Delayed neurological deterioration after mild head injury: cause, temporal course, and outcomes

Post-traumatic Transient Neurological Dysfunction: A Proposal for Pathophysiology

Unexplained neurological deterioration is occasionally observed in patients with traumatic brain injuries (TBIs). We aimed to describe the clinical features of post-traumatic transient neurological dysfunction and provide new insight into its pathophysiology. We retrospectively collected data from patients with focal neurological deterioration of unknown origin during hospitalization for acute TBI for 48 consecutive months. Brain imaging, including computed tomography, diffusion-weighted imaging and perfusion-weighted imaging, and electroencephalography were conducted during the episodes. Fourteen (2.0%) patients experienced unexplained focal neurological deterioration among 713 patients who were admitted for traumatic intracranial hemorrhage during the study period. Aphasia was the predominant symptom in all patients, and hemiparesis or hemianopia was accompanied in three patients. These symptoms developed within 14 days after trauma. Structural imaging did not show any significant interval change, and electroencephalography showed persistent arrhythmic slowing in the corresponding hemisphere in most patients. Perfusion imaging revealed increased cerebral blood flow in the symptomatic hemisphere. Surgical intervention and anti-seizure medications were ineffective in abolishing the symptoms. The symptoms disappeared spontaneously after 4 h to 1 month. Transient neurological dysfunction (TND) can occur during the acute phase of TBI. Although TND may last longer than a typical transient ischemic attack or seizure, it eventually resolves regardless of treatment. Based on our observation, we postulate that this is a manifestation of spreading depolarization occurring in the injured brain, which is analogous to migraine aura.

Risk Factors Associated With Neurosurgical Intervention in Patients With Mild Traumatic Intracranial Hemorrhage

INTRODUCTION

Community centers commonly transfer patients with traumatic intracranial hemorrhage (ICH) to level 1 and 2 trauma centers for neurosurgical evaluation regardless of the degree of injury. Determining risk factors leading to neurosurgical intervention (NSI) may reduce morbidity and mortality of traumatic ICH and the transfer of patients with lower risk of NSI.

METHODS

A retrospective chart review was performed on patients admitted or transferred to a level 1 trauma center from October 2015 to September 2019 with Glassgow Coma Scale score 13-15 and traumatic ICH on initial head computerized tomography (CTH) scan. Bivariate analyses and multivariable regression were used to identify factors associated with progression to NSI.

RESULTS

Of 1542 included patients, 8.2% required NSI. A greater proportion were male (69.1% versus 52.3%, P = 0.0003), on warfarin (37.7% versus 21.6%, P = 0.0023), presented with subdural hemorrhage (98.4% versus 63.3%, P < 0.0001, larger subdural hemorrhage size (median 19 mm [interquartile range {IQR}: 14-25] versus 5 mm [IQR: 3-8], P < 0.0001), and had a worsening repeat CTH (24.4% versus 13%, P < 0.0001). On physical examination, more patients had confusion (40.5% versus 31.4%, P = 0.0495) and hemiparesis (16.2% versus 2.6%, P < 0.0001). CTH findings of midline shift (80.2% versus 10.8%, P < 0.0001) and shift size (median 8.0 mm [IQR: 5.0-12.0] versus 4 mm [IQR: 3-5], P < 0.0001) were significantly associated with NSI.

CONCLUSIONS

Clinical factors and patient characteristics can be used to infer a greater risk of requiring NSI. These factors could reduce unnecessary transfers and hasten the transfer of patients more likely to progress to NSI.

Rapid prediction of secondary neurologic decline after traumatic brain injury: a data analytic approach

Secondary neurologic decline (ND) after traumatic brain injury (TBI) is independently associated with outcome, but robust predictors of ND are lacking. In this retrospective analysis of consecutive isolated TBI admissions to the R. Adams Cowley Shock Trauma Center between November 2015 and June 2018, we aimed to develop a triage decision support tool to quantify risk for early ND. Three machine learning models based on clinical, physiologic, or combined characteristics from the first hour of hospital resuscitation were created. Among 905 TBI cases, 165 (18%) experienced one or more ND events (130 clinical, 51 neurosurgical, and 54 radiographic) within 48 h of presentation. In the prediction of ND, the clinical plus physiologic data model performed similarly to the physiologic only model, with concordance indices of 0.85 (0.824-0.877) and 0.84 (0.812-0.868), respectively. Both outperformed the clinical only model, which had a concordance index of 0.72 (0.688-0.759). This preliminary work suggests that a data-driven approach utilizing physiologic and basic clinical data from the first hour of resuscitation after TBI has the potential to serve as a decision support tool for clinicians seeking to identify patients at high or low risk for ND.

