The management of patients with an International Normalized Ratio (INR) that falls outside the therapeutic range is a critical aspect of anticoagulation therapy, particularly for those on warfarin. The INR is a standardized measure used to assess the coagulation status of patients, and maintaining it within the therapeutic range is essential to minimize the risks of thromboembolic events and bleeding complications. When a patient's INR is found to be outside this range, it is imperative to conduct a thorough assessment to identify potential causes and implement appropriate management strategies.

First and foremost, adherence to warfarin therapy must be evaluated. Non-adherence can lead to significant fluctuations in INR levels, resulting in either sub-therapeutic or supra-therapeutic values (Türen & Turen, 2022). Factors contributing to non-adherence may include missed doses or accidental overdosing, which can be exacerbated by a lack of understanding of the medication's importance and its interactions with food and other substances (Türen & Turen, 2022). Additionally, the use of other medications, including over-the-counter products, vitamins, and herbal remedies, can significantly impact INR levels. For instance, certain herbal supplements may potentiate the effects of warfarin, while others may reduce its efficacy (Kılıç, 2017).

Furthermore, lifestyle factors such as alcohol consumption and dietary habits must be assessed. Alcohol can potentiate warfarin's effects, leading to increased INR levels, while dietary changes, particularly in the intake of vitamin K-rich foods like green leafy vegetables, can counteract warfarin's anticoagulant effects (Sekaggya et al., 2016). Acute illnesses, weight changes, and smoking cessation also play crucial roles in INR variability; for example, acute illnesses can increase warfarin sensitivity, while weight gain may necessitate dosage adjustments due to altered drug metabolism (Ham et al., 2013).

Anticoagulant use (e.g., warfarin, DOACs) is increasingly common in older adults with cardiovascular conditions, but it significantly raises the risk of intracranial hemorrhage (ICH) after head trauma. Studies show that anticoagulated patients face a fourfold to fivefold higher mortality risk from traumatic brain injuries (Pang et al., 2015). Consequently, primary care clinicians must remain vigilant when assessing head injuries in these individuals, promptly arranging CT imaging and monitoring for delayed hemorrhage (Fuller et al., 2019; Marques et al., 2019).

NICE guidelines recommend a 24-hour observation period after any head injury in anticoagulated patients, followed by repeat CT imaging if necessary (Chenoweth et al., 2018). In severe cases, clinicians should evaluate the need for anticoagulation reversal, carefully balancing bleeding risks against possible thromboembolic events (Miller et al., 2015).

Head Injury Triage Form

1. Injury Details

2. Symptoms

3. Patient History

4. Observation and Care

Quick Reference Table: Key Head Injury Recommendations (NICE)

In conclusion, the intersection of anticoagulant therapy and head injury presents a complex challenge for primary care clinicians. Understanding the increased risks associated with anticoagulation, adhering to established guidelines for assessment and management, and maintaining a high index of suspicion for complications are essential for optimizing patient outcomes in this vulnerable population.

References
NICE. Head injury: assessment and early management. (Clinical Guideline; 2003, amended 2007, 2014, 2023)
NICE. Shared decision making. (Guideline; 2021, reviewed 2023)
NICE. Decision making and mental capacity. (Guideline; 2018, updated 2020, reviewed 2023)

1. Alrajhi, K., Perry, J., & Forster, A. (2015). Intracranial bleeds after minor and minimal head injury in patients on warfarin. Journal of Emergency Medicine, 48(2), 137–142. https://doi.org/10.1016/j.jemermed.2014.08.016

2. Chenoweth, J., Gaona, S., Faul, M., Holmes, J., & Nishijima, D. (2018). Incidence of delayed intracranial hemorrhage in older patients after blunt head trauma. JAMA Surgery, 153(6), 570. https://doi.org/10.1001/jamasurg.2017.6159

3. Fuller, G., Evans, R., Preston, L., Woods, H., & Mason, S. (2019). Should adults with mild head injury who are receiving direct oral anticoagulants undergo computed tomography scanning? A systematic review. Annals of Emergency Medicine, 73(1), 66–75. https://doi.org/10.1016/j.annemergmed.2018.07.020

4. Grewal, K., Atzema, C., Austin, P., Wit, K., Sharma, S., Mittmann, N., … & McLeod, S. (2021). Intracranial hemorrhage after head injury among older patients on anticoagulation seen in the emergency department: A population-based cohort study. Canadian Medical Association Journal, 193(40), E1561–E1567. https://doi.org/10.1503/cmaj.210811

