Management of Patients Over 65 on Apixaban After Loss of Consciousness and Fall
A patient over 65 years old on Eliquis (apixaban) who experiences loss of consciousness and fall should undergo immediate CT scan of the head to rule out intracranial hemorrhage, with careful assessment of neurological status and fall etiology. 1, 2
Initial Assessment and Imaging
- Obtain a detailed history focusing on location and cause of fall, difficulty with gait/balance, previous falls, time spent on ground, and whether loss of consciousness occurred 1
- Perform a thorough neurological examination to assess for focal deficits, which are significantly associated with increased risk of traumatic brain lesions (RR = 6.36) 3
- Obtain an immediate head CT scan, particularly important in patients on anticoagulants like apixaban due to increased bleeding risk 2, 3
- Look for specific risk factors that increase likelihood of intracranial hemorrhage: consciousness impairment, focal neurological deficit, and history of previous traumatic brain injury 3, 4
CT Scan Decision-Making
- Male sex (RR = 2.19), consciousness impairment (RR = 1.56), focal neurological deficit (RR = 6.36), and past history of traumatic brain injury (RR = 7.17) are significantly associated with positive findings on CT scan 3
- Optimal timing for CT scan is within 5 hours of head trauma for best detection of lesions 3
- Patients on apixaban have increased bleeding risk, though recent research suggests the risk of delayed intracranial hemorrhage with direct oral anticoagulants (0.95%) may be lower than with warfarin (0.6-6.0%) 5
- Even with a negative initial CT scan, patients on apixaban with additional risk factors (especially concurrent antiplatelet therapy) should be monitored closely 5
Management Based on CT Results
If CT Shows Intracranial Hemorrhage:
- Consider reversal of anticoagulant effect using an agent to reverse the anti-factor Xa activity of apixaban 2
- The pharmacodynamic effect of apixaban can persist for at least 24 hours after the last dose 2
- Prothrombin complex concentrate (PCC), activated prothrombin complex concentrate, or recombinant factor VIIa may be considered, though these have not been extensively evaluated in clinical studies 2
- Neurosurgical consultation should be obtained immediately 5
If CT is Negative:
- Consider admission for observation if the patient has additional risk factors such as:
- If none of these risk factors are present, discharge may be considered with appropriate follow-up and instructions 6, 5
Apixaban Management
- If apixaban must be temporarily discontinued due to bleeding, consider that premature discontinuation increases risk of thrombotic events 2
- If apixaban is discontinued for bleeding, consider coverage with another anticoagulant when safe to resume 2
- Full therapeutic anticoagulation should typically be resumed 24-72 hours after bleeding is controlled and surgical hemostasis (if any intervention was needed) is confirmed 7, 8
Additional Considerations
- Evaluate for orthostatic hypotension, carotid sinus hypersensitivity, and other cardiovascular causes of syncope, which are common in this age group 1
- Assess medication regimen for polypharmacy issues, particularly high-risk medications that may contribute to falls 1
- Consider referral to a multidisciplinary team including a pharmacist to review medications that may increase fall risk 1
- Evaluate home safety and consider physical therapy assessment for gait and balance training 1
Common Pitfalls to Avoid
- Failing to obtain a head CT scan in patients on anticoagulants with loss of consciousness 3, 9
- Overlooking focal neurological deficits or new headache, which significantly increase the likelihood of intracranial pathology 9
- Premature discontinuation of apixaban without adequate alternative anticoagulation, which increases thrombotic risk 2
- Failing to consider other causes of syncope beyond trauma, such as cardiac or neurological etiologies 1, 9