Successful conservative management of a large acute epidural hematoma in a patient with arrested hydrocephalus: A case report

Background:

Arrested hydrocephalus is a condition wherein congenital hydrocephalus spontaneously ceases to progress due to a balance between production and absorption of cerebrospinal fluid. These patients rarely present with pressure symptoms so conservative treatment may be instituted. There are, however, little data on the long-term outcomes of these patients and how they present in the presence of other intracranial pathologies as they transition into adulthood. We aim to add to the growing knowledge about the management of patients with arrested hydrocephalus who have sustained traumatic hematomas.

Case Description:

To the best of our knowledge, we present the only reported case of a 34-year-old female with arrested hydrocephalus who sustained an acute epidural hematoma secondary to a fall and underwent a conservative management. She was asymptomatic except for mild headache that started on the 3^rd day postinjury and was thus treated conservatively with favorable outcomes. A review of literature showed that adults with arrested hydrocephalus may develop intracranial hematomas after head injuries despite them manifesting with little or no symptoms. The hydrocephalus may have provided them with a form of internal decompression thus delaying symptomatology.

Conclusion:

Clinicians should be vigilant as these patients will present with either delayed or completely without neurologic symptomology. Tailored and individualized management of other intracranial pathologies should be adapted in this subset of patients.

The Use of PECARN and CATCH Rules in Children With Minor Head Trauma Presenting to Emergency Department 24 Hours After Injury

OBJECTIVE

Major studies (PECARN [Pediatric Emergency Care Applied Research Network], CATCH [Canadian Assessment of Childhood Head Injury]) that regulate the use of computed tomography (CT) algorithms in children with minor head trauma (MHT) have been conducted among children presenting in 24 hours after injury. In this study, we aimed to compare use and results of PECARN and CATCH rules in children presenting in and after 24 hours following injury.

METHODS

Records of children who were admitted to emergency department and underwent CT imaging because of MHT during a 5-year period were retrospectively reviewed. Efficacy of PECARN and CATCH rules was investigated for predicting traumatic CT findings in patients presenting in and after 24 hours. Logistic regression was performed to evaluate whether presenting after 24 hours affected the ability of guidelines in predicting traumatic CT findings.

RESULTS

This study included 2490 patients who met the criteria. Of these patients, 6.7% (168/2490) presented after 24 hours following injury. Traumatic CT findings were found in 6.7% (168/2490) of patients. This rate was 6.9% (161/2322) in those presenting in 24 hours and 4.2% (7/168) in those presenting after 24 hours, and there was no significant difference in the incidence of traumatic CT findings between the 2 groups (P = 0.17). Among children presenting in 24 hours, the sensitivity of PECARN was 96.3% (95% confidence interval [CI], 91.7%-98.5%), whereas the sensitivity of CATCH was 91.9% (95% CI, 86.3%-95.4%) in detecting traumatic intracranial injury. The sensitivity of both PECARN and CATCH was 85.7% (95% CI, 42.0%-99.2%) among children presenting after 24 hours. Presence of CT scan indication according to PECARN statistically predicted intracranial damage, and this was not affected by the admission time.

CONCLUSIONS

Patients with MHT presenting after 24 hours following injury constitute a clinically important population. Regardless of the admission time, current guidelines predict traumatic CT abnormalities.

Emergency department observation of mild traumatic brain injury with minor radiographic findings: shorter stays, less expensive, and no increased risk compared to hospital admission

OBJECTIVE

The management of mild traumatic brain injury (mTBI) with minor radiographic findings traditionally involves hospital admission for monitoring, although this practice is expensive with unclear benefit. We implemented a protocol to manage these patients in our emergency department observation unit (EDOU), hypothesizing that this pathway was cost effective and not associated with any difference in clinical outcome.

METHODS

mTBI patients with minor radiographic findings were managed under the EDOU protocol over a 3-year period from May 1, 2015 to April 30, 2018 (inclusions: ≥19 years old, isolated acute head trauma, normal neurological exam [except transient alteration in consciousness], and a computed tomography [CT] scan of the head with at least 1 of the following: cerebral contusions <1 cm in maximum extent, convexity subarachnoid hemorrhage, or closed, non-displaced skull fractures). These patients were retrospectively analyzed; clinical outcomes and charges were compared to a control cohort of matched mTBI hospital admissions over the preceding 3 years.

