GOLEZ, Steffi Gabrielle R.

February 05, 2020

4NUR-2 RLE 2 Sir Carlo G. Ranoco

Title: Head injury on Warfarin: likelihood of delayed intracranial bleeding in patients with
negative initial head CT
Authors: Amer Afaneh, Jennifer Ford, Jenna Gharzeddine, Alexandre Mazar, R. David
Hayward and Joseph Buck
APA: Afaneh, A., Ford, J., Gharzeddine, J., Mazar, A., Hayward, R. D., & Buck, J. (2018). Head
injury on Warfarin: likelihood of delayed intracranial bleeding in patients with negative initial
head CT. BMC Research Notes, 11(1). doi:10.1186/s13104-018-3291-z

1.) Using the PICO format, formulate your questions.

a. What is the population of interest?
- A total of 394 patients having head injury and on warfarin therapy.

b. What is the intervention implemented or the interest?

- Of the 394 patients, 121 (31%) of these patients did not receive a second CT while
273 patients (69%) underwent a second CT. Most of the patients who did not undergo
a second CT were treated prior to the full phase-in of the current protocol for head
injury on Warfarin at our institution, which began in October 2011, before which time
the decision to order a second CT depended upon surgeon preference.
- 6 of the 273 patients who had a repeat head CT (2.2%) developed a delayed bleed.
Only two patients had a clinically significant bleed (0.7%). A chart review of the six
patients who had a delayed bleed did not reveal that they had any neurosurgical
intervention. Of the two patients that had a clinically significant bleed, one patient
was transferred to a rehabilitation facility due to overall debility. The second patient
had neurologic decline and was ventilator dependent. The patient had multiple
injuries and comorbidities and was given palliative care. It was unclear on
examination of the medical record if neurologic changes preceded the repeat CT or if
they occurred after the repeat CT.
c. What is the comparison? Or the current applicable practice or status?
- Head injury is any sort of injury to your brain, skull, or scalp which can range from a
mild bump or bruise to a traumatic brain injury. The consequences and treatments
vary greatly, depending on what caused the head injury and how severe it is.
- Antithrombotic agent use such as anticoagulants and antiplatelet agents, including but
not limited to: warfarin, aspirin (ASA), clopidogrel, and direct acting oral
anticoagulants (DOAC), are commonly accepted risk factors for traumatic intracranial
bleeding.
 d. What is the outcome of interest?
- This study, which was based on long-term from 2009 to 2014, revealed a low rate of
delayed bleeding in warfarin anticoagulated patients presenting after head injury. The
utility of repeat head CT in the neurologically stable patient is thus questioned and
may not be necessary in all patients.
2.) Discuss your process of evidence search.
a. Identify key words used
- Journal articles for mild head injury and on anti-thrombotic therapy
b. Identify data bases used
- Science Direct
c. Identify at least 5 potential articles relevant to your problem

1) Barmparas, G., Kobayashi, L., Dhillon, N. K., Patel, K. A., Ley, E. J., Coimbra, R., &
Margulies, D. R. (2018). The risk of delayed intracranial hemorrhage with direct acting
oral anticoagulants after trauma: A two-center study. The American Journal of Surgery.
2) Afaneh, A., Ford, J., Gharzeddine, J., Mazar, A., Hayward, R. D., & Buck, J. (2018).
Head injury on Warfarin: likelihood of delayed intracranial bleeding in patients with
negative initial head CT. BMC Research Notes, 11(1).
3) Huang, G. S., Dunham, C. M., Chance, E. A., & Hileman, B. M. (2019). Detecting
delayed intracranial hemorrhage with repeat head imaging in trauma patients on
antithrombotics with no hemorrhage on the initial image: A retrospective chart review
and meta-analysis. The American Journal of Surgery.
4) Scantling, D., Fischer, C., Gruner, R., Teichman, A., McCracken, B., & Eakins, J. (2017).
The role of delayed head CT in evaluation of elderly blunt head trauma victims taking
antithrombotic therapy. European Journal of Trauma and Emergency Surgery, 43(6),
741–746.
5) Verschoof, M. A., Zuurbier, C. C. M., de Beer, F., Coutinho, J. M., Eggink, E. A., & van
Geel, B. M. (2017). Evaluation of the yield of 24-h close observation in patients with
mild traumatic brain injury on anticoagulation therapy: a retrospective multicenter study
and meta-analysis. Journal of Neurology, 265(2), 315–321.

Rate the identified articles according to the level of evidence.

1) Level IV: Evidence from well-designed case-control and cohort studies
2) Level IV: Evidence from well-designed case-control and cohort studies
3) Level V: Evidence from systematic reviews of descriptive and qualitative studies (meta-
synthesis)
4) Level IV: Evidence from well-designed case-control and cohort studies
5) Level V: Evidence from systematic reviews of descriptive and qualitative studies (meta-
synthesis)
d. Choose ONE (1) article to appraise.
- Afaneh, A., Ford, J., Gharzeddine, J., Mazar, A., Hayward, R. D., & Buck, J. (2018). Head
injury on Warfarin: likelihood of delayed intracranial bleeding in patients with negative initial
head CT. BMC Research Notes, 11(1).
e. Assess the available evidence for its appropriateness and applicability for our practice
 Appropriateness of the research questions
- There were no research questions indicated in the article.

 Appropriateness of the research design

- It is appropriate because in a retrospective study, in contrast to a prospective study,
the outcome of interest has already occurred at the time the study is initiated. This
retrospective study was performed between January 2009 and August 2014, 121
(31%) of these patients did not receive a second CT while 273 patients (69%)
underwent a second CT.

 Rigors of the study/validity and reliability issues

- The study has some limitations, including the retrospective nature of this work
introduces potential selection and other bias. It is possible that patients with unknown
home medications were excluded from this analysis. Although most of our patients
underwent a repeat CT of the brain, almost 31% did not, potentially missing a delayed
ICH not captured on imaging.

 Validity of the interventions (internal and external validity) (if applicable)

- The method is helpful in determining the delayed intracranial hemorrhage by having
second CT and further close monitoring to the patient.

 Adequacy of the sample

- The sample size was valid and enough to be a basis in order to come up with a result.

 Validity and reliability of the instruments, data collection activities and

measures
- All tools, data collection activities and measures were not questionable and were all
valid to be a reliable source

 Appropriateness of statistical treatments or analysis measures

- All statistical treatments and analysis measures are appropriate and reliable.

 Findings and conclusions

- In conclusion, results demonstrated a low rate of delayed bleeding in warfarin
anticoagulated patients presenting after head injury. The utility of repeat head CT in
the neurologically stable patient is thus questioned and may not be necessary in all
 patients. They believed repeat head CT may be beneficial in patients with baseline
abnormal neurologic status and those with INR greater than 3.

3.) Give your general comment on the study identified

- I can say that this study has a great impact on the doctors and greatly affects the result
of the CT of the patients who had mild head injury or trauma. This study is consistent
with the fndings in the literature of low rate of delayed bleeding in patients on
warfarin. Peck et. al found a 1% delayed hemorrhage rate however the study looked
at both Warfarin and patients on anti-platelet therapy

4.) Give your recommendation for Evidence based practice

- I recommend this research because this may help or benefit a lot of surgeons,
internists and doctor regarding handling patients with mild head injury who are
undergoing warfarin or other anti-coagulant medications.