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How do we treat ICH patients with an elevated INR Andy Jagoda, MD, FACEP Professor and Vice Chair Department of Emergency Medicine Mount Sinai School of Medicine New York, NY. Disclosures. Astra Zeneca, NovoNordisk, UCB Pharma Advisory Boards Eisai Speakers’ Bureau

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Disclosures

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  1. How do we treat ICH patients with an elevated INRAndy Jagoda, MD, FACEPProfessor and Vice Chair Department of Emergency MedicineMount Sinai School of Medicine New York, NY

  2. Disclosures • Astra Zeneca, NovoNordisk, UCB Pharma Advisory Boards • Eisai Speakers’ Bureau • Chair, ACEP Clinical Policies Committee • Executive Board, Brain Attach Coalition • Executive Board, Foundation for Education and Research in Neurologic Emergencies

  3. Common Etiologies of ICH Acquired Coagulopathy – Anticoagulation • Incidence of anticoagulant-associated ICH rose from 5% to 18% of cases of spontaneous ICH in 1990s • INR 2.5-4.5 increases risk of ICH 10X • ICH expansion in over 50% of patients on warfarin • Doubles ICH mortality

  4. Treatment • ICH in patients with INR > 1.5 is life-threatening • Time until initiation of warfarin reversal is predictive of outcome • Reversal may not occur in 1 of 6 patients Goldstein JN, et al. Stroke. 2006;37:151-155.

  5. Reversal Options • Fresh frozen plasma (FFP) • Administration time • Response time • Recombinant factor VIIa • Limited experience • Prothrombin complex concentrates (PCC) • Not available • Vitamin K

  6. Trauma ModelTx of trauma patients with ICH on preinjury warfarin. J Trauma 2006; 61:318-321 • “Coumadin protocol” in place • Mean time until FFP administration was 4.3 hours +/- 4.4 hours • No difference from the preprotocol group • Reasons for delay: • Failure to recognize urgency • Delay in delivery from blood bank • Delay in initiation of infusion • Delay in completion of infusion

  7. Stroke ModelTiming of FFP administration. Stroke 2006; 37:151-155 • CT to FFP time: 60 – 375 min • FFP: 1 – 6 units • Vit K: 0 – 10 mg • 12 / 57 patients INR did not reverse at 24 hours • Rapid correction of INR did not correlate with outcome • Delay in presentation • Delay in administration • Delay in reversal

  8. Conclusions • Protocols need to exist to facilitate rapid reversal of warfarin induced coagulopathy • Protocol: • 2 - 4 units FFP; begin with 2 units of universal donor FFP • 10 mg Vit K slowly IV over 10 minutes • Need for further research on the role of rFactor VII and PCC

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