How to Order a STAT Non-Contrast Head CT for This Patient
Order an immediate STAT non-contrast head CT without delay—this 70-year-old male on warfarin with GCS 8 after motor vehicle collision meets multiple absolute indications for emergent imaging. 1, 2
Ordering the CT Scan
Specify the Following on Your Order:
- Study type: Non-contrast head CT (NCCT head) 3
- Priority: STAT/Emergent 1, 2
- Clinical indication: "70-year-old male on warfarin, GCS 8, s/p motor vehicle collision—concern for traumatic intracranial hemorrhage" 1, 2
- Request multiplanar reformatted images (coronal and sagittal reconstructions), as these increase diagnostic accuracy and affect acute management decisions 4
Why This Patient Requires Immediate Imaging:
This patient meets multiple high-risk criteria that independently mandate emergent head CT:
- GCS <15 (patient has GCS 8)—this alone is an absolute indication 3, 1
- Anticoagulation with warfarin—increases risk of significant intracranial injury from 1.5% to 3.9%, with warfarin carrying the highest hemorrhage risk among oral anticoagulants (10.2% incidence) 1, 2, 5
- Age >65 years—elderly patients sustain serious intracranial injuries even with low-energy mechanisms 1, 2
- High-energy mechanism (motor vehicle collision)—dangerous mechanism of injury is an independent indication 1
The American College of Radiology rates non-contrast head CT as "usually appropriate" (rating 9/9) for acute head trauma with these features. 3
Critical Management Steps While Awaiting CT Results:
- Check INR immediately upon arrival—warfarin patients with INR ≥2.0 have dramatically higher rates of intracranial hemorrhage 6
- Establish large-bore IV access for potential reversal agents 2, 7
- Have fresh frozen plasma (FFP) or 4-factor prothrombin complex concentrate (4F-PCC) readily available at bedside before CT results return 2, 7
- Alert neurosurgery given the combination of severe head injury (GCS 8) and anticoagulation 2, 7
If CT Shows Intracranial Hemorrhage:
Immediately reverse anticoagulation with the following protocol 2, 7:
- Administer 4-factor prothrombin complex concentrate to achieve INR <1.5 2
- Give 5 mg intravenous vitamin K simultaneously 2
- Recheck INR after reversal to confirm adequacy 2
- Do not wait for INR results before starting reversal—rapid reversal (within 1.9 hours) reduces hemorrhage progression from 40% to near zero and decreases mortality from 48% to 10% 7
Follow-Up Imaging Protocol:
- Obtain repeat head CT within 24 hours if initial CT shows any hemorrhage, as anticoagulated patients have a 3-fold increased risk of hemorrhage expansion (26% vs 9%) 1, 4, 2
- Obtain immediate repeat CT for any neurological deterioration regardless of time since initial scan 4
Common Pitfalls to Avoid:
- Never delay CT imaging to "stabilize" the patient first—diagnosis of intracranial hemorrhage is time-critical in anticoagulated patients 2, 7
- Do not rely on mechanism severity—anticoagulated elderly patients develop life-threatening hemorrhages even after ground-level falls 2, 5
- Never wait for INR results before ordering the CT—imaging should proceed immediately 1, 2
- Do not assume normal initial vital signs exclude serious injury—71% of anticoagulated patients who died from traumatic intracranial hemorrhage initially presented with GCS ≥14 and "minor" appearing injuries 5, 7