What is the management for a patient on anticoagulants (blood thinners) and chemotherapy who fell and is now experiencing chest wall pain?

Management of Chest Wall Pain After Fall in Patient on Anticoagulation and Chemotherapy

Immediately assess for major bleeding by evaluating for hemodynamic instability, hemoglobin drop ≥2 g/dL, or need for ≥2 units RBCs transfusion, and if present, stop the anticoagulant, provide supportive care with volume resuscitation, and consider reversal agents based on the specific anticoagulant type. 1

Initial Assessment of Bleeding Severity

Determine if this is major bleeding by checking for at least one of the following criteria: 1

• Bleeding at a critical site (intracranial, intraspinal, intraocular, pericardial, intra-articular, intramuscular with compartment syndrome, or retroperitoneal)
• Hemodynamic instability
• Clinically overt bleeding with hemoglobin decrease ≥2 g/dL or administration of ≥2 units RBCs

Obtain vital signs immediately and repeat frequently to assess for hemodynamic instability, as patients with major bleeds require close monitoring in an acute or critical care setting. 1

Perform focused history and physical examination to determine: 1

• Time of last anticoagulant dose and type of anticoagulant (warfarin, DOAC, heparin)
• Mechanism and severity of trauma from the fall
• Whether chest wall pain suggests rib fractures, hemothorax, or internal bleeding
• Presence of visible bruising, swelling, or deformity

Order laboratory evaluation immediately: 1, 2

• Complete blood count with hemoglobin and hematocrit
• Coagulation studies (PT/INR if on warfarin, aPTT if on heparin)
• Type and screen for potential transfusion

Assess for chemotherapy-related complications that increase bleeding risk, including thrombocytopenia, uremia, or liver disease. 1

Management Based on Bleeding Severity

If Major Bleeding is Present:

Stop the oral anticoagulant and any antiplatelet agents immediately. 1

For patients on warfarin (VKA): 1

• Administer 5-10 mg IV vitamin K
• Consider prothrombin complex concentrates (PCCs) for rapid reversal
• Provide local therapy/manual compression if applicable

For patients on DOACs: 1, 2

• Consider specific reversal agents: idarucizumab for dabigatran, or andexanet alfa for apixaban or rivaroxaban
• Do NOT administer reversal agents for non-major bleeding on DOACs

Provide supportive care: 1

• Volume resuscitation
• Transfuse RBCs to maintain hemoglobin ≥7 g/dL (≥8 g/dL if coronary artery disease present)
• Transfuse platelets if count <50,000/μL due to chemotherapy

Consider surgical/procedural management if chest wall bleeding involves hemothorax or ongoing hemorrhage despite medical management. 1

If Non-Major Bleeding is Present:

Stop the oral anticoagulant temporarily. 1

Provide local therapy/manual compression. 1

For patients on warfarin, consider 2-5 mg PO/IV vitamin K (lower dose than for major bleeding). 1

For patients on DOACs, do NOT administer reversal/hemostatic agents. 1

Provide supportive care and volume resuscitation as needed. 1

If No Overt Bleeding is Identified:

Consider continuing the anticoagulant if there is appropriate indication and no evidence of bleeding, but maintain high suspicion for occult bleeding given the fall mechanism. 1

Obtain imaging (chest X-ray or CT chest) to rule out rib fractures, hemothorax, or pulmonary contusion that could lead to delayed bleeding. 1

Critical Pitfalls and Caveats

Do not assume chest wall pain is benign musculoskeletal pain in an anticoagulated patient who fell—occult bleeding can present with only pain before hemodynamic compromise develops. 1

The absolute risk of fall-related major hemorrhagic injury is relatively low (approximately 10% of falls cause major hemorrhagic injury, with intracranial hemorrhage being rare), but the consequences can be catastrophic, warranting aggressive evaluation. 3, 4

Chemotherapy-induced thrombocytopenia significantly increases bleeding risk beyond anticoagulation alone, requiring platelet transfusion if count <50,000/μL with active bleeding. 2, 5

Monitor serial hemoglobin levels even if initial assessment does not show major bleeding, as delayed bleeding can occur, particularly with rib fractures or chest wall hematomas. 2, 5

Restarting Anticoagulation

Once bleeding is controlled and the patient is stable, assess if there is a clinical indication for continued anticoagulation. 1

Delay restarting anticoagulation if: 1

• Bleed occurred at a critical site
• Patient is at high risk of rebleeding or death/disability with rebleeding
• Source of bleed has not been identified
• Surgical or invasive procedures are planned

Restart anticoagulation as soon as hemostasis is achieved if the patient has high thrombotic risk (e.g., mechanical valve, recent VTE). 6, 2

For patients with lower thrombotic risk, consider delaying restart until the risk of rebleeding is minimized. 2