5. Hadjigeorgiou, G., Anagnostopoulos, C., Chamilos, C., & Petsanas, A. (2014). Patients on anticoagulants after a head trauma: Is a negative initial CT scan enough? Report of a case of delayed subdural haematoma and review of the literature. Journal of Korean Neurosurgical Society, 55(1), 51. https://doi.org/10.3340/jkns.2014.55.1.51

6. Kerschbaum, M., Henssler, L., Ernstberger, A., Alt, V., Pfeifer, C., Worlicek, M., … & Popp, D. (2021). Influence of oral anticoagulation and antiplatelet drugs on outcome of elderly severely injured patients. Journal of Clinical Medicine, 10(8), 1649. https://doi.org/10.3390/jcm10081649

7. Liu, S., McLeod, S., Atzema, C., Austin, P., Wit, K., Sharma, S., … & Grewal, K. (2022). Delayed intracranial hemorrhage after head injury among elderly patients on anticoagulation seen in the emergency department. Canadian Journal of Emergency Medicine, 24(8), 853–861. https://doi.org/10.1007/s43678-022-00392-z

8. Mann, N., Welch, K., Martin, A., Subichin, M., Wietecha, K., Birmingham, L., … & George, R. (2018). Delayed intracranial hemorrhage in elderly anticoagulated patients sustaining a minor fall. BMC Emergency Medicine, 18(1). https://doi.org/10.1186/s12873-018-0179-0

9. Marques, R., Antunes, C., Machado, M., Ramos, R., Duarte, N., Oliveira, L., … & Sousa, N. (2019). Reappraising the need for a control CT in mild head injury patients on anticoagulation. European Journal of Trauma and Emergency Surgery, 47(5), 1461–1466. https://doi.org/10.1007/s00068-019-01172-8

10. Miller, J., Lieberman, L., Nahab, B., Hurst, G., Gardner-Gray, J., Lewandowski, A., … & Watras, J. (2015). Delayed intracranial hemorrhage in the anticoagulated patient. Journal of Trauma and Acute Care Surgery, 79(2), 310–313. https://doi.org/10.1097/ta.0000000000000725

11. Nash, T. (2024). Retrospective observational study of aged care facility residents presenting to ED post fall: A case for person‐centred shared decision making. Emergency Medicine Australasia, 36(4), 512–519. https://doi.org/10.1111/1742-6723.14391

12. Pang, C., Lee, S., & Yoo, H. (2015). Clinical factors and perioperative strategies associated with outcome in preinjury antiplatelet and anticoagulation therapy for patients with traumatic brain injuries. Journal of Korean Neurosurgical Society, 58(3), 262. https://doi.org/10.3340/jkns.2015.58.3.262

13. Savioli, G., Ceresa, I., Luzzi, S., Gragnaniello, C., Lucifero, A., Maestro, M., … & Bressan, M. (2020). Rates of intracranial hemorrhage in mild head trauma patients presenting to emergency department and their management: A comparison of direct oral anticoagulant drugs with vitamin K antagonists. Medicina, 56(6), 308. https://doi.org/10.3390/medicina56060308

Deep vein thrombosis (DVT) represents a significant public health concern, particularly in primary care settings where early diagnosis and management are crucial to prevent complications such as pulmonary embolism (PE) and post-thrombotic syndrome (PTS). The epidemiology of DVT in primary care is characterized by a relatively low incidence, estimated at 1-2 per 1000 individuals annually, but the condition remains underdiagnosed due to its often asymptomatic nature and the challenges in clinical assessment (Nothnagel, 2024). 

In the context of primary care, the integration of point-of-care testing (POCT) for D-dimer levels has emerged as a pivotal diagnostic tool. D-dimer is a fibrin degradation product that is typically elevated in the presence of thrombotic events. The utility of D-dimer testing lies in its ability to rule out DVT when results are negative, particularly when combined with clinical scoring systems (Janssen et al., 2011; Michiels et al., 2017). Recent studies have validated various point-of-care D-dimer tests, demonstrating their effectiveness in excluding DVT without the need for more invasive procedures (Geersing et al., 2010). For instance, a multicenter study highlighted the feasibility of general practitioners performing compression ultrasonography (US) alongside D-dimer testing, which can expedite diagnosis and treatment initiation (Mumoli et al., 2017).

