Why do I need to check if a patient is on anticoagulant (blood thinner) therapy after a fall?

Checking Anticoagulation Status After Patient Falls: Critical Nursing Assessment

Checking a patient's anticoagulation status after a fall is essential because anticoagulants significantly increase the risk of serious bleeding complications, particularly intracranial hemorrhage, which can lead to increased morbidity and mortality even with minor trauma.

Why Anticoagulation Status Matters After Falls

Increased Bleeding Risk

• Anticoagulants (blood thinners) inhibit normal clotting mechanisms, which can lead to:
  • Prolonged bleeding time
  • Larger hematoma formation
  • Delayed recognition of internal bleeding
  • Higher risk of intracranial hemorrhage

Mortality and Morbidity Considerations

• Intracranial hemorrhage has the worst prognosis among bleeding complications in anticoagulated patients 1
• Even minor head trauma can lead to significant bleeding in anticoagulated patients
• Prompt identification allows for timely intervention to reverse anticoagulation if necessary

Assessment Protocol After a Fall

Immediate Assessment

1. Determine if patient is taking:

   • Vitamin K antagonists (e.g., warfarin)
   • Direct oral anticoagulants (DOACs)
   • Antiplatelet agents (e.g., aspirin, clopidogrel)
   • Heparins (unfractionated or low molecular weight)

2. Document:

   • Type of anticoagulant
   • Last dose taken
   • Current INR level (for warfarin)
   • Renal and hepatic function 2

Physical Assessment

• Assess for signs of external bleeding
• Monitor for signs of internal bleeding:
  • Headache, dizziness
  • Changes in level of consciousness
  • Hypotension or tachycardia
  • Abdominal pain or swelling
  • Expanding hematomas

Laboratory Testing

According to the 2023 WSES guidelines, the following tests should be performed in elderly patients on anticoagulants after trauma 2:

• Prothrombin Time (PT) and INR (reliable for vitamin K antagonists)
• Activated Partial Thromboplastin Time (aPTT)
• Thromboplastin Time (TT)
• Anti-Xa levels (for DOACs and heparins)

Important Considerations

Timing of Bleeding

• Bleeding may not be immediately apparent
• Intracranial hemorrhage can develop hours to days after a fall
• Continued monitoring is essential, especially for head injuries

Risk vs. Benefit Assessment

• The 2018 CHEST guidelines note that a patient would need to fall 295 times per year for the risk of falls to outweigh the benefits of stroke reduction with anticoagulation 2
• Being at risk of falls alone is not a valid reason to avoid anticoagulation 3

Anticoagulant-Specific Considerations

1. Warfarin (VKA):

   • Higher risk of serious bleeding compared to newer agents
   • FDA warns about fatal or nonfatal hemorrhage from any tissue or organ 4
   • Reversal options include vitamin K, fresh frozen plasma, or prothrombin complex concentrates

2. DOACs:

   • May have lower risk of intracranial hemorrhage compared to warfarin
   • One study found no intracranial hemorrhages in 31 subjects taking DOACs after ground-level falls 5
   • Specific reversal agents are becoming available 1

3. Antiplatelet Agents:

   • Often underestimated risk
   • One study found aspirin users had a 4.6% rate of traumatic intracranial hemorrhage after ground-level falls 5

Common Pitfalls to Avoid

1. Assuming no bleeding without visible signs

   • Internal bleeding may not present with obvious external signs
   • Continued monitoring is essential

2. Focusing only on head injuries

   • While intracranial bleeding is most concerning, anticoagulated patients can develop significant bleeding in other areas

3. Delaying reversal of anticoagulation

   • For life-threatening bleeding, prompt reversal is crucial 1
   • Know your facility's protocol for anticoagulation reversal

4. Overestimating fall risk as a contraindication

   • The European Heart Rhythm Association notes that a patient would need to fall 295 times for subdural hematoma risk to outweigh anticoagulation benefits 2
   • Risk of falls should not automatically exclude patients from receiving necessary anticoagulation

By checking anticoagulation status after falls, nurses play a critical role in preventing serious complications and ensuring appropriate monitoring and intervention for these high-risk patients.