Rosh Emergency Medicine Practice Test

What is the most appropriate clinical intervention for a patient on warfarin with an INR of 5.6 after a fall?

1. Administer vitamin K 10 mg IV and recheck INR in 2 days

2. Hold warfarin for one to two doses and administer prothrombin complex concentrate

3. Hold warfarin for one to two doses and recheck INR at clinic

4. Refer for emergent neurosurgery consult

The correct answer is: Hold warfarin for one to two doses and administer prothrombin complex concentrate

The most appropriate clinical intervention for a patient on warfarin with an INR of 5.6 after a fall involves not only reversing the anticoagulation to prevent further bleeding but also acting swiftly due to the elevated risk of hemorrhage associated with such a high INR. Administering prothrombin complex concentrate (PCC) is vital as it rapidly reverses the effects of warfarin. PCC provides the necessary clotting factors directly, enabling quicker restoration of hemostasis compared to vitamin K, which requires time for the body to synthesize new clotting factors. With the INR at 5.6, there is a significant risk of spontaneous bleeding or intracranial hemorrhage, particularly in the context of a fall, necessitating immediate action. While holding warfarin is also a prudent step, simply holding doses without proactive reversal could leave the patient vulnerable. Optionally administering vitamin K might be considered in outpatient settings or for less critical situations, but in this scenario where there is an acute concern for bleeding, utilizing PCC allows for rapid intervention. A follow-up INR recheck is necessary, but it should be conducted after immediate treatment has been administered to assess the efficacy of the intervention and adjust future management accordingly. In summary,