What is the recommended course of action for an elderly patient who has fallen and hit their head, potentially taking anticoagulant medications such as warfarin (coumadin), aspirin, or clopidogrel (plavix)?

Management of Elderly Patients Who Fall and Hit Their Head

All elderly patients (≥65 years) who fall and hit their head require immediate non-contrast head CT imaging, regardless of symptom severity or mechanism of injury, with even lower thresholds for those on anticoagulants or antiplatelet medications. 1, 2, 3

Immediate Assessment and Imaging

Obtain an immediate non-contrast head CT scan for all elderly patients with head trauma. 2, 3 The evidence is unequivocal:

• Ground-level falls account for 34.6% of all trauma deaths in patients ≥65 years, with significantly higher rates of intracranial injury and mortality compared to younger patients 1
• Elderly patients sustain serious intracranial injuries even with low-energy mechanisms that would not injure younger patients 1, 4
• Among 3,659 elderly head trauma patients, 8.9% sustained significant injuries, and 14.8% of these had occult presentations with no high-risk clinical criteria beyond age 4

For patients on anticoagulants or antiplatelet medications (warfarin, apixaban, rivaroxaban, dabigatran, clopidogrel, aspirin), the threshold for CT imaging is even lower—essentially zero. 1, 2, 3

• Anticoagulated patients have a 3.9% risk of significant intracranial injury versus 1.5% in non-anticoagulated patients 2, 3
• Among anticoagulated patients with minor head injuries and GCS of 15,29% had intracranial hemorrhage 1
• Patients on clopidogrel have dramatically higher mortality rates (OR = 14.7) and are more likely to require long-term facility care (OR = 3.25) 1

Critical History Elements

Document the following specific factors that increase risk:

• Medication review: Identify use of warfarin, DOACs (apixaban, rivaroxaban, dabigatran), antiplatelet agents (clopidogrel, aspirin), or multiple agents 1
• Loss of consciousness or post-traumatic amnesia 1, 2
• Time spent on floor or ground (indicates potential for prolonged hypoperfusion) 1
• Systolic blood pressure <110 mmHg (represents shock in elderly patients) 1
• Heart rate >90 bpm (lower threshold than younger patients) 1
• Presence of headache or vomiting 2
• Any alteration in mental status (GCS <15) 1, 2

Management Based on Initial CT Results

If Initial CT Shows Intracranial Hemorrhage:

Immediately discontinue all anticoagulants and antiplatelet agents and obtain urgent neurosurgical consultation. 5, 3

For warfarin reversal: 1, 5, 3

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

For apixaban or rivaroxaban (factor Xa inhibitors): 1, 5, 3

• Administer andexanet alfa (400 mg IV bolus over 15 minutes followed by 480 mg infusion over 2 hours for low dose, or 800 mg bolus over 30 minutes followed by 960 mg over 2 hours for high dose)
• If andexanet alfa unavailable, give 2000 units of 4-factor PCC

For dabigatran (direct thrombin inhibitor): 1

• Administer idarucizumab 5 g IV
• If unavailable, give 50 units/kg of activated PCC

Obtain repeat head CT within 24 hours because anticoagulated patients have a 3-fold increased risk of hemorrhage expansion (26% versus 9% in non-anticoagulated patients). 2, 5, 3

If Initial CT is Negative:

Neurologically intact patients with negative initial CT can be safely discharged without routine repeat imaging or admission. 2, 3 The evidence strongly supports this approach:

• Risk of delayed intracranial hemorrhage requiring intervention is <1% 3
• Among patients on NOACs with negative initial CT, only 1.5% developed delayed ICH on repeat scanning, and none required neurosurgical intervention or died 3
• The American College of Emergency Physicians provides Level B recommendation against routine repeat imaging or admission in this population 2, 3

Consider brief observation (4-6 hours) before discharge for patients with high-risk features: 2, 3

• Age >80 years
• History of loss of consciousness or amnesia
• GCS <15
• Concomitant use of multiple anticoagulant/antiplatelet agents

Discharge Instructions and Follow-Up

Provide clear written discharge instructions that include: 2, 5, 3

• Signs of delayed hemorrhage: severe headache, confusion, vomiting, weakness, seizures
• Instructions to return immediately or call 911 if these symptoms develop
• Outpatient referral for fall risk assessment
• Reassessment of anticoagulation risk/benefit ratio

Do not routinely discontinue anticoagulation after negative initial CT in neurologically intact patients, as thromboembolic risk may outweigh the small risk of delayed hemorrhage. 2, 3

Common Pitfalls to Avoid

• Failing to obtain initial CT imaging in elderly patients after ground-level falls, assuming the mechanism is "too minor" to cause injury 1, 3, 4
• Underestimating injury risk in anticoagulated patients with seemingly minor trauma 1, 2, 3
• Unnecessarily admitting patients with negative initial CT for repeat imaging, which increases costs and healthcare-associated complications without improving outcomes 2, 3
• Discontinuing anticoagulation without considering the indication, as thromboembolic risk may be higher than delayed hemorrhage risk 2, 3
• Using normal vital signs to rule out serious injury, as 42% of elderly patients with serious injuries have "normal" vital signs by standard criteria 1
• Failing to recognize that elderly patients require lower threshold vital sign criteria: SBP <110 mmHg (not <90) and HR >90 bpm (not >120) 1