EM Critical Care: Emergency Management Of Coagulopathy In Acute Intracranial Hemorrhage

In the setting of an acute intracranial hemorrhage, very small amounts of additional bleeding may result in catastrophic consequences to the patient. When a coagulopathic patient with an intracranial hemorrhage presents to the emergency department, rapid reversal of coagulopathy is the most urgent medical intervention. Treatment of coagulopathy is necessary to both prevent hematoma expansion and facilitate neurosurgical interventions. In some cases, coagulopathy may be obvious and easily monitored, such as in a patient receiving warfarin. Other situations may be more complex, such as in a patient who is intermittently compliant with antiplatelet therapy. Many pharmacologic agents and blood products are avail¬able to modulate these clotting derangements, but they have varying efficacy and side-effect profiles. Furthermore, patients requiring anticoagulation have high rates of underlying thrombophilia and vascular disease. In these patients, tipping the coagulation system toward clotting may be necessary to stop bleeding but may also result in stroke, myocardial infarction, or other adverse thromboembolic events. This article reviews existing data and recommendations and suggests an approach to managing coagulopathy in patients with various forms of acute intracranial bleeding.