How should an elderly patient on chronic warfarin who sustained a ground‑level fall without obvious head injury be managed?

Management of Elderly Patients on Warfarin After Ground-Level Fall Without Obvious Head Injury

All elderly patients on warfarin who sustain a ground-level fall require immediate non-contrast head CT regardless of the absence of obvious head injury or symptoms, as warfarin increases the risk of intracranial hemorrhage by 40% and doubles mortality risk even after seemingly minor trauma. 1

Immediate Diagnostic Evaluation

Mandatory Imaging

• Obtain immediate non-contrast head CT in all anticoagulated patients with head trauma, regardless of mechanism severity, presence of symptoms, or Glasgow Coma Scale score. 1, 2
• Warfarin-anticoagulated patients have a 10.2% risk of intracranial hemorrhage after head trauma compared to 2.6% with NOACs and 1.5% in non-anticoagulated patients. 1
• The American College of Emergency Physicians provides Level B recommendation that all patients on anticoagulants require head CT after any head trauma. 1

Laboratory Assessment

• Check INR, PT, aPTT, and fibrinogen levels immediately upon presentation. 3
• The degree of coagulopathy (INR level) correlates with bleeding risk and guides reversal strategy. 4

Management Based on Initial CT Results

If CT Shows Intracranial Hemorrhage

Immediately discontinue warfarin and initiate urgent reversal with 4-factor prothrombin complex concentrate (4F-PCC) plus 5mg intravenous vitamin K to achieve INR <1.5. 4, 3

Reversal Protocol

• Administer 4F-PCC as first-line agent (strong recommendation over FFP). 4
• Give 5mg intravenous vitamin K concurrently. 4, 3
• PCC achieves INR reversal below 1.5 in 81% of patients within 8 hours, compared to only 29% with FFP. 5
• Recheck INR after reversal agents are administered to confirm adequate reversal (target INR <1.5). 3
• Use FFP only if PCC is unavailable (strong recommendation based on moderate quality evidence). 4
• Do NOT use recombinant factor VIIa as first-line reversal agent. 4

Additional Hemorrhage Management

• Consider tranexamic acid 1g IV over 10 minutes if treatment can be given within 3 hours of injury onset (reduces head injury-related death with risk ratio 0.78). 3, 1
• Obtain immediate neurosurgical consultation for all confirmed intracranial hemorrhages. 3, 1
• Obtain repeat head CT within 24 hours, as anticoagulated patients have 3-fold increased risk of hemorrhage expansion (26% versus 9% in non-anticoagulated patients). 3, 1, 2

If Initial CT is Negative

Neurologically intact patients (GCS 15, no loss of consciousness, no post-traumatic amnesia) with negative initial CT can be safely discharged without repeat imaging or observation. 1, 2

Discharge Criteria

• Patient must be at baseline neurologic examination. 1
• Glasgow Coma Scale score must be 15. 1
• No loss of consciousness or post-traumatic amnesia. 1
• Risk of delayed intracranial hemorrhage requiring intervention after negative initial CT is extremely low (<1%). 1, 2

Anticoagulation Management After Negative CT

• Do NOT routinely discontinue warfarin after negative initial CT in neurologically intact patients, as thromboembolic risk may outweigh the small risk of delayed hemorrhage. 1, 2
• The indication for anticoagulation (atrial fibrillation, mechanical valve, prior thromboembolism) must be weighed against fall risk. 4

Discharge Instructions

• Provide written discharge instructions including warning signs requiring immediate return (severe headache, vomiting, confusion, weakness, seizure). 1, 2
• Arrange for responsible adult observation at home. 1
• Schedule outpatient follow-up for fall risk assessment and reassessment of anticoagulation risk/benefit ratio. 3, 1

Special Considerations for High-Risk Elderly

Consider Brief Observation (4-6 Hours) If:

• Age >80 years with loss of consciousness or amnesia. 1
• Any alteration in mental status even if transient. 2
• Multiple falls or high fall risk. 1

Monitoring During Observation

• Document half-hourly neurologic checks until stable. 3
• Any neurological deterioration requires immediate repeat CT imaging. 3, 2

Common Pitfalls to Avoid

• Do NOT delay head CT based on absence of symptoms or minor mechanism—warfarin increases ICH risk even with ground-level falls. 1, 6
• Do NOT use FFP as first-line reversal when PCC is available—PCC is faster, requires smaller volume, and achieves better INR correction. 4, 5
• Do NOT delay reversal while waiting for laboratory confirmation if clinical suspicion for hemorrhage is high. 3
• Do NOT unnecessarily discontinue warfarin after negative CT without considering thromboembolic risk—the risk of stroke or thromboembolism may exceed the minimal risk of delayed hemorrhage. 1, 2
• Do NOT perform routine repeat imaging in stable patients with negative initial CT—this increases costs and radiation exposure without benefit. 1, 2

Prognostic Information

• Mortality in anticoagulated elderly with traumatic intracranial hemorrhage ranges from 50-91% depending on initial GCS and INR level. 6, 7
• Patients with initial GCS 13-15 can deteriorate rapidly within hours despite normal initial CT, emphasizing need for close monitoring if admitted. 7
• Warfarin use is associated with 75% unfavorable outcomes (death or severe disability) in elderly with fall-induced traumatic intracranial hemorrhage, compared to 27% in non-anticoagulated patients. 8