What should be done for a patient on warfarin with a persistent bleed from a scrape?

Management of Persistent Bleeding in a Patient on Warfarin

For a patient on warfarin with persistent bleeding from a scrape, the bleeding should be classified as a non-major bleed and managed with local therapy/manual compression while temporarily stopping warfarin if bleeding continues despite local measures. 1

Assessment of Bleeding Severity

First, determine if this is a major or non-major bleed:

• This scrape with persistent bleeding does not meet criteria for a major bleed as it:
  • Is not at a critical site
  • Has not caused hemodynamic instability
  • Has not resulted in a hemoglobin decrease ≥2 g/dL or required blood transfusions 1

Management Algorithm

Step 1: Local Measures

• Apply direct pressure to the wound for at least 15 minutes
• Consider topical hemostatic agents instead of bacitracin (which has no hemostatic properties)
• Apply pressure dressing after bleeding stops

Step 2: If Bleeding Persists Despite Local Measures

• Stop warfarin temporarily 1
• Continue local therapy/manual compression
• Consider 2-5 mg oral vitamin K if bleeding doesn't respond to local measures 1
• Check INR to determine the degree of anticoagulation 2

Step 3: INR-Based Management

• If INR is within therapeutic range (2.0-3.0): Hold next dose of warfarin until bleeding stops 2
• If INR is above therapeutic range but below 5: Omit next dose and resume at lower dose when bleeding stops 2
• If INR is between 5-9 without significant bleeding: Omit 1-2 doses and consider oral vitamin K (1-2.5 mg) 2, 3
• If INR is >9: Give oral vitamin K (3-5 mg) and monitor INR closely 2

Step 4: Resuming Anticoagulation

• Once bleeding stops, restart warfarin at a potentially lower dose based on INR results 1
• Check INR within one week to ensure adequate anticoagulation 1

Important Considerations

• Elderly patients (this 76-year-old) may be more sensitive to warfarin and require closer monitoring during dose adjustments 2
• Minor bleeding can progress to major bleeding if not properly managed 3
• The full impact of warfarin dose adjustments may not be evident until 3-5 days after changes 2

Pitfalls to Avoid

• Don't ignore persistent bleeding: Even minor bleeding in anticoagulated patients can become significant if not addressed properly
• Don't continue anticoagulation at the same dose if bleeding persists despite local measures 1
• Don't administer parenteral vitamin K for minor bleeding as it may cause excessive reversal 3
• Don't use fresh frozen plasma or prothrombin complex concentrate for minor bleeding - reserve these for major bleeding episodes 1, 4

By following this algorithm, the persistent bleeding from the scrape should be controlled while minimizing thrombotic risk from temporary warfarin interruption.