Anticoagulants and Head Anticoagulants and Head InjuriesInjuries

Robyn Mazzolini, RN, TNS

EMS Coordinator

Lutheran General Hospital

ObjectivesObjectives State the trend observed by LGH Trauma State the trend observed by LGH Trauma

Department regarding anticoagulants and head Department regarding anticoagulants and head injuries.injuries.

List some common anticoagulants and indications List some common anticoagulants and indications for use.for use.

Discuss how ECF staff is notified that a resident Discuss how ECF staff is notified that a resident takes an anticoagulant.takes an anticoagulant.

Review normal physiologic changes to the aging Review normal physiologic changes to the aging brain and mechanisms of injury.brain and mechanisms of injury.

Discuss medical management of the resident on an Discuss medical management of the resident on an anticoagulant with a head injury. anticoagulant with a head injury.

We Have Noted…We Have Noted… Lutheran General Trauma Lutheran General Trauma

Department has identified Department has identified over the last 6 months an over the last 6 months an increase in mortality due increase in mortality due to falls with head injuries to falls with head injuries for residents on for residents on anticoagulants. anticoagulants.

Did you know?Did you know?

According to the CDC, a According to the CDC, a person > 65 years of age person > 65 years of age dies every 35 minutes due dies every 35 minutes due to complications from a to complications from a fall.fall.

Common AnticoagulantsCommon Anticoagulantsand Indicationsand Indications

Coumadin Coumadin (warfarin) indicated for venous thrombosis, (warfarin) indicated for venous thrombosis, pulmonary embolism, atrial fibrillation, cardiac valve pulmonary embolism, atrial fibrillation, cardiac valve replacement, reduce risk of recurrent myocardial infarction replacement, reduce risk of recurrent myocardial infarction and stroke.and stroke.

AspirinAspirin indicated for treatment of pain/inflammation from indicated for treatment of pain/inflammation from arthritis, soft tissue injuries, pain, fever, and to decrease arthritis, soft tissue injuries, pain, fever, and to decrease risk of recurrent stroke, transient ischemic attack (TIA) and risk of recurrent stroke, transient ischemic attack (TIA) and myocardial infarction.myocardial infarction.

LovenoxLovenox indicated for deep vein thrombosis, unstable indicated for deep vein thrombosis, unstable angina, and myocardial infarction.angina, and myocardial infarction.

PlavixPlavix indicated to reduce thrombotic events such as indicated to reduce thrombotic events such as myocardial infarction, stroke, peripheral vascular disease myocardial infarction, stroke, peripheral vascular disease and acute coronary syndrome.and acute coronary syndrome.

How Does Your Staff Know?How Does Your Staff Know? How does your ECF staff How does your ECF staff

know that a particular know that a particular resident takes an resident takes an

anticoagulant?anticoagulant?

Time to brainstorm!Time to brainstorm!

Falls in Extended Care FacilitiesFalls in Extended Care FacilitiesReference: Centers for Disease Control and PreventionReference: Centers for Disease Control and Prevention

Each year, an average ECF Each year, an average ECF with 100 beds reports 100-with 100 beds reports 100-200 falls. 200 falls.

About 1800 older adults About 1800 older adults living in ECFs die each year living in ECFs die each year from fall-related injuries. from fall-related injuries. This accounts for 20% of This accounts for 20% of the deaths in this age the deaths in this age group.group.

Traumatic Brain Injury, or Traumatic Brain Injury, or TBI, is caused by a jolt, TBI, is caused by a jolt, bump or blow to the head.bump or blow to the head.

Physiologic ChangesPhysiologic Changes As we age, our As we age, our

brains lose mass brains lose mass which allows for which allows for increased increased movement within movement within the skull with any the skull with any kind of trauma.kind of trauma.

There is an There is an increased subdural increased subdural space – more room space – more room for bleeding.for bleeding.

Mechanism of InjuryMechanism of Injury

Even with Even with minorminor head trauma, the head trauma, the resident on an resident on an anticoagulant is at anticoagulant is at great risk for a great risk for a significant head significant head injury.injury.

Especially at risk: Especially at risk: unwitnessed falls.unwitnessed falls.

Possible InjuriesPossible InjuriesSubdural bleedSubdural bleed

Epidural bleedEpidural bleed

Intracerebral bleed

What Should You Do?What Should You Do? One of your residents falls – what should you do?One of your residents falls – what should you do?

Your staff should call 911.Your staff should call 911. Do not move the resident! Do not move the resident! Maintain cervical spine in alignment and keep airway Maintain cervical spine in alignment and keep airway

open.open.

What Do We Do At the What Do We Do At the Hospital?Hospital?

Stop the bleeding!Stop the bleeding!

With a patient on coumadin, within one hour of With a patient on coumadin, within one hour of positive CT scan we administer fresh frozen positive CT scan we administer fresh frozen plasma and vitamin K.plasma and vitamin K.

With a patient on aspirin, within one hour of With a patient on aspirin, within one hour of positive CT scan we administer platelets.positive CT scan we administer platelets.

We have an extensive 2 page guideline for We have an extensive 2 page guideline for reversal of anticoagulants. reversal of anticoagulants.

Case StudyCase StudyOne of our recent deaths:One of our recent deaths:

Mrs. S, an ECF resident, fell one evening while Mrs. S, an ECF resident, fell one evening while walking with her cane and bumped her head. walking with her cane and bumped her head. She denied any injury, felt fine, and the NCT She denied any injury, felt fine, and the NCT helped her up and into bed.helped her up and into bed.

Unfortunately, Mrs. S was unconscious and Unfortunately, Mrs. S was unconscious and unresponsive by the next morning. On CT she unresponsive by the next morning. On CT she had a large subdural bleed. Mrs. S was on had a large subdural bleed. Mrs. S was on Coumadin. Coumadin.

We believe delay in care contributed to her poor We believe delay in care contributed to her poor outcome.outcome.

In SummationIn Summation

We suggest any resident that is on a We suggest any resident that is on a blood thinner, that suffers a fall, needs to blood thinner, that suffers a fall, needs to be immediately transported to a hospital be immediately transported to a hospital for an evaluation.for an evaluation.

Do not wait for a change in mental Do not wait for a change in mental status, often it is then too late to status, often it is then too late to intervene to decrease morbidity and intervene to decrease morbidity and mortality.mortality.

Any Questions???Any Questions???