RESULTS

Sixty patients were observed in the EDOU over the 3-year period, and 85 patients were identified for the control cohort. There were no differences in rate of radiographic progression, neurological exam change, or surgical intervention, and the overall incidence of hemorrhagic expansion was low in both groups. The EDOU group had a significantly faster time to interval CT scan (Mean Difference (MD) 3.92 hours, [95%CI 1.65, 6.19]), P = 0.001), shorter length of stay (MD 0.59 days [95% CI 0.29, 0.89], P = 0.001), and lower encounter charges (MD $3428.51 [95%CI 925.60, 5931.42], P = 0.008). There were no differences in 30-day re-admission, 30-day mortality, or delayed chronic subdural formation, although there was a high rate of loss to follow-up in both groups.

CONCLUSIONS

Compared to hospital admission, observing mTBI patients with minor radiographic findings in the EDOU was associated with significantly shorter time to interval scanning, shorter length of stay, and lower encounter charges, but no difference in observed clinical outcome. The overall risk of hemorrhagic progression in this subset of mTBI was very low. Using this approach can reduce unnecessary admissions while potentially yielding patient care and economic benefits. When designing a protocol, close attention should be given to clear inclusion criteria and a formal mechanism for patient follow-up.

Management of the mild traumatic brain injured patient using a multidisciplinary observation unit protocol

OBJECTIVES

We developed an ED based multidisciplinary observation unit (OU) protocol for patients with mild traumatic brain injury (mTBI). We describe the cohort of patients who were placed in the ED OU and we evaluated if changes to our inclusion and exclusion criteria should be made.

METHODS

We conducted a retrospective cohort study to evaluate subjects who were admitted to the mTBI observation protocol. We included adults within 24 h of sustaining an mTBI with a Glasgow Coma Scale (GCS) of 14 or 15 who had pre-specified head CT findings, and did not meet exclusion criteria. Predictors of need for hospital admission after completing the OU protocol were determined using multivariable logistic regression analysis.

RESULTS

The mean age was 49 (SD 23), 58 (33%) were female, and 136 (78%) were Caucasian. No subjects discharged home required a surgical intervention or ICU admission, and there were no deaths in discharged or admitted subjects. 28 subjects (16%) were admitted to the hospital following their OU stay. Subjects admitted were older (mean age: 56 vs. 48, p = 0.1) and had a higher proportion of traumatic bleeds on head CT (85% vs. 76%, p = 0.3). In multivariable logistic regression, GCS of 15 (aOR 4.24), African-American race (aOR 5.84), and no comorbid cardiac disease predicted discharge home after the observation protocol (aOR 0.28).

CONCLUSIONS

A period of observation for a pre-defined cohort of patients with mTBI provided a triage plan that could allow appropriate patient management without requiring admission in the majority of subjects.

Acute subdural haematoma accompanied by anorexia nervosa

We report the case of a patient with anorexia nervosa accompanied by acute subdural haematoma following a fall. A 34-year-old Japanese woman had serious medical complications and brain atrophy. After careful nutritional treatment, her laboratory test results improved and brain atrophy was reversed, and we prevented to perform surgery. However, unexpected prominent oedema of her lower legs and pleural effusion occurred. After receiving treatment for these symptoms, she eventually returned to her former occupation and started following a normal diet. Very few cases of anorexia nervosa accompanied by intracranial haemorrhage have been reported. Coagulation disorder and brain atrophy are supposed to be the primary causes of haematoma formation in the present case. Intracranial haemorrhage likely occurs in patients with anorexia nervosa despite minor head trauma. Because anorexia nervosa is not rare and the age of such patients is advancing, knowledge regarding this disorder would be useful for neurosurgeons.

Improving Survival with Tranexamic Acid in Cerebral Contusions or Traumatic Subarachnoid Hemorrhage: Univariate and Multivariate Analysis of Independent Factors Associated with Lower Mortality

BACKGROUND

Fall with head injury is a pervasive challenge, especially in the aging population. Contributing factors for mortality include the development of cerebral contusions and delayed traumatic intracerebral hematoma. Currently, there is no established specific treatment for these conditions.

