What is the recommended workup for an elderly male on warfarin after a ground‑level fall without head injury or loss of consciousness?

Recommended Workup for Elderly Male on Warfarin After Ground-Level Fall Without Head Injury or Loss of Consciousness

Obtain an immediate non-contrast head CT scan regardless of the absence of symptoms, because warfarin increases the risk of occult intracranial hemorrhage by 40% and doubles mortality risk in elderly patients after head trauma. 1

Immediate Imaging

• Perform head CT immediately in any patient ≥65 years on warfarin after any fall, even when the patient denies head injury symptoms or loss of consciousness. 1
• The absence of symptoms does not exclude intracranial hemorrhage in anticoagulated elderly patients—occult bleeding is a significant risk that cannot be ruled out clinically. 1
• Warfarin-associated head trauma carries a 50% mortality rate compared to non-anticoagulated patients with similar injuries. 2

Laboratory Assessment at Presentation

• Draw INR, complete blood count (hemoglobin), platelet count, and serum creatinine immediately upon arrival to quantify the degree of coagulopathy. 1
• Higher INR values correlate proportionally with greater bleeding risk and guide potential reversal decisions. 1
• Document all concurrent medications, particularly beta-blockers, antiplatelets, and other anticoagulants that may mask physiologic responses or compound bleeding risk. 1

Trauma Activation Criteria

• Activate trauma response if heart rate >90 bpm or systolic blood pressure <110 mmHg in patients ≥65 years on warfarin. 1
• Recognize that beta-blockers and age-related cardiovascular changes blunt tachycardia and hypotension, potentially masking the severity of occult bleeding. 1

Management When Head CT Is Negative

• Discharge the patient with written instructions detailing warning signs of delayed hemorrhage: severe headache, confusion, vomiting, weakness, seizures, worsening drowsiness, slurred speech, or visual changes. 1
• Continue warfarin without interruption because the risk of delayed intracranial hemorrhage requiring intervention is <1% in neurologically intact patients with a negative scan. 1
• Arrange for a responsible adult to observe the patient for 24 hours for any new neurological symptoms. 1
• Do not obtain routine repeat head CT in stable patients—the incidence of clinically significant delayed deterioration is 0.006%. 1
• Overall delayed hemorrhage rates after negative CT in warfarin users range from 0.6–6%, but most do not require neurosurgical intervention. 1

Management When Head CT Shows Intracranial Hemorrhage

• Immediately administer 4-factor prothrombin complex concentrate (4F-PCC) plus 5 mg intravenous vitamin K to achieve target INR <1.5. 1, 3
• Do not wait for INR results before giving PCC—administer as soon as ICH is diagnosed, with dosing based on body weight (25–50 IU/kg for INR ≥2.0). 3
• Obtain emergent neurosurgical consultation. 1
• Perform a repeat head CT within 24 hours because anticoagulated patients have a 3-fold higher risk of hematoma expansion (26% vs 9% in non-anticoagulated patients). 1
• Any neurological decline warrants immediate repeat CT regardless of elapsed time. 1
• Hold warfarin until clearance by the neurosurgical team. 1
• Fresh-frozen plasma should be reserved only when PCC is unavailable due to longer infusion time, ABO compatibility requirements, and higher volume-overload risk. 1, 3
• Avoid recombinant activated factor VIIa as first-line therapy due to increased thromboembolic risk, especially in elderly patients. 3

Warfarin Reversal Decision-Making

• Do not reverse warfarin for isolated minor injuries (e.g., wrist fracture) unless one of the following is present: 1
  • Major life-threatening bleeding
  • Bleeding in a critical organ (central nervous system, intra-abdominal, thoracic)
  • Bleeding unresponsive to supportive measures
  • Urgent surgical/invasive procedure requiring hemostasis
• Routine reversal for minor bleeding raises thromboembolic risk without clear benefit. 1

Outpatient Follow-Up and Secondary Prevention

• Perform a fall-risk assessment to identify modifiable hazards (home environment, gait instability, polypharmacy, orthostatic hypotension) and implement preventive strategies. 1
• Re-evaluate the risk-benefit balance of continued anticoagulation in light of the recent fall. 1
• In frail elderly patients, consider a lower therapeutic INR target of 1.6–2.5, which maintains approximately 80% of anticoagulant efficacy while reducing bleeding risk. 1, 2
• Schedule INR monitoring within 1 week if any warfarin dose adjustment was made. 1
• Recognize that many elderly patients at high risk for stroke may not be optimal candidates for standard-intensity anticoagulation, and falling is the most common physician-cited reason for withholding warfarin in patients ≥80 years. 4

Common Pitfalls to Avoid

• Do not forgo head CT based on absent symptoms—occult hemorrhage risk is markedly increased by warfarin even without overt head trauma. 1
• Do not routinely reverse warfarin for minor bleeding or low-risk procedures, as this raises thromboembolic risk without clear benefit. 1
• Do not obtain repeat head CT in neurologically stable patients with an initial negative scan—the likelihood of clinically relevant change is negligible. 1
• Do not discontinue warfarin without weighing the indication (e.g., mechanical mitral valve, recent venous thromboembolism, atrial fibrillation with prior stroke) and individual thromboembolic risk. 1