The Anticoagulated Head Injury on a Night Shift
A 74-year-old man on warfarin for atrial fibrillation (last INR 2.8 three weeks ago) is brought in after a ground-level fall at 21:00, striking the back of his head. He has a 3 cm occipital hematoma, one episode of vomiting, and a brief loss of consciousness witnessed by his wife. GCS is 15, pupils equal, no focal deficit. BP 158/88, HR 82. He takes warfarin, amiodarone, and metoprolol. The CT scanner is available, but the on-call radiologist is off-site and reads are delayed by 30–40 minutes; the tech can scan immediately. The nearest neurosurgical center is 90 minutes by road; there is no on-site neurosurgery.
1. What is your immediate management priority, and how do you handle the delayed radiology read?
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Priority: exclude intracranial hemorrhage and reverse anticoagulation if present - do not wait for the formal read.
This patient has multiple risk factors for intracranial hemorrhage after minor head injury: age >65, anticoagulation with warfarin, witnessed LOC, vomiting, and a large hematoma. He meets criteria for urgent CT head.
Handling the delayed read:
- Scan immediately - the tech is available; the 30–40 minute read delay is not a reason to delay imaging.
- Request a wet read from the on-site tech/ED physician or use teleradiology/phone the off-site radiologist for a preliminary interpretation. Many systems permit an ED-initiated preliminary read.
- Do not discharge based on a normal-appearing clinical exam; the decision hinges on the CT.
- Check INR now and have vitamin K and PCC (or FFP if PCC unavailable) ready. If CT shows hemorrhage, reverse immediately (IV vitamin K 5–10 mg plus 4-factor PCC weight-based) and arrange transfer.
- If CT is negative, observe for a period per protocol (given anticoagulation, a longer observation and repeat CT at 6–24 hours is often advised) and involve the patient's anticoagulation team.
Key judgment: The off-site read and the 90-minute transfer distance mean you must be prepared to act on a preliminary read and start reversal before formal confirmation if the scan is clearly abnormal.
2. The CT shows a small acute subdural hematoma with 4 mm midline shift. The patient remains GCS 15. What do you do next, and what are the transport considerations?
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Immediate actions:
- Reverse anticoagulation now - IV vitamin K 5–10 mg plus 4-factor PCC (weight-based, typically 25–50 IU/kg) to correct INR rapidly. Do not wait for the neurosurgeon.
- Neurosurgical consultation - contact the receiving center now; a small subdural with 4 mm shift in a GCS 15 patient may be managed conservatively or may need evacuation depending on evolution. The decision is theirs, but the conversation starts immediately.
- Neuroprotective measures: head of bed 30°, avoid hypoxia and hypotension, maintain normocapnia, control BP per neurosurgical guidance (avoid both hypotension and excessive hypertension), serial GCS and pupillary checks.
- Repeat CT if any deterioration; a 4 mm shift can progress.
Transport considerations:
- 90 minutes by road - arrange urgent transfer with a critical care-capable ambulance and monitoring; consider air transport if available and faster.
- Send imaging electronically ahead; give a verbal handover to the receiving neurosurgery team.
- Do not delay transfer for a repeat CT if the patient is stable and the receiving center accepts; coordinate timing with them.
- Document the reversal, the consultation, and the transfer decision.
Key judgment: A GCS 15 patient with a small subdural and anticoagulation is not a 'watch at home' patient - reverse, consult, and transfer.