OBJECT

This study aimed to investigate the impact of independent factors on the mortality rate of traumatic brain injury with contusions or traumatic subarachnoid hemorrhage.

METHODS

Data were collected from consecutive patients admitted for cerebral contusions or traumatic subarachnoid hemorrhage at an academic trauma center from 2010 to 2016. The primary outcome was the 30-day mortality rate. Independent factors for analysis included patient factors and treatment modalities. Univariate and multivariate analyses were conducted to identify independent factors related to mortality. Secondary outcomes included thromboembolic complication rates associated with the use of tranexamic acid.

RESULTS

In total, 651 consecutive patients were identified. For the patient factors, low Glasgow Coma Scale on admission, history of renal impairment, and use of warfarin were identified as independent factors associated with higher mortality from univariate and multivariate analyses. For the treatment modalities, univariate analysis identified tranexamic acid as an independent factor associated with lower mortality (P = 0.021). Thromboembolic events were comparable in patients with or without tranexamic acid.

CONCLUSION

Tranexamic acid was identified by univariate analysis as an independent factor associated with lower mortality in cerebral contusions or traumatic subarachnoid hemorrhage. Further prospective studies are needed to validate this finding.

Continuous Vital Sign Analysis to Predict Secondary Neurological Decline After Traumatic Brain Injury

Background: In the acute resuscitation period after traumatic brain injury (TBI), one of the goals is to identify those at risk for secondary neurological decline (ND), represented by a constellation of clinical signs that can be identified as objective events related to secondary brain injury and independently impact outcome. We investigated whether continuous vital sign variability and waveform analysis of the electrocardiogram (ECG) or photoplethysmogram (PPG) within the first hour of resuscitation may enhance the ability to predict ND in the initial 48 hours after traumatic brain injury (TBI).

Methods: Retrospective analysis of ND in TBI patients enrolled in the prospective Oximetry and Noninvasive Predictors Of Intervention Need after Trauma (ONPOINT) study. ND was defined as any of the following occurring in the first 48 h: new asymmetric pupillary dilatation (>2 mm), 2 point GCS decline, interval worsening of CT scan as assessed by the Marshall score, or intervention for cerebral edema. Beat-to-beat variation of ECG or PPG, as well as waveform features during the first 15 and 60 min after arrival in the TRU were analyzed to determine physiologic parameters associated with future ND. Physiologic and admission clinical variables were combined in multivariable logistic regression models predicting ND and inpatient mortality.

Results: There were 33 (17%) patients with ND among 191 patients (mean age 43 years old, GCS 13, ISS 12, 69% men) who met study criteria. ND was associated with ICU admission (P < 0.001) and inpatient mortality (P < 0.001). Both ECG (AUROC: 0.84, 95% CI: 0.76,0.93) and PPG (AUROC: 0.87, 95% CI: 0.80, 0.93) analyses during the first 15 min of resuscitation demonstrated a greater ability to predict ND then clinical characteristics alone (AUROC: 0.69, 95% CI: 0.59, 0.8). Age (P = 0.02), Marshall score (P = 0.001), penetrating injury (P = 0.02), and predictive probability for ND by PPG analysis at 15 min (P = 0.03) were independently associated with inpatient mortality.

Conclusions: Analysis of variability and ECG or PPG waveform in the first minutes of resuscitation may represent a non-invasive early marker of future ND.

The Risk of Deterioration in GCS13-15 Patients with Traumatic Brain Injury Identified by Computed Tomography Imaging: A Systematic Review and Meta-Analysis

