What is the appropriate management for an elderly patient on Xarelto (rivaroxaban) who has experienced a ground level fall?

Sample HPI for Ground-Level Fall on Xarelto

For an elderly patient on Xarelto (rivaroxaban) presenting after a ground-level fall, document a comprehensive trauma-focused history that prioritizes detection of occult injuries and bleeding risk, as these patients face up to 7% mortality and require heightened suspicion for intracranial hemorrhage even without classic signs. 1

Essential Historical Elements to Document

Mechanism and Timing:

• Exact circumstances of the fall (location, witnessed vs. unwitnessed, any prodrome) 1
• Time spent on floor/ground before discovery 1
• Any loss of consciousness or altered mental status during or after fall 1
• Presence of syncope, near-syncope, or orthostatic symptoms preceding fall 1

Anticoagulation Details:

• Last dose of Xarelto taken (timing critical - rivaroxaban has rapid onset) 2
• Current dosing regimen (10 mg, 15 mg, or 20 mg daily) 2
• Indication for anticoagulation (atrial fibrillation, VTE prophylaxis, etc.) 2
• Duration of therapy and adherence 1
• Renal function status if known (CrCl affects rivaroxaban levels significantly) 2

Injury Assessment:

• Any head strike or direct trauma to head/neck 1
• Complaints of headache, neck pain, or neurological symptoms 1
• Presence of visible injuries, bruising, or deformities 1
• Any bleeding (external or suspected internal - melena, hematemesis) 1

Fall Risk Factors:

• Number of prior falls in past year 1
• Gait or balance difficulties 1
• Visual impairments or peripheral neuropathies 1
• Footwear at time of fall 1

Comorbidities:

• Specific high-risk conditions: dementia, Parkinson's disease, prior stroke, diabetes, depression 1
• Cardiac history including atrial fibrillation/flutter (calculate CHA2DS2-VASc score if applicable) 3
• Renal impairment (critical for rivaroxaban metabolism) 2

Medication Review:

• Complete medication list with attention to polypharmacy 1
• Other antiplatelet agents (aspirin, clopidogrel) - combination increases bleeding risk 4, 5
• High-risk medications: vasodilators, diuretics, antipsychotics, sedative/hypnotics 1
• P-glycoprotein or CYP3A4 inhibitors that affect rivaroxaban levels 2
• Alcohol use 1

Functional Status:

• Baseline activities of daily living 1
• Living situation and safety of home environment 1

Critical Clinical Context

Ground-level falls in elderly patients on Xarelto warrant aggressive evaluation because:

• 6% will sustain fractures, 10-30% may have polytrauma despite seemingly minor mechanism 1
• Traumatic intracranial hemorrhage occurs in 1.7-4.3% of anticoagulated patients with ground-level falls 4, 5
• Injuries may be "occult" without classic signs - high-risk injuries include blunt head trauma, spinal fractures, hip fractures 1
• Mortality in this population reaches 7% even with ground-level falls 1

Key pitfall to avoid: Research shows antiplatelet therapy (aspirin) may confer equal or higher risk of traumatic intracranial hemorrhage compared to anticoagulation in ground-level falls, contrary to traditional teaching 4, 5. Document all antiplatelet agents, not just anticoagulants.

Documentation should answer: "If this patient was a healthy 20-year-old, would they have fallen?" If no, the fall represents a sentinel event requiring comprehensive evaluation beyond trauma assessment 1