In an elderly patient on warfarin who sustained a ground‑level fall with a normal Glasgow Coma Scale, no loss of consciousness, no vomiting and no obvious head injury, should an emergent non‑contrast head CT be performed?

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Last updated: February 11, 2026 • View editorial policy

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Head CT is Indicated for This Patient

An emergent non-contrast head CT should be performed in this elderly patient on warfarin who sustained a ground-level fall, even with a normal GCS of 15, no loss of consciousness, no vomiting, and no apparent head injury. 1, 2

Rationale for Imaging

Warfarin Creates High-Risk Status

  • Warfarin use is an independent indication for head CT in elderly patients with head trauma, regardless of mechanism or symptoms. 1, 2
  • Anticoagulated patients have a 3.9% risk of significant intracranial injury versus 1.5% in non-anticoagulated patients (2.6-fold increased risk). 2, 3
  • Warfarin carries the highest hemorrhage risk among oral anticoagulants at 10.2%, compared to 2.6% for direct oral anticoagulants. 2, 3
  • Among anticoagulated patients with minor head injuries and GCS of 15, 29% had intracranial hemorrhage. 2

Guideline-Based Recommendations

  • The American College of Emergency Physicians Level B recommendation explicitly states: "A noncontrast head CT should be considered in head trauma patients with no loss of consciousness or posttraumatic amnesia if there is coagulopathy." 1
  • The American College of Emergency Physicians further recommends that all elderly patients (≥65 years) who fall and hit their head require immediate non-contrast head CT imaging, with even lower thresholds for those on anticoagulants. 2
  • Coagulopathy is listed as a specific indication for CT imaging in multiple clinical decision rules including the NICE guidelines and NCWFNS criteria. 1

Clinical Context for Elderly Ground-Level Falls

  • 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. 2
  • Elderly patients sustain serious intracranial injuries even with low-energy mechanisms that would not injure younger patients. 2
  • The overall prevalence of traumatic intracranial hemorrhage in elderly patients with ground-level fall-related head injury is 6.8%, with 8.0% of those requiring urgent neurosurgical intervention. 4

Management After Negative Initial CT

Safe Discharge Criteria

  • If the initial CT is negative and the patient remains neurologically intact (GCS 15, no focal deficits), the patient can be safely discharged without repeat imaging or prolonged observation. 2, 3
  • The risk of delayed intracranial hemorrhage requiring intervention after a negative CT is extremely low (<1%) in neurologically intact patients. 2, 3
  • 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. 2

Anticoagulation Management

  • 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. 2, 3
  • The decision to continue warfarin must balance the indication for anticoagulation (e.g., atrial fibrillation, mechanical valve) against the individual's fall risk. 3

Discharge Instructions

Provide clear written discharge instructions that include:

  • Warning signs of delayed hemorrhage (severe headache, vomiting, confusion, weakness, seizure) requiring immediate return to the ED or calling 911. 2
  • Arrangement for responsible adult observation at home. 2
  • Outpatient referral for fall risk assessment to prevent future injuries. 2
  • Reassessment of anticoagulation risk/benefit ratio with the patient's primary care provider or cardiologist. 2

Common Pitfalls to Avoid

  • Do not withhold CT based on "minor mechanism"—mechanism severity does not predict intracranial injury in anticoagulated elderly patients. 2
  • Do not assume that absence of symptoms (no LOC, no vomiting, normal GCS) eliminates the need for imaging in anticoagulated patients. 1, 2
  • Avoid routine repeat head CT in stable patients with an initially negative scan, as it adds cost and radiation without improving outcomes. 1, 2

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Guideline

Management of Elderly Patients Who Fall and Hit Their Head

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

3
Guideline

Evaluation of Head Injury in Anticoagulated Patients

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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