From the Guidelines
Management of a patient on Plavix who has experienced a fall with loss of consciousness requires immediate medical evaluation with urgent neuroimaging (CT scan of the head) due to the increased bleeding risk from clopidogrel, as supported by the most recent study 1. The patient should be assessed for traumatic brain injury, and vital signs, neurological examination, and evaluation for other injuries should be performed promptly. Consideration of temporary discontinuation of Plavix is necessary if intracranial hemorrhage is detected, but this decision must balance bleeding risks against thrombotic risks, especially in patients with recent coronary stents, as noted in 1 and 1. Consultation with cardiology and neurology for guidance on antiplatelet management is recommended. If imaging is negative, investigation of other causes of syncope, including cardiac arrhythmias (obtaining ECG, telemetry monitoring), orthostatic hypotension, and seizures, should be undertaken. Addressing fall risk factors by reviewing medications that may contribute to falls, assessing home safety, and considering physical therapy is also crucial. Laboratory tests, including complete blood count to check for anemia or thrombocytopenia, electrolytes, and renal function, should be conducted. Documentation of the duration of unconsciousness, any witnessed seizure activity, and preceding symptoms is necessary to help determine the cause. Once stabilized, a clear follow-up plan, including when to safely resume Plavix if it was discontinued, with close monitoring for both bleeding and thrombotic complications, should be established, as suggested by the studies 1. Key points to consider include:
- Urgent neuroimaging to assess for traumatic brain injury
- Balancing bleeding and thrombotic risks in managing antiplatelet therapy
- Consultation with specialists for guidance on antiplatelet management
- Investigation of other causes of syncope if imaging is negative
- Addressing fall risk factors and conducting necessary laboratory tests
- Creating a clear follow-up plan with close monitoring for complications.
From the FDA Drug Label
Tell your doctor about all the medicines you take,including prescription, non-prescription medicines, vitamins and herbal supplements. Clopidogrel tablets may affect the way other medicines work, and other medicines may affect how clopidogrel tablets work. Taking clopidogrel tablets with certain other medicines may increase your risk of bleeding. Especially tell your doctor if you take: aspirin, especially if you have had a stroke. Always talk to your doctor about whether you should take aspirin along with clopidogrel tablets to treat your condition. Talk with your doctor about stopping your clopidogrel tablets before you have surgery. Your doctor may tell you to stop taking clopidogrel tablets at least 5 days before you have surgery to avoid excessive bleeding during surgery.
The management steps for a patient on Plavix (clopidogrel) who has experienced a fall with loss of consciousness are not directly addressed in the provided drug label. However, it is essential to inform the doctor about the fall and loss of consciousness, as this may impact the patient's treatment plan, especially if surgery or any invasive procedure is required. The doctor may need to assess the risk of bleeding and decide whether to stop or continue clopidogrel tablets. It is crucial to follow the doctor's instructions regarding the management of clopidogrel therapy in this situation 2.
From the Research
Management Steps for a Patient on Plavix (Clopidogrel) Who Has Experienced a Fall with Loss of Consciousness
The management of a patient on Plavix (clopidogrel) who has experienced a fall with loss of consciousness involves several key steps:
- Immediate medical attention: The patient should be taken to the emergency department for evaluation and treatment.
- Head computed tomography (CT) scan: A head CT scan should be performed to rule out intracranial hemorrhage, as patients on clopidogrel are at increased risk of bleeding 3, 4.
- Monitoring: The patient should be closely monitored for signs of bleeding, such as headache, confusion, or weakness.
- Laboratory tests: Laboratory tests, including complete blood count, prothrombin time, and partial thromboplastin time, should be performed to assess the patient's coagulation status.
- Neurosurgical consultation: A neurosurgical consultation should be obtained to evaluate the need for surgical intervention, if necessary.
Risk of Intracranial Hemorrhage
The risk of intracranial hemorrhage in patients on clopidogrel is a concern, particularly in the setting of head trauma. Studies have shown that patients on clopidogrel are at increased risk of intracranial hemorrhage compared to those not on antiplatelet therapy 3, 4. However, the absolute risk of intracranial hemorrhage is still relatively low, and the decision to perform a head CT scan should be individualized based on the patient's clinical presentation and risk factors.
Reversal of Antiplatelet Therapy
In patients on clopidogrel who require urgent neurosurgery, platelet transfusion may be considered to reverse antiplatelet therapy 5. However, the use of platelet transfusion should be carefully weighed against the risk of thrombotic complications.
Clinical Guidelines
Clinical guidelines for the management of patients on antiplatelet therapy who have experienced a fall with loss of consciousness are not well established. However, studies suggest that patients on clopidogrel should be closely monitored for signs of bleeding and that head CT scans should be performed to rule out intracranial hemorrhage 3, 6, 4.