What tests should be performed if a patient on Plavix (clopidogrel) falls?

Assessment and Management of Patients on Plavix (Clopidogrel) After a Fall

For patients on Plavix (clopidogrel) who experience a fall, a comprehensive evaluation should include neurological assessment, bleeding risk evaluation, and appropriate imaging studies, with CT head being the most critical test to rule out intracranial hemorrhage. 1, 2

Initial Assessment

• Perform a complete head-to-toe evaluation, even with seemingly isolated injuries, to assess for occult injuries that may be exacerbated by antiplatelet therapy 2
• Assess fall risk factors using the P-SCHEME approach: Pain (axial or lower extremity), Shoes (footwear characteristics), Cognitive impairment, Hypotension (orthostatic or iatrogenic), Eyesight (vision impairment), Medications (centrally acting), and Environmental factors 1
• Conduct mobility assessment using validated tools such as the Timed Up and Go (TUG) test, where a time >12 seconds indicates increased fall risk 1

Imaging and Laboratory Studies

• CT head scan is the primary imaging study to rule out intracranial hemorrhage, even with minor head trauma, as patients on antiplatelet therapy have increased bleeding risk 2, 3
• Consider additional imaging based on clinical findings:
  • X-rays of suspected fracture sites if Ottawa or Pittsburgh criteria are met 2
  • CT of other body regions if high-energy mechanism or signs of occult injury 2
• Laboratory studies to consider:
  • Complete blood count to assess for anemia or active bleeding 1
  • Platelet count before considering platelet transfusion 1
  • Consider platelet function testing if available, especially in patients with suspected drug-induced platelet dysfunction 1, 4

Risk Assessment and Management

• The absolute risk of intracranial hemorrhage after ground-level falls in patients on clopidogrel is approximately 4.3%, which is higher than the general population but lower than commonly perceived 3
• Patients with shock index (heart rate/systolic blood pressure) ≥0.9 should undergo more comprehensive evaluation for occult hemorrhage 2
• For patients with confirmed bleeding:
  • Consider platelet transfusion only if significant active bleeding is present and platelet function testing confirms antiplatelet effect 1, 4
  • Note that a significant percentage of patients reportedly on clopidogrel may have low or undetectable platelet inhibition (potentially non-responders or non-compliant), making platelet transfusions unnecessary 4

Monitoring and Disposition

• Maintain a high index of suspicion for delayed presentation of injuries in patients on antiplatelet therapy 2
• Consider admission for observation if:
  • Patient has any evidence of intracranial hemorrhage 2, 3
  • High-energy mechanism of fall 2
  • Inability to bear weight or perform activities of daily living safely 2
• For patients being discharged:
  • Provide clear instructions about warning signs that should prompt return to medical care 1
  • Consider fall prevention interventions including physical therapy referral if mobility assessment is abnormal 1

Special Considerations

• Patients with CYP2C19 poor metabolizer status may have diminished platelet inhibition despite clopidogrel therapy, potentially reducing bleeding risk but also reducing therapeutic efficacy 1
• For patients requiring surgery after a fall, evidence suggests that early hip fracture surgery can be performed safely without increased bleeding risk in patients on clopidogrel 5
• Consider the risk-benefit ratio of continuing clopidogrel therapy, especially in patients with recent coronary stent placement where premature discontinuation could lead to stent thrombosis 1

Remember that while bleeding risk is a concern, the counterintuitive finding that patients on warfarin had lower rates of fall-related hemorrhagic injuries than those on no therapy in some studies suggests that physicians may overestimate bleeding risk, potentially denying beneficial therapy to patients who need it 6.