1. Patient Demographics and Medical History

2. Symptoms Assessment

3. Risk Factors for DVT (Wells Score)

Additional Risk Factors for DVT

Continuing or Intrinsic Risk Factors:

• A history of DVT
• Cancer (known or undiagnosed)
• Age over 60 years
• Being overweight or obese
• Male sex
• Heart failure
• Medical illness (e.g., acute infection)
• Acquired or familial thrombophilia
• Inflammatory disorders (e.g., vasculitis, inflammatory bowel disease)
• Varicose veins
• Smoking

Temporary Risk Factors:

• Recent major surgery
• Recent hospitalization
• Recent trauma
• Chemotherapy
• Significant immobility (bedbound or unable to walk unaided)
• Prolonged travel (more than 4 hours)
• Significant trauma or direct trauma to a vein (e.g., intravenous catheter)
• Hormone treatment (e.g., estrogen-containing contraception or HRT)
• Pregnancy and the postpartum period
• Dehydration

4. Pulmonary Embolism (PE) Symptoms

Ultrasound, particularly duplex ultrasonography (DUS), remains the gold standard for confirming DVT diagnosis. It is non-invasive and provides real-time imaging of venous structures, allowing for the identification of thrombus presence (Michiels et al., 2017). The sequential use of DUS followed by D-dimer testing has been recommended as a safe and effective strategy in primary care settings to diagnose DVT while minimizing unnecessary referrals for imaging (Michiels et al., 2017). Furthermore, the incorporation of POCT D-dimer assays has been shown to be cost-effective and patient-friendly, enhancing the accessibility of DVT diagnostics in primary care (Heerink et al., 2023).

NICE guidance : Venous thromboembolic diseases: diagnosis, management and thrombophilia testing

1) DVT Likely (Wells score 2 points or more)

1. Initial Test

   • Offer a proximal leg vein ultrasound scan within 4 hours if possible.
   • If the scan result cannot be obtained within 4 hours, do a D‑dimer test and start interim therapeutic anticoagulation; then arrange a scan within 24 hours.

2. If Ultrasound Scan is Positive

   • Start (or continue) anticoagulation therapy.
   • If anticoagulation is contraindicated, offer a mechanical intervention (e.g., IVC filter).
   • Symptomatic iliofemoral DVT: consider thrombolytic therapy.

3. If Ultrasound Scan is Negative

   • Perform a D‑dimer test if not already done.
   • If the D-dimer test is positive, stop interim anticoagulation (unless it’s long-term secondary prevention or short-term COVID-19 prophylaxis), and repeat ultrasound in 6–8 days:
     • If repeat scan is positive → follow positive-scan management (start or continue anticoagulation).
     • If repeat scan is negative → follow the guidance for negative scan and negative D-dimer (see below).
   • If the D-dimer test is negative, stop interim anticoagulation (except long-term or short-term COVID-19 prophylaxis), consider alternative diagnoses, and reassure the patient that DVT is unlikely.

DVT Unlikely (Wells score 1 point or less)

1. Initial Test

   • Offer a D‑dimer test with the result available within 4 hours.
   • If the D‑dimer result cannot be obtained within 4 hours, begin interim therapeutic anticoagulation while waiting for the result.

2. If D‑dimer is Negative

   • Follow the advice given in the guidance for a negative scan and negative D-dimer (essentially, stop interim anticoagulation if started, but do not stop long-term or COVID-19 prophylaxis).
   • Consider alternative diagnoses.
   • Reassure the patient that DVT is not likely and advise them on what symptoms to watch for.

3. If D‑dimer is Positive

   • Offer a proximal leg vein ultrasound scan within 4 hours if possible.
   • If not possible within 4 hours, start interim therapeutic anticoagulation and arrange a scan within 24 hours.

4. If the Ultrasound Scan is Positive

   • Manage as DVT confirmed (start or continue anticoagulation, or use mechanical intervention if anticoagulation is contraindicated).

5. If the Ultrasound Scan is Negative

   • Stop interim anticoagulation (but continue any long-term or short-term COVID-19 prophylaxis).
   • Consider alternative diagnoses.
   • Reassure the patient that DVT is not likely, and advise them on follow-up measures.

1. Dybowska, M., Tomkowski, W., Kuca, P., Ubysz, R., Jóźwik, A., & Chmielewski, D. (2015). Analysis of the accuracy of the wells scale in assessing the probability of lower limb deep vein thrombosis in primary care patients practice. Thrombosis Journal, 13(1). https://doi.org/10.1186/s12959-015-0050-4

2. Geersing, G., Toll, D., Janssen, K., Oudega, R., Blikman, M., Wijland, R., … & Moons, K. (2010). Diagnostic accuracy and user-friendliness of 5 point-of-care d-dimer tests for the exclusion of deep vein thrombosis. Clinical Chemistry, 56(11), 1758–1766. https://doi.org/10.1373/clinchem.2010.147892

