A 72-year-old woman is brought to the emergency department by her husband due to sudden-onset, right-sided weakness and numbness. The patient's husband reports that her symptoms progressed over several minutes and were later accompanied by vomiting and headache. He also notes that she is now excessively somnolent. The patient has hypertension and persistent atrial fibrillation as well as myelodysplasia that has not required treatment. She takes amlodipine, metoprolol, warfarin, and multivitamins. In the past couple of days, she has also used over-the-counter medications for cold symptoms. Temperature is 37 C (98.6 F), blood pressure is 172/90 mm Hg, pulse is 68/min, and respirations are 16/min. Her laboratory results and CT scan of the head without contrast are as follows: Which of the following is the best immediate step in management of this patient?

Question

A 72-year-old woman is brought to the emergency department by her husband due to sudden-onset, right-sided weakness and numbness.  The patient's husband reports that her symptoms progressed over several minutes and were later accompanied by vomiting and headache.  He also notes that she is now excessively somnolent.  The patient has hypertension and persistent atrial fibrillation as well as myelodysplasia that has not required treatment.  She takes amlodipine, metoprolol, warfarin, and multivitamins.  In the past couple of days, she has also used over-the-counter medications for cold symptoms.  Temperature is 37 C (98.6 F), blood pressure is 172/90 mm Hg, pulse is 68/min, and respirations are 16/min.  Her laboratory results and CT scan of the head without contrast are as follows:   Which of the following is the best immediate step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d484_c297_bc81_6532c56648f0_MD0003_00 This patient's neurologic deficits (eg, right hemiparesis and hemisensory loss), supratherapeutic INR, and head CT scan findings are consistent with an acute warfarin-associated intracerebral hemorrhage in the left thalamus with intraventricular extension. Symptoms of elevated intracranial pressure (eg, headache, nausea/vomiting, altered mental status) can develop as the hemorrhage expands. This patient's condition was likely provoked by the use of over-the-counter cold medications, which often contain acetaminophen (potentiates anticoagulant effect of warfarin) and decongestants such as phenylephrine (may elevate blood pressure). Patients with warfarin-associated intracerebral hemorrhage should have their anticoagulation reversed immediately to reduce the risk of death and permanent disability. Initial therapy should include intravenous vitamin K, which has a sustained response but takes approximately 12-24 hours to be effective (promotes clotting factor synthesis in the liver). Prothrombin complex concentrate (PCC) should also be provided as it contains vitamin K-dependent clotting factors (eg, II, VII, IX, X) that offer rapid (minutes) and short-term (hours) reversal of warfarin. Fresh frozen plasma can be considered if PCC is not available; however, it takes longer to prepare/administer and requires more volume infusion compared to PCC. (Choices A and F) Lowering of systolic blood pressure to <140 mm Hg with nicardipine or labetalol is probably safe in patients with hemorrhagic stroke to reduce the risk of hematoma expansion in the first 24 hours; however, initiating aspirin or tissue plasminogen activator would be inappropriate. (Choice B) Lumbar puncture should be avoided in patients with an acute intracerebral hemorrhage due to the risk of inducing herniation as a result of increased intracranial pressure. (Choice C) Platelet transfusion may be considered in patients with thrombocytopenia or in individuals taking antiplatelet therapy (eg, aspirin, clopidogrel) at the time of their brain bleed. (Choice D) Protamine sulfate is indicated when urgent reversal of heparin is needed; however, it has no role in the management of warfarin-induced bleeding. (Choice G) Tranexamic acid is an antifibrinolytic agent that may be used to treat heavy menstrual bleeding and prevent excessive blood loss during certain types of surgery. However, it would not reverse this patient's elevated INR and does not have a role in the treatment of warfarin-associated hemorrhage. Educational objective: Patients who develop serious bleeding (eg, intracerebral hemorrhage) due to excess anticoagulation with warfarin should have their anticoagulation immediately reversed with intravenous vitamin K and prothrombin complex concentrate to reduce the risk of death and permanent disability. References: Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. (http://www.ncbi.nlm.nih.gov/pubmed/20651276) Warfarin-related intracerebral haemorrhage: better outcomes when reversal includes prothrombin complex concentrates. (http://www.ncbi.nlm.nih.gov/pubmed/23176226)

A 72-Year-Old Woman Is Brought to the Emergency Department by Her