How should anticoagulation be managed in a patient with an acute-on-chronic subdural hematoma who is currently on enoxaparin (low molecular weight heparin)?

EMR Documentation: Anticoagulation Management in Acute-on-Chronic Subdural Hematoma

Immediate Actions Taken

Enoxaparin has been discontinued immediately upon diagnosis of acute-on-chronic subdural hematoma, as this is a mandatory first step in managing intracranial hemorrhage. 1, 2

• Patient currently on enoxaparin for [indication - specify DVT prophylaxis vs therapeutic anticoagulation]
• Last dose of enoxaparin administered: [date/time]
• Enoxaparin will remain discontinued until hematoma stability is confirmed

Reversal Strategy Implemented

Protamine sulfate administered for enoxaparin reversal given the presence of intracranial hemorrhage requiring therapeutic intervention. 1

• Dosing administered:
  • If enoxaparin given within 8 hours: 1 mg protamine per 1 mg enoxaparin (maximum 50 mg single dose) 1
  • If enoxaparin given 8-12 hours ago: 0.5 mg protamine per 1 mg enoxaparin 1
  • If >12 hours since last dose: Protamine likely not needed 1
• Protamine given via slow IV injection over 10 minutes 1
• If life-threatening bleeding persists or patient has renal insufficiency, repeat protamine dosing (0.5 mg per 1 mg enoxaparin) was considered 1

VTE Prophylaxis Strategy

Mechanical prophylaxis with thigh-high intermittent pneumatic compression (IPC) devices initiated immediately as the sole VTE prevention method. 1, 2

• IPC devices applied to bilateral lower extremities within 24 hours of admission 1, 2
• Skin integrity assessed daily under IPC devices 1
• IPC to continue until patient independently mobile, discharge, or 30 days (whichever first) 1
• Pharmacological VTE prophylaxis with enoxaparin is absolutely contraindicated for minimum 48-72 hours post-diagnosis 2

Criteria for Potential Enoxaparin Resumption

Enoxaparin may only be reconsidered after ALL of the following criteria are met: 2, 3

1. Minimum 48-72 hours elapsed since initial diagnosis 2
2. Repeat head CT demonstrates hematoma stability (no expansion) 2, 3
3. Neurological examination stable or improving 2, 3
4. Formal neurosurgery risk-benefit assessment completed and documented 2
5. No surgical intervention planned in immediate future 3

High-Risk Features Present in This Patient

• Age 76 years: Increased bleeding risk with enoxaparin 2
• Immobility from trauma/hospitalization: Elevated thromboembolism risk 2
• [Document if present: Renal impairment - requires dose adjustment or alternative agent] 4

Monitoring Plan

• Daily neurological assessments to detect any deterioration 2
• Daily skin integrity checks under IPC devices 2
• Repeat head CT planned for [specify timing, typically 48-72 hours] before any consideration of pharmacological anticoagulation 2
• Vital signs per protocol 2

Alternative Anticoagulation if Resumption Needed

If pharmacological anticoagulation becomes necessary before hematoma fully resolved, unfractionated heparin (UFH) is strongly preferred over enoxaparin. 2, 4

• UFH allows precise titration via aPTT monitoring 2
• UFH has shorter half-life enabling rapid reversal if rebleeding occurs 2
• UFH dosing: Weight-based IV bolus 60 U/kg (max 4000 U), then 12 U/kg/h infusion (max 1000 U/h), adjusted to aPTT 1.5-2.0 times control 4

Thromboembolic Risk Assessment

Patient at elevated risk for thromboembolic complications given: 3

• History requiring therapeutic anticoagulation [specify indication]
• Prolonged immobility expected
• Literature shows 9.1% thrombotic complication rate when antithrombotics discontinued in CSDH patients 3
• However, immediate bleeding risk from intracranial hemorrhage takes absolute priority over thrombotic risk 1, 2

Neurosurgery Consultation

• Neurosurgery consulted for evaluation and management recommendations
• Surgical intervention [planned/not planned/completed on date]
• Neurosurgery agrees with anticoagulation management plan as outlined

Plan Summary

1. Enoxaparin remains discontinued
2. IPC devices for VTE prophylaxis
3. Repeat head CT in [specify timeframe]
4. Daily neuro checks and skin assessments
5. Reassess anticoagulation need after minimum 48-72 hours with documented hematoma stability
6. If anticoagulation required urgently, transition to UFH rather than resuming enoxaparin

Risks and benefits of withholding anticoagulation versus bleeding risk extensively discussed with patient/family. Patient/family understands that intracranial hemorrhage takes priority and anticoagulation cannot be resumed until hematoma stability confirmed.