What is the assessment and management plan for an elderly patient with a subdural hematoma after a fall, who may be taking anticoagulant medications such as warfarin (coumadin) or aspirin?

Assessment and Management of Subdural Hematoma After Fall in Elderly Patients on Anticoagulants

Immediate Assessment

All elderly patients on anticoagulants (warfarin, NOACs) or antiplatelet agents (aspirin, clopidogrel) who sustain a fall require immediate non-contrast head CT imaging, regardless of symptom severity or mechanism of injury. 1

Key Clinical Features to Document:

• Glasgow Coma Scale (GCS) score with individual components (Eye, Motor, Verbal) 2
• Pupillary size and reactivity 2
• Focal neurological deficits indicating mass effect 2
• History of loss of consciousness or post-traumatic amnesia 1
• Current anticoagulation regimen and timing of last dose 3

Risk Stratification:

• Patients on warfarin have 3.9% risk of significant intracranial injury versus 1.5% in non-anticoagulated patients 1
• Warfarin-associated subdural hematomas carry 42.5 times higher risk compared to non-anticoagulated patients 4
• Anticoagulated patients have a 3-fold increased risk of hemorrhage expansion (26% versus 9%) 3, 5

---

Management Algorithm for Confirmed Subdural Hematoma

Step 1: Immediate Actions (Within Minutes)

Discontinue all anticoagulants and antiplatelet agents immediately upon diagnosis of subdural hematoma. 3, 2

Obtain immediate neurosurgical consultation for all patients with confirmed subdural hematoma, regardless of GCS score or neurological stability. 3, 2

Step 2: Anticoagulation Reversal (Urgent)

For patients on warfarin:

• Administer 4-factor prothrombin complex concentrate (4F-PCC) to achieve INR <1.5 3
• Give 5mg intravenous vitamin K concurrently 3
• Recheck INR after reversal to confirm adequate correction 3

For patients on therapeutic-dose enoxaparin (Lovenox):

• If given within 8 hours: 1 mg protamine per 1 mg enoxaparin (maximum 50 mg single dose) by slow IV over 10 minutes 3
• If given within 8-12 hours: 0.5 mg protamine per 1 mg enoxaparin 3
• If life-threatening bleeding persists: redose protamine at 0.5 mg per 1 mg enoxaparin 3

For patients on NOACs (apixaban, rivaroxaban, dabigatran):

• Administer specific reversal agent if available (andexanet alfa for apixaban/rivaroxaban) 5
• If unavailable, use 4F-PCC or activated PCC 5

For patients on aspirin alone:

• Consider tranexamic acid 1g IV over 10 minutes if within 3 hours of symptom onset (reduces head injury-related death, RR 0.78,95% CI 0.64-0.95) 3

Step 3: Laboratory Monitoring

Obtain immediately:

• INR, PT, aPTT, fibrinogen levels 3
• Platelet count (ensure >100 × 10⁹/L before any procedure) 1
• If fibrinogen <150 mg/dL after reversal, administer cryoprecipitate 3

Step 4: Repeat Imaging Protocol

Obtain repeat head CT at 6-8 hours after initial scan to assess for hemorrhage expansion, as most expansion occurs within the first 6 hours. 5, 2

Obtain immediate repeat CT for any of the following:

• GCS decline of ≥2 points 2
• Development of pupillary changes or posturing 2
• New or worsening focal neurological deficits 2
• Any neurological deterioration whatsoever 5, 2

Step 5: Admission and Monitoring

Admit all patients with documented subdural hematoma for 24-72 hours of close neurological observation, regardless of initial neurological stability. 2

Neurological monitoring schedule:

• GCS every 15 minutes for first 2 hours 2
• Hourly GCS for following 12 hours 2
• Document individual GCS components and pupillary exam at each evaluation 2

---

Surgical Intervention Thresholds

Immediate surgical consultation is warranted for:

• Pupillary changes or posturing indicating herniation 2
• GCS decline of ≥2 points 2
• Development of focal neurological deficits indicating mass effect 2
• Failure to show neurological improvement within 72 hours 2

---

Special Considerations for Elderly Patients

Elderly patients (≥65 years) on aspirin with subdural hematomas require the same aggressive management as those on warfarin due to 3-fold increased hemorrhage progression risk. 5, 2

Do NOT administer corticosteroids (dexamethasone) for traumatic brain injury management, as they may worsen outcomes. 2

---

Discharge Planning (Only for Negative Initial CT)

Patients with confirmed subdural hematoma should NOT be discharged, even with normal neurological examination, due to risk of delayed deterioration requiring neurosurgery. 2

For patients with negative initial CT who are neurologically intact:

• Discharge is safe without repeat imaging or observation 1, 5
• Provide clear discharge instructions about symptoms of delayed hemorrhage 1, 5
• Arrange outpatient follow-up for fall risk assessment and anticoagulation risk/benefit reassessment 1, 5

---

Critical Pitfalls to Avoid

Do NOT:

• Discharge patients with documented subdural hematomas based solely on normal neurological examination 2
• Administer long-acting sedatives or paralytics before neurosurgical evaluation, as this masks clinical deterioration 2
• Delay reversal while waiting for laboratory confirmation if clinical suspicion is high 3
• Use protamine for reversal of fondaparinux—it is ineffective 3
• Fail to maintain mean arterial pressure ≥80 mmHg to ensure adequate cerebral perfusion 2
• Unnecessarily withhold anticoagulation in patients with negative CT, as thromboembolic risk may outweigh delayed hemorrhage risk 5