Suspected traumatic intracranial haemorrhage during warfarin treatment — MRCEM SBA MCQ

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HardTraumaSuspected traumatic intracranial haemorrhage during warfarin treatmentMRCEM SBA

A 76-year-old woman taking warfarin for atrial fibrillation arrives after falling and striking her head 3 hours ago. Her initial GCS score is 15, but during assessment it falls to 13 and she develops new right arm weakness. Her INR is 2.9. She is haemodynamically stable, with no other apparent injury. An urgent CT head scan has been requested but has not yet been performed. Which anticoagulation reversal strategy is most appropriate now?

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Correct answer: C — Give four-factor prothrombin complex concentrate with intravenous vitamin K immediately.

The falling GCS score and new focal weakness after a head injury create strong suspicion of intracranial haemorrhage. They also make urgent CT necessary independently of her warfarin use. Her elevated INR identifies a reversible contributor to potentially expanding bleeding. NICE recommends immediate prothrombin complex concentrate (PCC) for warfarin-treated patients with head injury and suspected intracerebral haemorrhage: reversal should begin while urgent imaging is arranged, not await its result. Intravenous vitamin K accompanies PCC to provide sustained reversal, and the INR should be rechecked. CT findings and clinical progression will guide neurosurgical discussion and disposition. ([nice.org.uk](https://www.nice.org.uk/guidance/ng24/resources/bloodtransfusion-1837331897029)) **A** delays reversal despite strong clinical suspicion; waiting for CT would be more reasonable if suspicion were not strong. **B** provides vitamin K but not the immediate factor replacement needed here. **D** offers factor replacement, but fresh frozen plasma is not the recommended means of urgent vitamin K antagonist reversal when PCC is available. **E** supplies prompt factors but omits vitamin K, leaving reversal less durable. All four alternatives miss either the urgency or a component of effective reversal in this case. ([nice.org.uk](https://www.nice.org.uk/guidance/ng39/chapter/Recommendations))

Reference: NICE NG24, Blood transfusion, section 1.6: Prothrombin complex concentrate (26 February 2026) — https://www.nice.org.uk/guidance/ng24/resources/blood-transfusion-pdf-1837331897029 NICE NG232, Head injury: assessment and early management, recommendation 1.5.8 (18 May 2023) — https://www.nice.org.uk/guidance/NG232/chapter/recommendations NICE NG24 full guideline, prothrombin complex concentrates: thresholds and targets (2015) — https://www.nice.org.uk/guidance/ng24/update/NG24/documents/transfusion-full-guideline2