How should I assess a geriatric patient on edoxaban (direct oral anticoagulant) who has had a fall and hit their head?

Assessment of Geriatric Patient on Edoxaban After Head Injury

All geriatric patients on edoxaban who have fallen and hit their head should receive immediate CT imaging of the brain, regardless of symptoms, due to the high risk of intracranial hemorrhage associated with anticoagulation. 1

Initial Evaluation

History Assessment

• Location and cause of fall
• Time spent on floor or ground
• Loss of consciousness or altered mental status
• Symptoms: headache, vision changes, weakness, numbness, difficulty speaking
• Last dose of edoxaban
• Renal function status (affects drug clearance)
• Other medications (especially antiplatelet agents)

Physical Examination

• Complete head-to-toe evaluation (even with seemingly isolated injuries)
• Neurological assessment with special attention to:
  • Mental status changes
  • Pupillary abnormalities
  • Focal neurological deficits
  • Signs of head trauma (contusions, lacerations, hematomas)

Diagnostic Workup

Immediate Imaging

• Non-contrast CT brain should be performed urgently 1
• Do not delay imaging even if patient appears asymptomatic

Laboratory Testing

• Complete blood count
• Renal function (creatinine clearance)
• Coagulation studies:
  • PT/INR (may not accurately reflect edoxaban activity)
  • Anti-Factor Xa activity (preferred test for edoxaban if available) 1, 2
  • Consider chromogenic anti-FXa assay calibrated for edoxaban 1

Management Based on Findings

If Intracranial Hemorrhage Present:

1. Hold edoxaban immediately
2. Consult neurosurgery
3. Consider reversal agent based on severity:
   • For life-threatening bleeding: 1, 2
     • If anti-FXa activity is detected, consider PCC (25-50 U/kg) as edoxaban does not have a specific reversal agent like andexanet alfa
     • Co-administer tranexamic acid (15 mg/kg or 1 g)
   • Monitor for thromboembolic complications after reversal 3

If No Intracranial Hemorrhage on Initial CT:

1. For high-risk patients (signs of head trauma or history of LOC):

   • Consider observation for 24 hours 4
   • Repeat neurological assessments
   • Consider repeat CT if symptoms develop

2. For low-risk patients (no signs of head trauma AND no LOC):

   • May consider discharge with close follow-up
   • Provide clear return precautions
   • Consider delaying next edoxaban dose by 24 hours 2

Risk Factors for Increased Bleeding

Pay special attention to patients with:

• Hemoglobin <12.3 g/dL 5
• Prothrombin time ≥12.7 seconds 5
• Creatinine clearance <30 mL/min 5, 6
• Age ≥80 years with additional bleeding risk factors 6

Follow-up Recommendations

• Arrange follow-up within 1-2 days for high-risk patients
• Implement fall prevention strategies
• Consider medication review to minimize fall risk
• Evaluate need for home safety assessment

Common Pitfalls to Avoid

1. Delaying CT imaging in asymptomatic patients
2. Relying on normal mental status to rule out intracranial injury
3. Failing to recognize that standard coagulation tests may not accurately reflect edoxaban activity
4. Overlooking the need for complete evaluation despite seemingly isolated injuries
5. Resuming anticoagulation too early after reversal (optimal timing is typically 7-12 days after major bleeding) 3

Remember that the negative predictive value of absence of both LOC and signs of head trauma is 97.3%, but this still misses approximately 2.7% of intracranial injuries in geriatric patients 4. Therefore, a low threshold for imaging is warranted in this high-risk population.