From the Guidelines
An elevated TEG-CKH-R in a patient with a subdural hematoma indicates delayed clot formation and potential coagulopathy, which increases bleeding risk, and the immediate treatment should focus on correcting this coagulopathy with prothrombin complex concentrate (PCC) at 25-50 units/kg if available, as it works faster than fresh frozen plasma (FFP). Given that the patient already received vitamin K yesterday, which takes 24-48 hours for full effect 1, additional measures are needed for more rapid correction. The use of PCC is supported by recent guidelines, which suggest that it can rapidly correct the INR when given with or without vitamin K 1. However, it is essential to note that vitamin K should be administered regardless of the type of coagulation factor replacement, and a dose of 5 to 10 mg IV is recommended 1. Some key considerations in the treatment of this patient include:
- Administering PCC at 25-50 units/kg if available, as it works faster than FFP
- Considering platelet transfusion if the platelet count is low or if the patient is on antiplatelet medications
- Administering tranexamic acid 1g IV over 10 minutes to inhibit fibrinolysis, especially if administered within 3 hours of injury
- Obtaining neurosurgical consultation immediately, as surgical evacuation may be necessary depending on the size of the hematoma and the patient's neurological status
- Close monitoring of coagulation parameters and repeat TEG testing after treatment to assess the response to therapy. The elevated R time suggests inadequate clotting factors, which is particularly dangerous in a patient with intracranial bleeding, and prompt treatment is essential to prevent further complications 1.
From the Research
Elevated TEG-CKH-R in Subdural Hematoma
- An elevated TEG-CKH-R (thromboelastography) result in a patient with a subdural hematoma may indicate coagulopathy or abnormal clotting, which can worsen the hematoma 2, 3.
- The patient's recent administration of vitamin K is a common treatment approach to reverse anticoagulation and promote clotting in patients with intracranial hemorrhage, including subdural hematoma 2, 3.
Treatment of Subdural Hematoma with Coagulopathy
- Treatment options for subdural hematoma with coagulopathy may include:
- Reversal of anticoagulation using vitamin K, fresh frozen plasma, or prothrombin complex concentrate 2, 3.
- Surgical evacuation of the hematoma, which may be necessary in severe cases or if the patient's condition worsens 4, 5.
- Close monitoring of the patient's coagulation status and neurological condition to prevent further complications 6, 5.
Management of Anticoagulation in Subdural Hematoma
- The management of anticoagulation in patients with subdural hematoma is crucial to prevent further bleeding and promote clotting 6, 5.
- The decision to resume anticoagulation therapy after surgical treatment of subdural hematoma should be made on a case-by-case basis, taking into account the patient's individual risk factors and medical history 5.