Signs of Bleeding in Patients Taking Xarelto After a Fall
After a fall in a patient taking Xarelto (rivaroxaban), immediate evaluation for signs of bleeding is critical as this medication increases bleeding risk and can cause serious or fatal bleeding.
Immediate Assessment for Critical Bleeding Signs
External Bleeding Signs
- Visible blood from wounds, lacerations, or abrasions
- Bruising or hematomas that are expanding or large
- Blood in urine (hematuria) - may appear pink, red, or tea-colored
- Blood in stool or black, tarry stools (melena)
- Vomiting blood or coffee-ground material (hematemesis)
- Bleeding from gums or nose that is difficult to control 1, 2
Neurological Signs (Critical)
- Headache (especially sudden, severe headache)
- Altered mental status or confusion
- Decreased level of consciousness
- Unequal pupils
- Weakness or numbness on one side of the body
- Difficulty speaking or slurred speech
- Vision changes
- Dizziness or loss of balance
- Seizures 1, 2
Signs of Internal Bleeding
- Abdominal, flank, or back pain
- Abdominal distention or rigidity
- Joint pain or swelling (hemarthrosis)
- Muscle pain or swelling (intramuscular bleeding)
- Retroperitoneal bleeding (may present as lower back pain) 1
Hemodynamic Instability Signs
- Tachycardia (heart rate >100 beats/minute)
- Hypotension (systolic blood pressure <90 mmHg)
- Drop in systolic blood pressure >40 mmHg
- Orthostatic changes (drop in systolic BP ≥20 mmHg upon standing)
- Cold, clammy skin
- Decreased urine output
- Rapid, shallow breathing
- Anxiety or restlessness 1, 2
Severity Assessment
Major/Life-Threatening Bleeding
- Bleeding in critical sites (intracranial, intraocular, spinal, retroperitoneal, intra-articular, pericardial, intramuscular with compartment syndrome)
- Hemodynamic instability
- Drop in hemoglobin ≥2 g/dL
- Requirement for ≥2 units of blood transfusion 1, 2
Non-Major Clinically Relevant Bleeding
- Bleeding that doesn't meet major criteria but requires medical attention
- Prolonged bleeding (>10 minutes) after minor trauma
- Recurrent or persistent bleeding
- Large surface hematomas (>5 cm) 1, 3
Delayed Signs of Bleeding
Bleeding complications may not be immediately apparent after a fall. Monitor for:
- Progressive anemia (fatigue, weakness, pallor)
- Delayed neurological deterioration (especially with head trauma)
- Increasing pain in injured areas
- Expanding hematomas
- Worsening vital signs over 24-48 hours 2
Special Considerations
Fall Risk Assessment
Patients on Xarelto should have regular fall risk assessments using tools like the one below:
- Previous falls
- Taking >4 medications
- Taking psychotropic medications
- Low visual acuity
- Diminished sensation
- Inability to stand in near tandem position for 10 seconds
- Inability to complete alternate step test in 10 seconds
- Inability to rise from sitting to standing in 12 seconds 1
Risk Factors for Increased Bleeding
- Age >75 years
- Heart failure
- Vascular disease
- Uncontrolled hypertension
- Concomitant use of antiplatelet drugs, NSAIDs, or paracetamol
- Heavy alcohol use 4
Management Approach
If bleeding is suspected after a fall in a patient taking Xarelto:
Assess severity of bleeding
For life-threatening bleeding:
For non-life-threatening bleeding:
Remember that the half-life of rivaroxaban is 5-9 hours in patients with normal renal function, but may be prolonged in elderly patients or those with renal impairment 5.
Pitfalls and Caveats
- Do not administer vitamin K for Xarelto reversal (unlike warfarin, it has no effect on direct Xa inhibitors)
- Standard coagulation tests (PT, INR) may not accurately reflect the anticoagulant effect of Xarelto
- Anti-Factor Xa activity is the most accurate test to assess Xarelto activity but may not be readily available in emergency settings
- Bleeding risk is highest if the fall occurred within 4-12 hours of Xarelto administration
- Patients with head trauma require close neurological monitoring for at least 24 hours, even if initial assessment is normal 1, 2, 5