What are the immediate steps for a patient on anticoagulants (blood thinners), such as warfarin (warfarin), aspirin (acetylsalicylic acid), or novel oral anticoagulants (NOACs) like apixaban (apixaban) or rivaroxaban (rivaroxaban), who has fallen, hit their head, and is now showing neurological deficits, including non-reactive pupils and impaired extraocular movement, but is refusing to go to the emergency room (ER)?

Emergency Management of Patient on Blood Thinners with Neurological Deficits After Head Trauma

This patient requires immediate emergency medical services activation and transport to the nearest trauma center regardless of refusal, as these findings represent a life-threatening emergency requiring immediate intervention.

Initial Assessment and Immediate Actions

• Airway management is the first priority 1

  • Ensure patent airway
  • Apply supplemental oxygen if available
  • Position patient to prevent aspiration

• Vital signs monitoring

  • Blood pressure (maintain SBP >100 mmHg or MAP >80 mmHg) 2
  • Heart rate, respiratory rate, oxygen saturation
  • Temperature

• Neurological assessment

  • Pupils size 2 and non-reactive to light with inability to follow to left side indicates severe neurological compromise
  • These findings suggest possible intracranial hemorrhage with increased intracranial pressure
  • Document GCS motor score 2

Management of Patient Refusal

1. Explain the critical nature of the situation

   • Inform patient that fixed, non-reactive pupils represent a life-threatening emergency
   • Explain that anticoagulants significantly increase risk of intracranial bleeding after head trauma

2. Involve family members/caregivers to help persuade patient

3. Contact emergency medical services immediately

   • This is a medical emergency requiring involuntary transport
   • The neurological findings indicate potential life-threatening intracranial hemorrhage

4. Legal considerations

   • Document patient's altered mental status which may impair decision-making capacity
   • In most jurisdictions, emergency providers can override patient refusal in life-threatening situations

Anticoagulation Reversal Considerations

While awaiting EMS arrival or during transport, prepare for potential reversal based on the specific anticoagulant:

• For Warfarin: Administer 4F-PCC based on INR 2

  • INR 2 to <4: 25 units/kg
  • INR 4-6: 35 units/kg
  • INR >6: 50 units/kg
  • Plus vitamin K 5-10 mg IV

• For Dabigatran: Prepare for idarucizumab 5g IV 2

• For Apixaban/Rivaroxaban: Prepare for andexanet alfa 2, 3

  • If andexanet alfa unavailable, use PCC 25-50 U/kg

• For Aspirin/Antiplatelet agents: No specific reversal agent, but include this information in handoff to trauma team

Hospital Management (to communicate to EMS/ED)

1. Immediate brain CT scan upon arrival to evaluate for intracranial hemorrhage 2

2. Neurosurgical consultation for potential emergent intervention 2

3. ICP monitoring may be required based on CT findings 2

4. Blood product administration as needed:

   • Maintain platelet count >50,000/mm³ (>100,000/mm³ for neurosurgical intervention) 2
   • Consider RBC transfusion for hemoglobin <7 g/dL 2

Critical Pitfalls to Avoid

• Do not delay transport to attempt reversal at the scene
• Do not accept patient refusal with these neurological findings
• Do not administer aspirin or NSAIDs which can worsen bleeding
• Do not lower blood pressure as this can worsen cerebral perfusion
• Do not assume mild head trauma is benign in anticoagulated patients - delayed intracranial hemorrhage is common 3
• Do not overlook the need for repeat imaging even if initial CT is negative 3

Follow-up Considerations

• Patients on blood thinners remain at risk for delayed intracranial hemorrhage (0.95-4.5% risk) 3
• Decisions regarding restarting anticoagulation should be made by specialists after bleeding is controlled

Remember that fixed, dilated pupils with impaired extraocular movements in a patient on anticoagulation after head trauma represents a true emergency requiring immediate intervention regardless of patient wishes.