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Warfarin Protocol This protocol reflects current evidence based clinical practice. It is not a substitution for appropriate clinical evaluation and does not supersede clinical judgment. Initiating Warfarin therapy:
Extreme Caution: Consider effects of Aspirin, Corticosteroids, NSAIDs and Plavix when initiating therapy.
1. Obtain baseline PT and CBC within 48 hours prior to initiation of therapy. 2. DC all Intramuscular injections. 3. Consider ordering Dietary Consult to assess patient's Vitamin K intake. 4. Do not order to hold enteral nutrition at time of administration. 5. Use approved Warfarin form for all warfarin orders. Exclusion Criteria: 1. Do not initiate on patient with epidural analgesia. 2. Do not initiate on patient with platelets <30,000 3. Do not initiate on pregnant patients. Dosing: Dose will not be dispensed by pharmacy until a baseline INR is made available. If no such order has been placed, pharmacist shall write order to gain baseline INR. Once baseline INR is received, pharmacist will either process order as written or conduct appropriate clinical intervention by contacting prescriber for changes. 1. Patients admitted with a therapeutic INR who are already on warfarin therapy shall continue with the 2. All patients who begin warfarin therapy shall be started with 5mg PO daily at 1400. 3. Patients who have significant liver disease, recent major surgeries, weigh less than 45kg or are older than 70 years of age should consider starting at doses lower than 5mg daily. 4. Doses will be held by nurse for INR≥4 (Laboratory Critical Value will be reported to Nurse or LIP) 5. Drug-Drug interactions with certain classes of medications impact the effects of warfarin and should be considered upon initiation of therapy. Drug-Drug / Drug-Food / Drug-Dietary Supplement Interactions
Items that Increase the Effects of Warfarin Items that Decrease the Effects of Warfarin Amoxicillin/Clavulanate Brussels sprouts Celecoxib (NSAIDs) Chlordiazepoxide Influenza Vaccine Warfarin Protocol Adjusting Initial Warfarin Dose: The following table may be used as a guideline in changing warfarin doses after initiation of warfarin therapy. Warfarin Dose (mg)
Adjusting Existing Warfarin Regimen: The following table may be used as a guideline in changing warfarin doses on a patient who has been on a therapeutic regimen for a target INR 2-3. ACTION: TWD (Total Weekly Dose)
Increase TWD by 15-25%; Give extra dose for 2 days. Increase TWD by 10-15%; Give extra dose for 1 day. Decrease TWD by 10-15%; Hold dose for 1 day. Decrease TWD by 15-25%; Hold dose for 2 days. Decrease TWD by 25-30%; Hold until INR < 3 1. Obtain daily PT with AM Labs until INR goal is therapeutic and stable ≥ 2 days, thereafter less frequently as clinically indicated. 2. Obtain CBC daily with AM Labs. Goal INRs per Indication: Indication
INR Target
1. 1. Antiphospholipid Antibody Syndrome 2. 2. Atrial Fibrillation 3. 3. DVT/PE Treatment and Prophylaxis 4. 4. Mechanical valves in aortic position 1. Mechanical valves in mitral positions. 1. "High Risk" patients with Mechanical valves in the aortic position. 2. "High Risk" patients with bioprosthetic valves in the mitral position. High Risk: Patients with Atrial fibrillation, prior embolus, LA or LV clot, severe LV dysfunction (EF<30%), hypercoagulable
state and coronary artery disease.

Warfarin Protocol Bridge Therapy: Converting patient from all anti-coagulants to warfarin (with exception of Argatroban) 1. For those with active clot or high risk for clotting, there must be a five day overlap of both drugs. 2. Achieve therapeutic INR ≥ 2 days prior to stopping the Heparin, Lovenox or Arixtra. Reversal Agents: Correction of INR Hold dose. Resume at a lower dose when the INR is therapeutic. (No significant bleeding) Hold next 1-2 doses. Resume at a lower dose when the INR is therapeutic. Alternatively, (No significant bleeding) hold 1 dose, administer Vitamin K 1-2.5 mg PO x 1 Administer Vitamin K 2-4 mg PO to decrease INR within 24 hours. May give additional 1- (No significant bleeding) 2mg PO x 1 if INR remains elevated. Alternatively, administer Vitamin K 2-4mg IV over 60 Urgent Surgery Needed minutes for faster reversal with FFP for imminent surgical candidates. Administer Vitamin K 3-5mg PO x 1. INR should decrease over the next 24 hours. Administer additional Vitamin K if needed. Resume warfarin at a lower dose when INR is (No significant bleeding) Hold warfarin. Give Vitamin K 10mg IV over a minimum of 60 minutes. FFP is indicated if INR >20 with serious bleeding reversal is needed sooner than 4 hours. Vitamin K may be repeated every 12 hours (to a maximum dose of 30mg). Hold warfarin. Administer FFP along with Vitamin K 5-10mg IV over a minimum of 60 Life-threatening bleeding minutes. Consider using Recombinant Factor VII or "Prothrombin Complex Concentrate (e.g. intracranial hemorrhage) Vitamin K (phytonadione): Appropriate Use Oral is the preferred route and corrects INR within 24-48 hours. Subcutaneous route is not effective and should not be used. Intravenous delivery is the fastest and most reliable route. There are many potential side effects to consider with this route of administration. Infusing Vitamin K over 60 minutes is the key to avoiding adverse effects. DO NOT USE IV Vitamin K in patients with prosthetic valves because of the increased risk of thromboembolism. References: Commission, T. J. (2008). Medication Use: A Systems Approach to reducing Errors, 2nd Edition. Oakbrook Terrace, IL. Institute of Safe Medication Practices. (2011). Retrieved from www.ismp.org Joint Commission Resources. (2011). Retrieved from www.jcrinc.com Practices, I. f. (2005). ISMP Medication Safety Self Assessment for Antithrombotic Therapy in Hospitals. Horsham, PA. The Joint Commission. (2011). Retrieved from www.jointcommission.org The Joint Commission. (2008). Anticoagulation Therapy: Toolkit for Implementing the National Safety Goal. Oakbrook Terrace, IL.

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Clinical Management of Mental, Neurological and Substance Use Conditions in Humanitarian Emergencies mental health Gap Action Programme WHO Library Cataloguing-in-Publication Data mhGAP Humanitarian Intervention Guide (mhGAP-HIG): clinical management of mental, neurological and substance use conditions in humanitarian emergencies. 1.Mental Disorders. 2.Substance-related Disorders. 3.Nervous System Diseases. 4.Relief Work. 5.Emergencies. I.World Health Organization. II.UNHCR.

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Management of Concussion and Post-Concussion SyndromeBarry Willer, PhD*John J. Leddy, MD Address*University at Buffalo, G 96 Farber Hall, 3435 Main Street, Buffalo, NY 14214, USA.E-mail: willer@vaxxine.com Current Treatment Options in Neurology 2006, Current Science Inc. ISSN 1092–8480Copyright © 2006 by Current Science Inc.