Ms. Brown is a 80 year old woman with a history of atrial fibrillation and mitral mechanical valve replacement who underwent wide local excision of a right nipple-areolar complex squamous cell carcinoma and primary closure 2 weeks ago. She was discharged home on Lovenox as a bridge to warfarin for anticoagulation given the history of a mechanical mitral valve. She is now presenting after a fall while anticoagulated on lovenox and warfarin. 

In terms of a more detailed history, after Ms. Brown received a wide local excision of the squamous cell carcinoma 2 weeks ago, she was discharged home. About a week ago, she noticed intermittent weakness while standing for prolonged periods of time. She also noticed increased pain and swelling of her right breast, and some sanguinous oozing of the nipple. Yesterday night, she fell and developed a hematoma over her breasts. She reported to her local ED, where her INR at that time was 1.9. Her hemoglobin was found to be 7.9, down from 12.0 the day prior. At her local ED she received 5mg of IV vitamin K and 1 unit of blood and was transferred to UMHS for further management.

Thus, in patients undergoing life-threatening bleeding, it is appropriate to choose IV Vitamin K over oral Vitamin K for faster correction of INR. Ms. Brown was given IV Vitamin K by the outside hospital for her bleed, even though her INR (1.3) was not supratherapeutic. If a patient requires more than one or two days of Vitamin K to correct INR, impaired absorption of an oral preparation should be suspected. (This does not apply in our case.)