How should I manage a 72‑year‑old man on chronic warfarin who sustained a wrist injury after a ground‑level fall, with no head injury, loss of consciousness, nausea, vomiting, or amnesia?

Management of 72-Year-Old Male on Warfarin with Wrist Injury After Ground-Level Fall

Obtain an immediate non-contrast head CT scan despite the absence of head injury symptoms, check INR and hemoglobin, and manage the wrist injury orthopedically without warfarin reversal unless active bleeding or urgent surgery is required. 1

Immediate Head Imaging is Mandatory

• Obtain a non-contrast head CT scan immediately, even though the patient denies head injury, loss of consciousness, nausea, vomiting, or amnesia. 2
• Warfarin increases the odds of intracranial hemorrhage by 40% after head trauma and doubles the risk of mortality in elderly patients. 1
• The risk of intracranial hemorrhage in anticoagulated patients after trauma is 10.2% compared to 1.5% in non-anticoagulated patients. 3
• Ground-level falls are the most common mechanism of traumatic intracranial hemorrhage in elderly patients on warfarin, with mortality rates reaching 50% when hemorrhage occurs. 4
• Age >65 years combined with warfarin and any head trauma creates a lethal triad that frequently produces fatal brain hemorrhage. 4

Laboratory Assessment

• Check INR, complete blood count with hemoglobin, platelet count, and creatinine immediately. 1
• Document the degree of coagulopathy on presentation, as bleeding risk increases with higher INR values. 1
• Obtain baseline labs to guide potential reversal decisions if hemorrhage is discovered. 1

Wrist Injury Management Without Reversal

Do NOT reverse warfarin for an isolated wrist injury unless there is major life-threatening bleeding, bleeding not responding to supportive measures, or urgent surgical intervention is required. 1

Criteria for Warfarin Reversal (None Apply to This Case):

• Major life-threatening bleeding 1
• Bleeding located in critical organs (central nervous system, abdominal, thoracic) 1
• Bleeding not responding to supportive measures 1
• Urgent surgical or invasive procedures requiring hemostasis 1

If Reversal Were Needed:

• Administer 4-factor prothrombin complex concentrate (4F-PCC) plus 5 mg intravenous vitamin K to achieve INR <1.5. 1
• Fresh frozen plasma should only be used if no other reversal agent is available. 1
• Do not use recombinant activated factor VII (rFVIIa) as first-line reversal. 1

Management Based on Head CT Results

If Head CT is Negative:

• Discharge the patient home with clear written instructions about signs of delayed hemorrhage (severe headache, confusion, vomiting, weakness, seizures, worsening drowsiness, slurred speech, vision changes). 3, 2
• Continue warfarin without interruption if the patient is neurologically intact with negative CT, as the risk of delayed intracranial hemorrhage requiring intervention is <1%. 2
• Arrange close observation by a responsible adult for the next 24 hours who can monitor continuously for warning signs. 3
• Do NOT perform routine repeat head CT in neurologically intact patients with negative initial CT, as the risk of deterioration is extremely low (0.006%). 2
• The risk of delayed intracranial hemorrhage is 0.6-6% for warfarin patients with negative initial CT, but rarely requires neurosurgical intervention. 3, 2

If Head CT Shows Intracranial Hemorrhage:

• Immediately administer 4F-PCC plus 5 mg intravenous vitamin K to achieve INR <1.5. 1
• Obtain immediate neurosurgical consultation. 3, 2
• Obtain repeat head CT within 24 hours, as anticoagulated patients have a 3-fold increased risk of hemorrhage expansion (26% versus 9%). 3, 2
• Perform immediate repeat CT for any neurological deterioration regardless of time since injury. 2
• Hold warfarin until cleared by neurosurgery. 3

Wrist Fracture Management

• Proceed with standard orthopedic evaluation and treatment (radiographs, splinting, orthopedic referral). 1
• If closed reduction or surgical fixation is required, assess the bleeding risk of the procedure. 1
• For low-bleeding risk procedures (closed reduction, splinting), warfarin can typically be continued. 1
• For high-bleeding risk procedures (open reduction internal fixation), warfarin should be stopped 5-6 days before surgery to allow INR to normalize, with bridging anticoagulation considered based on thromboembolic risk. 1

Trauma Activation Considerations

• Use lower threshold for trauma activation in geriatric patients: heart rate >90 bpm and systolic blood pressure <110 mmHg. 1
• Elderly patients on warfarin have blunted physiologic responses to injury due to medications like beta-blockers and age-related cardiovascular changes. 1
• Document the patient's polypharmacy profile, including beta-blockers, steroids, and other anticoagulants/antiplatelets. 1

Common Pitfalls to Avoid

• Do not skip head CT imaging based on absence of symptoms—warfarin dramatically increases occult hemorrhage risk even with minor mechanisms. 2, 4
• Do not routinely reverse warfarin for non-critical bleeding or minor procedures, as this increases thromboembolic risk without clear benefit. 1
• Do not perform unnecessary repeat imaging in stable patients with negative initial CT and normal neurological exam. 2
• Do not discontinue warfarin unnecessarily without considering the indication and thromboembolic risk. 3, 2
• Do not use fresh frozen plasma as first-line reversal when PCC is available, as FFP requires longer infusion time, ABO compatibility testing, and carries higher risk of volume overload and transfusion reactions. 1

Outpatient Follow-Up

• Arrange fall risk assessment to prevent future injuries. 3, 2
• Reassess the risk/benefit ratio of continued anticoagulation given fall risk. 3, 2
• Consider lower therapeutic INR targets (1.6-2.5) in frail elderly patients to reduce bleeding risk while maintaining approximately 80% of anticoagulation efficacy. 5
• Schedule INR monitoring within 1 week if warfarin dosing was adjusted. 1