The optimal management of mild traumatic brain injury (TBI) patients with injuries identified by computed tomography (CT) brain scan is unclear. Some guidelines recommend hospital admission for an observation period of at least 24 h. Others argue that selected lower-risk patients can be discharged from the Emergency Department (ED). The objective of our review and meta-analysis was to estimate the risk of death, neurosurgical intervention, and clinical deterioration in mild TBI patients with injuries identified by CT brain scan, and assess which patient factors affect the risk of these outcomes. A systematic review and meta-analysis adhering to PRISMA standards of protocol and reporting were conducted. Study selection was performed by two independent reviewers. Meta-analysis using a random effects model was undertaken to estimate pooled risks for: clinical deterioration, neurosurgical intervention, and death. Meta-regression was used to explore between-study variation in outcome estimates using study population characteristics. Forty-nine primary studies and five reviews were identified that met the inclusion criteria. The estimated pooled risk for the outcomes of interest were: clinical deterioration 11.7% (95% confidence interval [CI]: 11.7%-15.8%), neurosurgical intervention 3.5% (95% CI: 2.2%-4.9%), and death 1.4% (95% CI: 0.8%-2.2%). Twenty-one studies presented within-study estimates of the effect of patient factors. Meta-regression of study characteristics and pooling of within-study estimates of risk factor effect found the following factors significantly affected the risk for adverse outcomes: age, initial Glasgow Coma Scale (GCS), type of injury, and anti-coagulation. The generalizability of many studies was limited due to population selection. Mild TBI patients with injuries identified by CT brain scan have a small but clinically important risk for serious adverse outcomes. This review has identified several prognostic factors; research is needed to derive and validate a usable clinical decision rule so that low-risk patients can be safely discharged from the ED.

Coagulopathy in the Setting of Mild Traumatic Brain Injury: Truths and Consequences

Mild traumatic brain injury (mTBI) is a common, although poorly-defined clinical entity. Despite its initially mild presentation, patients with mTBI can rapidly deteriorate, often due to significant expansion of intracranial hemorrhage. TBI-associated coagulopathy is the topic of significant clinical and basic science research. Unlike trauma-induced coagulopathy (TIC), TBI-associated coagulopathy does not generally follow widespread injury or global hypoperfusion, suggesting a distinct pathogenesis. Although the fundamental mechanisms of TBI-associated coagulopathy are far from clearly elucidated, several candidate molecules (tissue plasminogen activator (tPA), urokinase plasminogen activator (uPA), tissue factor (TF), and brain-derived microparticles (BDMP)) have been proposed which might explain how even minor brain injury can induce local and systemic coagulopathy. Here, we review the incidence, proposed mechanisms, and common clinical tests relevant to mTBI-associated coagulopathy and briefly summarize our own institutional experience in addition to identifying areas for further research.

The risk of intra-cranial haemorrhage in those presenting late to the ED following a head injury: a systematic review

BACKGROUND

Head injury represents an extremely common presentation to emergency departments (ED), but not all patients present immediately after injury. There is evidence that clinical deterioration following head injury will usually occur within 24 h. It is unclear whether this means that head injury patients that present in a delayed manner, especially after 24 h, have a lower prevalence of significant traumatic injuries including intra-cranial haemorrhages.

METHODS

A systematic review protocol was designed with the aim of systematically identifying and evaluating studies in delayed ED presentation head injury populations in order to establish whether the prevalence of significant intra-cranial injury was affected by delay in presentation. Two independent researchers assessed retrieved studies for inclusion against pre-determined inclusion criteria. Studies had to be conducted in ED head injury populations presenting in a delayed manner, and report a measure of prevalence of traumatic CT abnormality as an outcome.

RESULTS

Three studies were eligible for inclusion. They were all of poor methodological quality, and heterogeneity prevented meta-analysis. The reported prevalence of traumatic intra-cranial injury on CT was between 2.2 and 6.3%. This is generally lower than reported in the literature for non-delayed presentation head injury populations.

CONCLUSIONS

Available evidence suggests that head injury patients who present in a delayed fashion to the ED may have lower rates of intra-cranial injury compared to non-delayed head injury patients. However, the evidence is sparse and it is of too low quality to guide clinical practice. Further research is required to help the clinical risk assessment of this group.

TRIAL REGISTRATION

PROSPERO

CRD42015016135.

Understanding Why Patients Return to the Emergency Department after Mild Traumatic Brain Injury within 72 Hours

INTRODUCTION

Although there are approximately 1.1 million case presentations of mild traumatic brain injury (mTBI) in the emergency department (ED) each year, little data is available to clinicians to identify patients who are at risk for poor outcomes, including 72-hour ED return after discharge. An understanding of patients at risk for ED return visits during the hyperacute phase following head injury would allow ED providers to develop clinical interventions that reduce its occurrence and improve outcomes.

METHODS

This institutional review board-approved consecutive cohort study collected injury and outcome variables on adults with the purpose of identifying positive predictors for 72-hour ED return visits in mTBI patients.