3. Heerink, J., Nies, J., Koffijberg, H., Oudega, R., Kip, M., & Kusters, R. (2023). Two point-of-care test-based approaches for the exclusion of deep vein thrombosis in general practice: a cost-effectiveness analysis. BMC Primary Care, 24(1). https://doi.org/10.1186/s12875-023-01992-z

4. Janssen, K., Velde, E., Cate, A., Prins, M., Weert, H., Stoffers, J., … & Moons, K. (2011). Optimisation of the diagnostic strategy for suspected deep-vein thrombosis in primary care. Thrombosis and Haemostasis, 105(01), 154–160. https://doi.org/10.1160/th10-04-0242

5. Michiels, J., Moosdorff, W., Lao, M., Maasland, H., Michiels, J., Neumann, H., … & Palareti, G. (2017). Diagnosis and treatment of dvt and prevention of dvt recurrence and the pts: bridging the gap between dvt and pts in the primary care setting or outpatient ward. Journal of Vascular Diagnostics and Interventions, 5, 21–34. https://doi.org/10.2147/jvd.s62734

6. Michiels, J., Moossdorff, W., Strijkers, R., Lao, M., Smeets, H., Han, M., … & Gadisseur, A. (2020). Evidence-based novel management options of acute deep vein thrombosis (dvt) and prevention of dvt recurrence in primary care medicine anno 2018 – 2020. Acta Scientific Medical Sciences, 4(3), 01–13. https://doi.org/10.31080/asms.2020.04.0568

7. Monkhouse, A. (2012). Deep vein thrombosis and pulmonary embolism. Innovait Education and Inspiration for General Practice, 5(11), 670–679. https://doi.org/10.1093/innovait/ins182

8. Mumoli, N., Vitale, J., Giorgi‐Pierfranceschi, M., Sabatini, S., Tulino, R., Cei, M., … & Dentali, F. (2017). General practitioner–performed compression ultrasonography for diagnosis of deep vein thrombosis of the leg: a multicenter, prospective cohort study. The Annals of Family Medicine, 15(6), 535–539. https://doi.org/10.1370/afm.2109

9. Nothnagel, K. (2024). Evaluating the benefits of machine learning for diagnosing deep vein thrombosis compared with gold standard ultrasound: a feasibility study. BJGP Open, 8(4), BJGPO.2024.0057. https://doi.org/10.3399/bjgpo.2024.0057

10. Velde, E., Toll, D., Cate-Hoek, A., Oudega, R., Stoffers, J., Bossuyt, P., … & Weert, H. (2011). Comparing the diagnostic performance of 2 clinical decision rules to rule out deep vein thrombosis in primary care patients. The Annals of Family Medicine, 9(1), 31–36. https://doi.org/10.1370/afm.1198
    

    Venous thromboembolic diseases: diagnosis, management and thrombophilia testing https://www.nice.org.uk/guidance/ng158/chapter/Recommendations#diagnosis-and-initial-management

    
    

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Suicide and suicidal behavior present a pressing public health concern in the UK, exacerbated by ongoing socio-economic stressors, including the recent cost of living crisis. Effective assessment hinges on identifying both individual risk factors—such as mental health disorders, previous suicide attempts, and psychosocial stressors—and broader contextual influences (Cruz et al., 2010).

In response, comprehensive prevention strategies emphasize a coordinated effort among healthcare providers, community organizations, and families. Clinical frameworks like the Zero Suicide Model advocate for systematic risk assessment, means restriction, and ongoing patient monitoring (Brodsky et al., 2018). Complementary community-based interventions, including gatekeeper training for pharmacists and family members (Carpenter et al., 2021; Morton et al., 2021), as well as school-based educational initiatives (Pistone et al., 2019), have demonstrated effectiveness in reducing suicidal ideation. Strengthening family dynamics and support systems further enhances prevention efforts by bolstering resilience and early intervention (Frey et al., 2016). Collectively, these approaches underscore the importance of multidimensional assessment and targeted strategies to mitigate suicide risk in the UK.

Suicide Risk Assessment Triage Questionnaire

A structured triage process for suicide assessment ensures that clinicians comprehensively evaluate risk and allocate resources appropriately. Even if an acute crisis assessment is not immediately required—or has been arranged for a future date—providing safety-net support is critical. Below are several organizations that can offer help, reassurance, and guidance to individuals experiencing suicidal thoughts:

• Samaritans: 116 123 (24/7 helpline)
• Papyrus HOPELINEUK (for individuals up to 35 years old): 0800 068 4141
• Mind Infoline: 0300 123 3393
• Shout (Text Service): Text “SHOUT” to 85258
• Campaign Against Living Miserably (CALM): 0800 58 58 58 (daily, 5pm–midnight)

Equipping patients and their families with these contact details ensures they know where to turn for immediate emotional support, bridging the gap until further clinical evaluation can take place.

