 × 10⁹/L and creatinine clearance is 40 mL/min. The hospital has CT but no 24-hour neurosurgery; the nearest neurosurgical unit is 2 hours away by road. There is one ICU bed and no on-site neurointensivist. The family asks whether he can be observed locally because he is 'talking'. The ambulance service can provide a doctor for transfer but only after 45 minutes. Discuss the first 6 hours of care.
1. What are the immediate priorities in the first 60 minutes, and how would you reverse anticoagulation before transfer?
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Airway, breathing, circulation, cervical spine precaution, and a repeat CT before transfer are the priorities. GCS 13 with a new contusion and anticoagulation is not a 'talk and observe' situation. For warfarin-related intracranial haemorrhage with INR 3.2, give intravenous vitamin K 5–10 mg plus a four-factor prothrombin complex concentrate, usually 25–50 IU/kg based on INR and weight, rather than fresh frozen plasma alone; PCC corrects INR faster and with less volume in a patient with creatinine clearance 40. Do not give platelets routinely for a count of 110 unless there is a documented platelet function defect or ongoing bleeding, because platelet transfusion can worsen outcomes in spontaneous ICH. Check glucose, haemoglobin, and coagulation profile, and catheterise if urinary output cannot be monitored. Because the patient is anticoagulated with any intracranial haemorrhage, transfer to the neurosurgical unit after reversal and a repeat CT is safer than local overnight observation. The family should be told that 'talking' does not exclude delayed deterioration. The 2-hour transfer should be done by a team able to secure the airway.
2. Would you place an intracranial pressure monitor? Explain your threshold and how transfer affects the decision.
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An ICP monitor is not mandated by a GCS of 13 alone; the usual threshold is GCS 3–8 with an abnormal CT, or a normal CT with two of three adverse features. This patient is above that threshold but has a contusion, anticoagulation, and a planned 2-hour transfer. I would monitor neurological observations hourly and repeat CT before leaving. If he is sedated and intubated for transfer, if GCS falls to 8 or below, or if repeat CT shows expansion or new mass effect, I would place an ICP monitor before or at the receiving unit. A monitor is also reasonable if the receiving team cannot perform reliable hourly examinations because of sedation or staffing. The risk of monitor-related haemorrhage is increased by anticoagulation, so reversal must be confirmed (INR <1.4) and platelets checked before insertion. I would not place a monitor solely for the road transfer in a wakeful GCS 13 patient, because the examination remains the best monitor; the transfer team should have a low threshold to intubate and return.
3. When would you repeat imaging, and what CT findings would trigger immediate decompression rather than transfer?
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Repeat non-contrast CT within 6 hours, or immediately for any GCS drop, new focal deficit, vomiting, or severe headache. In an anticoagulated patient with a contusion I would repeat it before transfer and again 6–8 hours after reversal, because contusion expansion typically occurs in the first 24–48 hours. Findings that trigger immediate decompression at the district hospital, rather than a 2-hour transfer, include a new acute subdural or epidural haematoma with midline shift greater than 5 mm or basal cistern effacement, a contusion expanding to more than 30 mL with mass effect, clinical herniation (GCS drop of 2 or more, anisocoria, bradycardia with hypertension), or a coagulopathy that cannot be corrected before transfer. If none of these are present, transfer after reversal is preferable to operating in a non-neurosurgical hospital. The decision is not based on contusion volume alone: an 18 mL frontal contusion can be observed, but a 4 mm subdural can enlarge quickly in a warfarinised patient. I would document the post-PCC INR and repeat CT findings in the transfer note.