How should I assess and treat a superficial scalp bleed in an elderly patient after a head injury who may be on anticoagulant therapy?

Assessment and Management of Superficial Scalp Bleeding in Elderly Head Injury Patients

Immediate Assessment Priority

All elderly patients (≥65 years) who fall and hit their head require immediate non-contrast head CT imaging, regardless of whether the scalp bleeding appears superficial or the mechanism seems minor, with an even lower threshold for those on anticoagulants or antiplatelet medications. 1

Why Superficial Bleeding Doesn't Rule Out Serious Injury

• Ground-level falls account for 34.6% of all trauma deaths in patients ≥65 years, with elderly patients sustaining serious intracranial injuries even from low-energy mechanisms that would not injure younger patients 1
• The presence of external scalp bleeding does not predict the presence or absence of intracranial hemorrhage—these are independent findings 2
• Anticoagulated patients have a 3.9% risk of significant intracranial injury versus 1.5% in non-anticoagulated patients, making CT mandatory regardless of external injury appearance 1, 3

Critical History Elements to Obtain

While preparing for CT imaging, rapidly obtain:

• Complete medication list: Specifically identify warfarin, DOACs (apixaban, rivaroxaban, dabigatran), clopidogrel, aspirin, or multiple agents—warfarin carries 10.2% risk of intracranial hemorrhage versus 2.6% for DOACs 3, 4
• Loss of consciousness or post-traumatic amnesia: This increases risk substantially and was associated with 21.9% intracranial bleeding rate in one study 5
• Time spent on ground: Indicates potential prolonged hypoperfusion 1
• Vital signs with elderly-specific thresholds: Systolic BP <110 mmHg represents shock in elderly patients; heart rate >90 bpm is abnormal (lower thresholds than younger patients) 2

Local Wound Management

While awaiting imaging:

• Apply direct pressure to control superficial scalp bleeding—scalp wounds are highly vascular but respond well to pressure 2
• Avoid aggressive fluid resuscitation that could worsen intracranial bleeding if present; maintain mean arterial pressure ≥80 mmHg in suspected traumatic brain injury 2
• Do NOT delay CT imaging to complete wound closure 1

Management Based on CT Results

If CT Shows Intracranial Hemorrhage:

Immediately discontinue all anticoagulants and antiplatelet agents and obtain urgent neurosurgical consultation 1, 4

Reversal protocols:

• For warfarin: Administer 4-factor prothrombin complex concentrate (4F-PCC) plus 5 mg intravenous vitamin K simultaneously to achieve INR <1.5; recheck INR after reversal 2
• For apixaban or rivaroxaban: Administer andexanet alfa; if unavailable, give 2000 units of 4F-PCC 2
• For dabigatran: Administer idarucizumab 5 g IV; if unavailable, give 50 units/kg activated PCC 2
• Obtain repeat head CT within 24 hours because anticoagulated patients have 3-fold increased risk of hemorrhage expansion 4

If CT is Negative and Patient is Neurologically Intact:

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

• The risk of delayed intracranial hemorrhage requiring intervention after negative CT is extremely low (<1%) 1
• In a prospective cohort of 178 anticoagulated patients with negative initial CT, only 1.7% developed delayed ICH within 30 days; none required neurosurgery 1
• Do NOT routinely discontinue anticoagulation after negative CT, as thromboembolic risk may outweigh the small risk of delayed hemorrhage 2, 4

High-Risk Features Requiring Brief Observation

Consider 4-6 hour observation before discharge for patients with:

• Age >80 years 3, 4
• History of loss of consciousness or amnesia 3, 4
• Glasgow Coma Scale <15 3, 4
• Concomitant use of multiple anticoagulant/antiplatelet agents 3, 4
• INR >3.0 (14-fold increased risk of delayed hemorrhage) 6

Discharge Instructions (Mandatory Components)

Provide clear written instructions including:

• Warning signs of delayed hemorrhage: Severe headache, vomiting, confusion, weakness, seizures—instruct patient to call 911 immediately if these develop 1, 4
• Outpatient referral for fall risk assessment 1, 4
• Reassessment of anticoagulation risk/benefit ratio with primary care physician or cardiologist 1, 4
• Wound care instructions for scalp laceration if present 2

Common Pitfalls to Avoid

• Do NOT withhold CT based on "minor mechanism" or superficial appearance—mechanism severity does not predict intracranial injury in anticoagulated elderly patients 1, 4
• Do NOT routinely admit for repeat CT in stable patients with initially negative scan—this adds cost and healthcare-associated complications without improving outcomes 2, 1
• Do NOT assume antiplatelet agents like clopidogrel are safer than anticoagulants—clopidogrel carries dramatically higher mortality rates (OR=14.7) 1, 4
• Do NOT focus solely on the scalp wound and miss the need for neuroimaging—external injury does not correlate with intracranial injury 2, 1