What is the best course of action for a patient who has fallen and hit their head, is currently taking aspirin (acetylsalicylic acid), and is complaining of dizziness?

Immediate Head CT Scan Required

This patient requires an immediate non-contrast head CT scan without delay, given the combination of head trauma, aspirin use, and new neurological symptoms (dizziness). 1, 2

Immediate Assessment Priorities

Clinical Evaluation

• Document Glasgow Coma Scale score - any score <15 increases risk and mandates imaging 1
• Assess for focal neurological deficits - weakness, speech changes, vision changes, or coordination problems 2
• Check vital signs - particularly blood pressure and heart rate to identify hemodynamic instability 1
• Examine for signs of skull fracture - Battle's sign, raccoon eyes, hemotympanum, CSF leak 1

Why This Patient Is High Risk

Aspirin significantly increases intracranial hemorrhage risk after head trauma. Antiplatelet therapy patients have a 3.9% risk of significant intracranial injury versus 1.5% in non-anticoagulated patients 3. While this is lower than warfarin (10.2%), it still represents substantial risk 2.

The presence of dizziness is a red flag symptom that may indicate:

• Evolving intracranial hemorrhage 1
• Vestibular injury 4
• Posterior fossa pathology 2
• Early signs of increased intracranial pressure 1

Imaging Protocol

Initial CT Scan

• Obtain non-contrast head CT immediately - this is a Level B recommendation from ACEP for patients on antiplatelet therapy with head trauma 1, 2
• Include cervical spine imaging if mechanism suggests possible cervical injury 1
• Do not delay imaging for observation - the initial CT determines all subsequent management 1, 2

If Initial CT Shows Hemorrhage

• Immediate neurosurgical consultation 3
• Hold aspirin immediately 3
• Obtain repeat CT within 24 hours - patients on antiplatelet therapy have 3-fold increased risk of hemorrhage expansion (26% vs 9%) 2, 3
• Consider platelet transfusion if neurosurgical intervention is needed 1
• Monitor in ICU setting with serial neurological examinations 1

If Initial CT Is Normal

• Brief observation period (4-6 hours minimum) is reasonable given the dizziness symptom 1, 2
• Serial neurological examinations every 30-60 minutes during observation 4
• Repeat CT is NOT routinely indicated if patient remains neurologically stable at baseline - this is Level B evidence from ACEP 1, 2
• The risk of delayed hemorrhage with normal initial CT is 0.6-6% for antiplatelet agents, and most delayed hemorrhages do not require intervention 1, 3

Common Pitfalls to Avoid

Failing to obtain initial CT imaging - even "minor" mechanisms in aspirin patients warrant imaging given increased hemorrhage risk 1, 2

Discharging too quickly with persistent symptoms - dizziness represents an abnormal neurological finding that warrants observation until resolved or explained 1, 4

Unnecessary repeat imaging in stable patients - if initial CT is normal and patient returns to neurological baseline, repeat CT adds no value and increases radiation exposure 1, 2

Continuing aspirin without assessment - hold the next dose until CT results are known and patient is evaluated 3

Disposition Algorithm

If CT Shows Hemorrhage:

• Admit to ICU 1
• Neurosurgery consultation 3
• Hold aspirin 3
• Repeat CT in 24 hours 2, 3

If CT Normal BUT Dizziness Persists:

• Observe minimum 4-6 hours 1
• Repeat neurological exam every 30-60 minutes 4
• Consider holding next aspirin dose 3
• Discharge only when dizziness resolves or alternative explanation found 1

If CT Normal AND Dizziness Resolves:

• May discharge with responsible adult observer 3
• Provide written discharge instructions with return precautions 2, 3
• Hold aspirin for 24-48 hours (balance against cardiovascular risk) 3
• Arrange outpatient follow-up for fall risk assessment 2, 3

Discharge Instructions (If Applicable)

Return immediately or call 911 for: 2, 3

• Severe or worsening headache
• Repeated vomiting
• Confusion or difficulty waking
• Weakness or numbness
• Seizures
• Vision changes
• Slurred speech
• Loss of consciousness

Ensure responsible adult supervision for 24 hours who can monitor continuously and recognize warning signs 3