Suspected traumatic intracranial haemorrhage during warfarin treatment — MRCEM SBA MCQ

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HardTraumaSuspected traumatic intracranial haemorrhage during warfarin treatmentMRCEM SBA

A 68-year-old man taking warfarin for atrial fibrillation strikes his head in a fall. He initially speaks normally, but during assessment in the emergency department develops a severe headache and new left-arm weakness. His GCS falls from 15 to 14. His INR is 3.1. He is haemodynamically stable and protecting his airway. An urgent CT head scan is available, but has not yet been performed. What is the most appropriate immediate plan for warfarin reversal and imaging?

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Correct answer: B — Give prothrombin complex concentrate with intravenous vitamin K now and arrange urgent CT.

The new focal weakness, severe headache and fall in GCS after a witnessed head injury create strong suspicion of intracranial haemorrhage. His warfarin effect is confirmed by the INR of 3.1. NICE recommends immediate prothrombin complex concentrate (PCC) for a warfarin-treated patient with a head injury and *suspected* intracerebral haemorrhage: CT confirmation is not a prerequisite. Intravenous vitamin K is given alongside PCC to sustain reversal. The focal deficit independently requires CT head within 1 hour; reversal and imaging should proceed in parallel, not delay one another. ([nice.org.uk](https://www.nice.org.uk/guidance/ng24/resources/bloodtransfusion-1837331897029)) **A** starts reversal but vitamin K alone does not provide the required immediate factor replacement; it could be appropriate for a different, non-urgent warfarin-reversal indication. **C** correctly prioritises CT but incorrectly waits for confirmation before treating this strongly suspected bleed; waiting may be appropriate when intracranial bleeding is not clinically suspected. **D** supplies immediate PCC but omits concurrent vitamin K, risking loss of reversal as PCC’s effect wanes; PCC without immediate vitamin K would be considered if vitamin K could not be administered. **E** recognises the urgency but substitutes fresh frozen plasma for the recommended PCC; plasma might be considered if PCC were unavailable, with specialist advice. Subsequent CT findings and clinical progress determine neurosurgical discussion and disposition. ([nice.org.uk](https://www.nice.org.uk/guidance/ng24/resources/bloodtransfusion-1837331897029))

Reference: NICE NG24, Blood transfusion, section 1.6: Prothrombin complex concentrate (26 February 2026) — https://www.nice.org.uk/guidance/ng24/resources/bloodtransfusion-1837331897029 NICE NG232, Head injury: assessment and early management, recommendations 1.5.8 and 1.4.15–1.4.16 (18 May 2023) — https://www.nice.org.uk/guidance/NG232/chapter/recommendations NICE NG24, Transfusion: full guideline, prothrombin complex concentrate discussion (2015) — https://www.nice.org.uk/guidance/ng24/update/NG24/documents/transfusion-full-guideline2