According to the CEP guidelines, does an elderly patient (≥65) on warfarin who sustains a ground‑level fall without obvious head injury require an immediate non‑contrast head CT?

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

All elderly patients (≥65 years) on warfarin who sustain a ground-level fall require immediate non-contrast head CT imaging, regardless of whether there is obvious head injury, loss of consciousness, or any symptoms. 1, 2

Rationale for Universal Imaging

The American College of Emergency Physicians provides explicit guidance that warfarin use constitutes a Level A recommendation for head CT when loss of consciousness or post-traumatic amnesia is present, and a Level B recommendation even without loss of consciousness or amnesia when combined with age ≥65 years. 1

Key Risk Statistics

• Warfarin dramatically increases mortality risk: Elderly patients on warfarin with intracranial injury have a 48% mortality rate compared to 10% in non-anticoagulated patients with similar head injuries—nearly a 5-fold increase. 3

• High rate of intracranial hemorrhage despite minor mechanisms: 27% of warfarin patients with any head trauma develop documented intracranial injury, and this occurs even with ground-level falls. 3

• Warfarin carries the highest hemorrhage risk among anticoagulants: 10.2% incidence of intracranial hemorrhage with warfarin versus 2.6% with direct oral anticoagulants. 2

• Loss of consciousness is not required for lethal injury: Two patients in one series died from isolated intracranial injury despite having no documented loss of consciousness. 3

Clinical Decision Algorithm

Step 1: Identify the patient

• Age ≥65 years + warfarin use + ground-level fall = Obtain head CT immediately 1, 2

Step 2: Do NOT rely on mechanism severity

• Ground-level falls are sufficient mechanisms for lethal intracranial hemorrhage in anticoagulated elderly patients 2, 4
• The "minor mechanism" does not predict safety in this population 2

Step 3: Do NOT wait for symptoms

• Absence of headache, vomiting, altered mental status, or focal deficits does NOT exclude significant intracranial injury 3
• Coagulopathy itself is an independent indication for imaging per ACEP guidelines 1

Management Based on Initial CT Results

If CT Shows Intracranial Hemorrhage:

• Immediately reverse anticoagulation: Administer 4-factor prothrombin complex concentrate to achieve INR <1.5, plus 5 mg intravenous vitamin K simultaneously 2

• Obtain urgent neurosurgical consultation 2

• Plan repeat head CT within 24 hours: Anticoagulated patients have a 3-fold increased risk of hemorrhage expansion (26% vs 9%) 2, 5

If CT is Negative:

• Neurologically intact patients can be safely discharged without repeat imaging or prolonged observation 2

• Risk of delayed hemorrhage requiring intervention is <1% in this scenario 2

• Do NOT routinely discontinue warfarin after a negative CT, as thromboembolic risk may outweigh the small risk of delayed hemorrhage 2, 5

Discharge Instructions (When CT is Negative)

Provide explicit written and verbal instructions including:

• Warning signs of delayed hemorrhage: Severe headache, vomiting, confusion, weakness, seizure 2, 6

• Clear action plan: Call 911 immediately if any warning signs develop 2

• Outpatient referrals: Fall-risk assessment and re-evaluation of anticoagulation risk-benefit ratio 2, 6

Common Pitfalls to Avoid

• Do NOT defer imaging based on "normal exam": A normal neurologic examination does not exclude intracranial injury in anticoagulated elderly patients 6, 3

• Do NOT use younger-patient thresholds: Age >60-65 years is itself a high-risk criterion that lowers the threshold for imaging 1, 6

• Do NOT obtain routine repeat CT in stable patients with negative initial scan: This adds unnecessary cost and radiation without improving outcomes 2, 5

• Do NOT assume aspirin-only patients are low-risk: While aspirin monotherapy has lower risk than warfarin, elderly patients (≥65 years) with high-risk features still warrant imaging 6, 5