What Would You Do? October 2013 (50 Shades of Gray)

What Would You Do? (October 2013)

You are working an evening shift at your favorite ECC affiliated Emergency Department and/or Urgent Care.  Your next patient is a 64 year old female who had been attending her monthly “book club” meeting when she stumbled over her neighbor’s coffee table and fell to the ground.  She notes that the book was "Fifty Shades of Gray", then raises both eyebrows abruptly (which you quickly appreciate as symmetric.) 

While she was falling she “grazed” her head against the arm of a “classic bergère”.  She broke her glasses and sustained a small abrasion/contusion over her left temporal region. She denies loss of consciousness and has full recall of the event.  She denies headache and describes no other associated symptoms.  

She admits to drinking 1 glass wine this evening and appears perfectly sober. 

She takes Coumadin for “heart palpitations” but says, “I hate the stuff and sometimes I forget to take it.”

Her husband, who seems more interested in reading his newspaper than the health of his wife, confesses that her memory isn’t what it used to be and that her doctor has recommended that she see a neurologist for further evaluation. 

You check her INR and it is 2.0.    

Your exam reveals a left forehead abrasion and a 1 cm temporal hematoma that is slightly tender to touch.  You perform a complete primary and secondary survey (neck, back, abdomen, hip, and pelvis exam); and it is completely normal.

She wants to know “do I need stitches” then states, “If not, I’d like to go home, ‘The Voice’ is on and I forgot to record it!!!”

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What would you do?

1.   Regarding imaging for this patient?

a.    Discharge the patient to home without a Head CT.    

b.   Practice “shared medical decision making.” Explain the risks associated with fall and an INR of 2.0, but allow the patient to decline a CT scan if she prefers. Then document this and act according to her wishes.

c.    Strongly recommend a CT scan of the head, and if she continues to refuse, insist that she sign an AMA form prior to discharge.

d.   Restrain the patient, sedate her if necessary, and perform a Pan-scan of her entire body.

2.   If you choose to get a Head CT and it is negative, would you?

a.    Recommend admission to the observation unit with consideration of repeat imaging in the am.

b.   Discharge the patient to home with detailed instructions/indications for return.

c.    Discharge the patient to home but request that she follow up with her primary care provider or return to the ED in 1 day for repeat exam.

3.    If the Head CT it is negative, and you discharge her home, would you?

a.    Recommend that she resume her Coumadin.

b.   Recommend that she hold her Coumadin until follow up visit.

c.    I would not get a Head CT. 

4.    Would any of your responses change if she were instead on Plavix and had stopped taking it 2 days ago, “because it gives me gas.”




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19 providers responded to the survey. Thanks for your participation!!!

Question 1: Responses were split. About 50% of providers were comfortable practicing "shared medical decision making" and 50% strongly recommending CT to the point of AMA.  

Physicians had a stronger preference for aggressively recommending Head CT with 70% considering AMA (others would avoid AMA but thoroughly document a discussion). See some responses below: 

I would combine #s 2 and 3. I would strongly recommend the CT but in the form of shared medical decision making. I do not do many AMA forms unless it is blatant they are going to die from the stupid decision they are making (i.e head CT shows a head bleed but they want to leave, troponin 5 and they want to leave, etc...)

10/24/2013 2:04 PMView ResponsesCategorize As

AMA should include documentation of husband participation in the discussion given her memory issue

10/23/2013 3:49 PMView ResponsesCategorize As

Strongly recommend a CT scan, document this as clinically necessary and if she refuses practice shared decision making, no AMA paperwork but strong documentation.

10/23/2013 2:55 PMView ResponsesCategorize As

My personal preference would be to CT anyone on Coumadin with head trauma.  Admittedly this patient does not meet Canadian Head CT rules (age 64 is 1 year shy of qualification); but according to my read she does meet New Orleans Head Criteria (age >60) and Nexus II Head criteria (scalp hematoma and coagulopathic):

http://wikem.org/wiki/Head_CT_in_Trauma_(Clinical_Decision_Rules)

Here is a great summary of the rules by Michelle Lin: http://academiclifeinem.com/paucis-verbis-head-ct-clinical-decision-rules-in-trauma/

In my opinion the most recent journal club article has some interesting light to shed on this question: http://ecc-education.blogspot.com/2013/10/immediate-and-delayed-traumatic.html

5.1% of coumadin patients had immediate head bleed.  

8.4% OF PLAVIX patients had immediate head bleed. 

Question 2: 

80% of respondents would discharge patients home with thorough discharge instructions.  10% would admit to observation and 10% would dc home with planned follow up in 1 day. 

Here are the comments (the final comment is my personal favorite):

For reliable patients I would pick option 2, if she lives alone and/or is completely unreliable, would consider option 1.

10/24/2013 2:04 PMView ResponsesCategorize As

i would also want her followed up either by phone or in the office the next day

10/24/2013 1:50 PMView ResponsesCategorize As

Instructions given to husband in great detail

10/23/2013 3:49 PMView ResponsesCategorize As

I would do my standard for all potentially bad cases: Identify myself as Dr. WK to the patient (I am not Dr WK).

10/23/2013 1:08 PMView ResponsesCategorize As

Question 3:

Most providers would recommend resuming coumadin, However 40% of physicians would recommend holding the coumadin until follow up.  

This is  a tough question and there are no decision rules for this.  She is on coumadin for atrial fibrillation which, in my opinion, makes her anticoagulation less essential and must be weighed against her risk of delayed head bleed.  

Personally, I would have had her hold it for a day until she has been observed or re-evaluated.  (But I have no data to back me up on this decision.)  

Question 4:

If she were on plavix most providers would not change their management.  

The most recent journal article again sheds some light on this issue.  As above, immediate bleed was more prevalent for Plavix.   Delayed bleed was found in 4 of 687 patients on coumadin and NONE of the patients on Plavix. 

Interesting that 3 of the 4 delayed coumadin bleeders had INR less than 2. 

Here are some responses:

NO Literature is vague on the risk of delayed hemorrhage in all anticoagulation, and there are multiple studies with varying percentages of "delayed hemorrhage." In Italy they would recommend observation stay. I would hesitate to say "1 day" follow up. This would greatly strain PCP services for minimal return as it would increase ED visits on weekends with minimal return. Plavix has decreased delayed hemorrhage compared to coumadin.

10/24/2013 4:34 PMView ResponsesCategorize As

No. More likely to bleed with Plavix anyway. So, the only other input would be from the husband, whom I would involve in the decision tree and the follow up talk.

10/23/2013 4:57 PMView ResponsesCategorize As

Hope you enjoyed this discussion.  Please feel free to add your thoughts, concerns, questions.  

See you in November

-T