References

[1] https://www.elft.nhs.uk/sites/default/files/ELFT%20PC%20teaching%20-%20Suicide%20and%20Self%20harm.pptx

[2] https://www.nimh.nih.gov/news/science-news/2022/a-clinical-pathway-for-suicide-risk-screening-in-adult-primary-care

[3] https://www.nimh.nih.gov/sites/default/files/documents/research/research-conducted-at-nimh/asq-toolkit-materials/adult-outpatient/bssa_outpatient_adult_asq_nimh_toolkit.pdf

[4] https://pmc.ncbi.nlm.nih.gov/articles/PMC3146379/

[5] https://www.ruralhealthinfo.org/toolkits/suicide/2/screening-tools

[6] https://patient.info/doctor/suicide-risk-assessment-and-threats-of-suicide

[7] https://www.dpt.nhs.uk/download/2hn1ZTaUXY

[8] https://www.mentalhealth.va.gov/docs/suicide_risk_assessment_reference_guide.pdf

Syringe drivers play a vital role in palliative care, delivering continuous subcutaneous medication to manage distressing symptoms such as pain, nausea, breathlessness, and agitation. This essential tool supports effective symptom control, particularly in the community setting, where timely and accurate assessment is critical for addressing the complex needs of patients.

The Comprehensive Triage Questionnaire for syringe driver initiation has been specifically designed to streamline the evaluation process. By systematically addressing key factors—clinical urgency, logistical considerations, and patient-specific needs—this tool ensures that decisions are both patient-centered and resource-conscious.

Syringe Driver Triage Questionnaire

Advisory for Clinicians

When managing patients on syringe drivers, it is essential to maintain clear and comprehensive documentation to ensure continuity of care. Consider the following guidelines:

1. Document All Changes Clearly:

   • Record any changes to medication doses, additions, or removals promptly.
   • Include the date, time, and rationale for each adjustment.

2. Rationale for Titration:

   • Provide a brief explanation for dose titration to help manage symptoms effectively (e.g., increased pain, uncontrolled nausea).
   • Note patient responses to changes in medication.

3. Ensure Readability:

   • Use clear, concise language to avoid misinterpretation.
   • Avoid abbreviations unless they are widely recognized and approved.

4. Highlight Key Information:

   • Clearly document current medication regimens, including doses, frequencies, and routes of administration.
   • Indicate if there are specific "as-needed" (PRN) medications or parameters for use.

5. Communicate Effectively:

   • Notify colleagues and other involved care providers of significant changes or updates.
   • Use secure communication channels to share updates, ensuring all relevant parties are informed.

6. Review and Update Regularly:

   • Reassess the patient frequently, especially during dose titration or significant symptom changes.
   • Update documentation to reflect the most current management plan.

7. Encourage Collaboration:

   • Engage with multidisciplinary teams, including district nurses, palliative care specialists, and family caregivers, to ensure seamless care delivery.

By adhering to these principles, clinicians can enhance patient safety, ensure effective symptom control, and facilitate smooth transitions of care.

References

[1] https://aci.health.nsw.gov.au/palliative-care/guideline/implementation/specialist-community-triage-guideline

[2] https://spcare.bmj.com/content/13/Suppl_5/A25.3

[3] https://aci.health.nsw.gov.au/palliative-care/guideline/triage

[4] https://www.palliativecarescotland.org.uk/content/publications/09.-Community-referrals.pdf

[5] https://spcare.bmj.com/content/14/Suppl_4/A33.1

[6] https://www.youtube.com/watch?v=jxlr7Kv7U9Q

Croup is a common respiratory condition in children, characterized by a distinctive barking cough and varying degrees of airway obstruction. Accurate triage is essential to determine the severity of the condition and ensure timely intervention. A well-designed croup triage questionnaire can empower primary care providers and caregivers to assess the child’s condition systematically, enabling swift identification of cases requiring urgent care or hospitalization.

In this guide, we’ll explore the essential components of a croup triage questionnaire, including primary and advanced questions tailored to assess symptom severity, risk factors, and home management feasibility. These structured questions help healthcare professionals not only evaluate the clinical presentation of croup but also provide clear recommendations for at-home care or escalation to higher levels of medical support.

Whether you’re a clinician or a concerned caregiver, understanding how to utilize these triage tools effectively is a crucial step in managing croup and ensuring the best outcomes for children.

Triage Questions for Suspected Croup