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Headache and High INR Guidelines

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Headache Guideline

1. Does a response to therapy predict the etiology of an acute headache?

Level C recommendation: Pain response to therapy should not be used as the sole diagnostic indicator of the underlying etiology of an acute headache.

2. Which patients with headache require neuroimaging in the ED?

Level B recommendations: i. Patients presenting to the ED with headache and new abnormal findings in a neurologic examination (eg, focal deficit, altered mental status, altered cognitive function) should undergo emergent* noncontrast head CT. ii. Patients presenting with new sudden-onset severe headache should undergo an emergent* head CT. iii. HIV-positive patients with a new type of headache should be considered for an emergent* neuroimaging study.
Level C recommendation: Patients who are older than 50 years and presenting with new type of headache but with a normal neurologic examination should be considered for an urgent† neuroimaging study.

*Emergent studies are those essential for a timely decision regarding potentially life-threatening or severely disabling entities. †Urgent studies are those that are arranged prior to discharge from the ED (scan appointment is included in the disposition) or performed prior to disposition when follow-up cannot be assured. Routine studies are indicated when the study is not considered necessary to make a disposition in the ED.

3. Does lumbar puncture need to be routinely performed on ED patients being worked up for nontraumatic subarachnoid hemorrhage whose noncontrast brain CT scans are interpreted as normal?

Level B recommendation: In patients presenting to the ED with sudden-onset, severe headache and a negative noncontrast head CT scan result, lumbar puncture should be performed to rule out subarachnoid hemorrhage.

4. In which adult patients with a complaint of headache can a lumbar puncture be safely performed without a neuroimaging study?

Level C recommendations:
i. Adult patients with headache and exhibiting signs of increased intracranial pressure (eg, papilledema, absent venous pulsations on funduscopic examination, altered mental status, focal neurologic deficits, signs of meningeal irritation) should undergo a neuroimaging study before having a lumbar puncture.
ii. In the absence of clinical findings suggestive of increased intracranial pressure, a lumbar puncture can be performed without obtaining a neuroimaging study. (Note: A lumbar puncture does not assess for all causes of a sudden severe headache.)

5. Is there a need for further emergent diagnostic imaging in the patient with sudden-onset, severe headache who has negative findings in both CT and lumbar puncture?

Level B recommendation: Patients with a sudden-onset, severe headache who have negative findings on a head CT, normal opening pressure, and negative findings in CSF analysis do not need emergent angiography and can be discharged from the ED with follow-up recommended.

Recommendations for Managing Elevated INRs or Bleeding in Patients Receiving Vitamin K Antagonists

INR more than therapeutic range but < 5.0; no significant bleeding: Lower dose or omit dose; monitor more frequently and resume at lower dose when INR therapeutic; if only minimally above therapeutic range, no dose reduction may be required (Grade 1C).

INR > 5.0, but < 9.0; no significant bleeding: Omit next one or two doses, monitor more frequently, and resume at an appropriately adjusted dose when INR in therapeutic range. Alternatively, omit dose and give vitamin K (1–2.5 mg po), particularly if at increased risk of bleeding (Grade 1C). If more rapid reversal is required because the patient requires urgent surgery, vitamin K (???? 5 mg po) can be given with the expectation that a reduction of the INR will occur in 24 h. If the INR is still high, additional vitamin K (1–2 mg po) can be given (Grade 2C).

INR > 9.0; no significant bleeding: Hold warfarin therapy and give higher dose of vitamin K (2.5–5 mg po) with the expectation that the INR will be reduced substantially in 24–48 h (Grade 1B). Monitor more frequently and use additional vitamin K if necessary. Resume therapy at an appropriately adjusted dose when INR is therapeutic.

Serious bleeding at any elevation of INR: Hold warfarin therapy and give vitamin K (10 mg by slow IV infusion), supplemented with FFP, PCC, or rVIIa, depending on the urgency of the situation; vitamin K can be repeated q12h (Grade 1C).

Life-threatening bleeding: Hold warfarin therapy and give FFP, PCC, or rVIIa supplemented with vitamin K (10 mg by slow IV infusion). Repeat, if necessary, depending on INR (Grade 1C).

Administration of vitamin K: In patients with mild to moderately elevated INRs without major bleeding, give vitamin K orally rather than subcutaneously (Grade 1A).

2008 ACEP Clincal Policy for Headache
ACCP Vit K Antagonist Guidelines 2008

Written by reuben

July 25th, 2011 at 11:23 pm

Posted in Required Reading