Should a patient on Eliquis (apixaban) with hip and forearm pain, headache, and possible head trauma after a fall be sent to the ER for further evaluation?

Management of Fall with Possible Head Injury in Patient on Eliquis

This patient on Eliquis with hip/forearm pain, headache, and possible head trauma should be sent to the emergency department immediately for evaluation due to the high risk of delayed intracranial hemorrhage.

Rationale for Emergency Evaluation

Patients on anticoagulants like Eliquis (apixaban) have a significantly increased risk of intracranial hemorrhage following head trauma, even when initial neurological examination appears normal:

• Anticoagulation use is associated with increased risk for intracranial hemorrhage following head injury 1
• Patients on anticoagulants who experience head trauma can undergo rapid decompensation and deterioration 1
• Even low-energy transfers such as ground-level falls can result in serious injuries in anticoagulated patients 1

Risk Assessment

Despite the patient's relatively normal neurological examination:

• GCS 14 (slightly decreased from normal)
• Headache after fall (concerning symptom)
• On Eliquis (direct factor Xa inhibitor)
• Uncertain if head impact occurred ("may have bumped her head")

These factors create a high-risk situation requiring urgent evaluation. The FDA label for Eliquis specifically warns that it "increases the risk of bleeding and can cause serious, potentially fatal bleeding" 2.

Why Normal Exam Doesn't Rule Out Serious Injury

The normal neurological examination is insufficient to rule out intracranial hemorrhage because:

• Occult intracranial injury can be present despite normal initial examination 1
• Delayed hemorrhage can occur in anticoagulated patients 1
• In one study of patients with mild head injury on anticoagulants with GCS 15,29% had intracranial hemorrhage despite normal initial presentation 1

Management Algorithm

1. Immediate transfer to ED for CT scan of the head

   • Brain CT scan should be performed without delay in any patient on anticoagulant therapy with suspected head trauma 1

2. ED evaluation should include:

   • Immediate head CT scan
   • Assessment of hip and forearm injuries
   • Laboratory tests including INR, complete blood count
   • Consideration of reversal agents if intracranial hemorrhage is detected

3. Observation period:

   • Even with a negative initial CT scan, observation is recommended
   • European Federation of Neurological Sciences recommends 24-hour observation with repeat CT scan for anticoagulated patients with minor head injury 1

Important Considerations

• Apixaban's anticoagulant effect persists for at least 24 hours after the last dose 2
• If intracranial hemorrhage is detected, reversal agents may be needed:
  • An agent to reverse anti-factor Xa activity of apixaban is available 2
  • Prothrombin complex concentrate may be considered in emergency situations 1, 2

Pitfalls to Avoid

1. Do not delay transfer to ED based on normal neurological examination
2. Do not assume low-energy falls are benign in anticoagulated patients
3. Do not discharge without proper imaging and observation period
4. Do not withhold anticoagulation reversal if intracranial hemorrhage is detected

The 2023 WSES guidelines emphasize that elderly trauma patients on anticoagulants who present with bleeding in critical organs like the central nervous system require urgent evaluation and possible reversal of anticoagulation 1.