In an elderly patient on warfarin who sustained a ground‑level fall without obvious head injury and has a normal Glasgow Coma Scale, should an emergent non‑contrast head CT be performed?

Head CT Imaging for Elderly Warfarin Patients After Ground-Level Falls

All elderly patients on warfarin who sustain a ground-level fall require emergent non-contrast head CT imaging, regardless of the absence of obvious head injury or a normal Glasgow Coma Scale score of 15. 1, 2

Rationale for Mandatory Imaging

The American College of Emergency Physicians explicitly recommends immediate head CT for all elderly patients (≥65 years) on anticoagulants who fall and hit their head, with even lower thresholds for imaging when anticoagulation is present. 1 This recommendation is driven by several critical risk factors:

• Warfarin carries the highest hemorrhage risk among oral anticoagulants, with a 10.2% incidence of intracranial hemorrhage compared to 2.6% for direct oral anticoagulants. 1

• Anticoagulated patients have a 3.9% risk of significant intracranial injury versus 1.5% in non-anticoagulated patients—more than doubling the baseline risk. 1, 2

• Among warfarin users with minor head injuries and GCS of 15, 29% had intracranial hemorrhage on initial CT. 1

• Mortality rates are dramatically elevated: in one study of warfarin patients with intracranial injury after head trauma, the mortality rate reached 48%, compared to only 10% in age-matched non-anticoagulated patients with similar injuries. 3

• Mechanism severity does not predict injury in anticoagulated elderly patients—ground-level falls account for 34.6% of all trauma deaths in patients ≥65 years. 1

Management Based on Initial CT Results

If Initial CT is Negative (No Hemorrhage)

Neurologically intact patients with a negative initial head CT can be safely discharged without repeat imaging or prolonged observation. 4, 1, 2

• The risk of delayed intracranial hemorrhage requiring neurosurgical intervention after a negative CT is extremely low (<1%). 1

• In a prospective cohort of 178 anticoagulated patients with an initial negative CT, only 3 patients (1.7%) developed delayed ICH within 30 days; none required neurosurgery and there was a single death. 4

• Do not routinely discontinue warfarin after a negative initial CT in neurologically intact patients, as thromboembolic risk may outweigh the small risk of delayed hemorrhage. 1, 2

• Consider brief observation (4-6 hours) before discharge only for patients with high-risk features: age >80 years, history of loss of consciousness or amnesia, or GCS <15. 1, 2

If Initial CT Shows Intracranial Hemorrhage

Immediately discontinue warfarin and obtain urgent neurosurgical consultation. 1, 2

• Administer 4-factor prothrombin complex concentrate (4F-PCC) to achieve INR <1.5, which is the first-line reversal agent with a strong recommendation over fresh frozen plasma. 2

• Give 5 mg intravenous vitamin K simultaneously to sustain INR normalization after PCC infusion. 1, 2

• Recheck INR after reversal to confirm adequacy of correction. 1

• 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). 1, 2

Discharge Instructions for Negative CT

Provide clear written discharge instructions that include:

• Warning signs of delayed hemorrhage: severe headache, vomiting, confusion, weakness, or seizure—advise patients to call 911 immediately if these develop. 1, 2

• Outpatient referral for fall risk assessment to prevent future injuries. 1, 2

• Reassessment of anticoagulation risk/benefit ratio in consultation with the patient's primary care provider or cardiologist. 1, 2

Common Pitfalls to Avoid

• Do not withhold CT based on "minor mechanism"—mechanism severity does not predict intracranial injury in anticoagulated elderly patients. 1

• Avoid routine repeat head CT in stable patients with an initially negative scan, as it adds cost and radiation without improving outcomes. 4, 1

• Do not routinely discontinue warfarin without considering thromboembolic risk (e.g., atrial fibrillation, mechanical valve, prior thromboembolism)—the indication for anticoagulation must be balanced against fall risk. 2

• Do not assume absence of loss of consciousness reliably indicates absence of intracranial injury—in one study, 2 of 12 warfarin patients who died from intracranial injury had no documented loss of consciousness. 3