RESULTS

Of 2,787 mTBI patients, 145 (5%) returned unexpectedly to the ED within 72 hours of hospital discharge. Positive predictors for ED return visits included being male (p=0.0298), being black (p=0.0456), having a lower prehospital Glasgow Coma Score (p=0.0335), suffering the injury due to a motor vehicle collision (p=0.0065), or having a bleed on head computed tomography (CT) (p=0.0334). ED return visits were not significantly associated with age, fracture on head CT, or symptomology following head trauma. Patients with return visits most commonly reported post-concussion syndrome (43.1%), pain (18.7%), and recall for further clinical evaluation (14.6%) as the reason for return. Of the 124 patients who returned to the ED within 72 hours, one out of five were admitted to the hospital for further care, with five requiring intensive care unit stays and four undergoing neurosurgery.

CONCLUSION

Approximately 5% of adult patients who present to the ED for mTBI will return within 72 hours of discharge for further care. Clinicians should identify at-risk individuals during their initial visits and attempt to provide anticipatory guidance when possible.

Risk factors of delayed surgical evacuation for initially nonoperative acute subdural hematomas following mild head injury

BACKGROUND

Although the majority of patients with minimal acute subdural hematomas (aSDHs) can be managed conservatively, some require delayed aSDH evacuation due to hematoma enlargement. This study was designed to determine the risk factors associated with delayed hematoma enlargement leading to surgery in patients with aSDHs who did not initially require surgical intervention.

METHODS

From 2002 to 2012, 98 patients were treated for nonoperative aSDHs following mild head injury (Glasgow Coma Scale scores of 13-15). The outcome variables were radiographic evidence of SDH enlargement on serially obtained computed tomography (CT) images and later surgical evacuation. Univariate and multivariate analyses were applied to both the demographic and initial radiographic features to identify risk factors for SDH progression and surgery.

RESULTS

Overall, 64 patients (65 %) revealed minimal SDH or spontaneous hematoma resolution (conservative group) with conservative management at their last follow-up CT scan. The remaining 34 patients (35 %) received delayed hematoma evacuation (delayed surgery group) a median of 17 days after the head trauma. There were no significant differences between the two groups for baseline characteristics, including age, injury type, degree of brain atrophy, prior history of antithrombotic drugs, and coagulopathy. The presence of cerebral contusions and subarachnoid hemorrhages was more common in the conservative group (p = 0.003 and p = 0.003, respectively). On multivariate analysis, hematoma volume (p = 0.01, odds ratio [OR] = 1.094, 95 % confidence interval [CI] = 1.021-1.173) and degree of midline shift (p = 0.01, OR = 1.433, 95 % CI = 1.088-1.888) on the initial CT scan were independently associated with delayed hematoma evacuation.

CONCLUSIONS

A critical proportion of patients with minimal aSDHs occurring after mild head injury can progress over several weeks and require hematoma evacuation. Especially patients with a large initial SDH volume and accompanying midline shift require careful monitoring of hematoma progression.

The epidemic of pre-injury oral antiplatelet and anticoagulant use

BACKGROUND

As the population ages, an increasing number of trauma patients are taking antiplatelet and anticoagulant medications (ACAP) prior to their injuries. These medications increase their risk of hemorrhagic complications, particularly intracerebral hemorrhage. Clopidogrel and warfarin are common and their mechanisms well understood, but optimal reversal methods continue to evolve. The novel direct thrombin and factor Xa inhibitors are less well described and do not have existing antidotes.

METHODS

This article reviews the relevant literature on traumatic outcomes with use of ACAP medications, as well as data on ideal reversal strategies. Suggested algorithms are introduced, and future research directions discussed.

RESULTS

Although they are beneficial in preventing clot formation, once bleeding occurs ACAP medications contribute to increased morbidity and mortality, particularly in geriatric patient populations. The efficacy of clopidogrel reversal with platelet transfusions and DDAVP remains unclear. Warfarin use is best treated with the algorithm-driven use of plasma, vitamin K, prothrombin complex concentrates (PCCs) and possibly recombinant factor VIIa depending upon specific patient and injury factors. Optimal treatment for direct thrombin and factor Xa inhibitors has yet to be developed, but PCCs are promising for rivaroxaban and apixaban while dabigatran is best treated with medication cessation and the possible addition of activated PCCs or hemodialysis.

CONCLUSION

New developments in reversal of the ACAP medications are promising, particularly PCCs for warfarin and the factor Xa inhibitors. Function assays and clear antidotes are needed for the thrombin and Xa inhibitors. Research on outcomes and appropriate treatments is actively ongoing.