Elderly Patient with Falls, Anticoagulation and a Head Injury
An 82-year-old woman on apixaban for atrial fibrillation is brought in after a mechanical fall at home. She struck her head and has a 3 cm scalp haematoma. GCS is 15, pupils equal and reactive, and there is no focal neurology. She lives alone and takes apixaban 5 mg twice daily; the last dose was 6 hours ago. She is on a busy shift; CT scanning is available but there is a 3-hour queue for non-urgent scans. She wants to go home.
1. How do you risk-stratify this patient and decide on imaging?
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Risk factors for intracranial haemorrhage after head injury:
- Age >65.
- Anticoagulation (apixaban) - a major risk factor.
- Head strike with haematoma.
- Mechanism (fall from standing is lower energy but still significant in the elderly).
Decision: a normal GCS does not exclude intracranial bleeding in an anticoagulated patient. She needs a CT head. A 3-hour queue is not acceptable for a patient on a direct oral anticoagulant with a head injury; escalate to the radiology team and request an urgent scan. If the scan cannot be done promptly, she should be observed in the ED with neurological monitoring until imaging is completed.
Additional considerations: check for other injuries (neck, hips, wrists), review her medication list, and assess for reversible causes of the fall (arrhythmia, postural hypotension, hypoglycaemia, infection, medication effects).
2. If the CT shows a small intracranial haemorrhage, what is your management, including reversal of anticoagulation?
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Management of anticoagulant-associated intracranial haemorrhage:
- Urgent neurosurgical referral and discussion of reversal.
- Reversal: for apixaban, specific reversal with andexanet alfa where available, or prothrombin complex concentrate (PCC) as an alternative. Fresh frozen plasma is less effective for direct oral anticoagulants. Consider tranexamic acid per local protocol.
- Blood pressure control to reduce haematoma expansion, avoiding hypotension.
- Stop anticoagulation, and reverse any other coagulopathy (check INR, platelets, renal function - apixaban accumulates in renal impairment).
- Supportive care: neuro-observations, seizure control, and ICU or high-dependency care as needed.
- Document the rationale and involve the family in discussions about goals of care.
3. She wants to go home. How do you handle this, including capacity and social factors?
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Assess capacity and safety, not just the patient's preference.
- Capacity: does she understand the risks, retain the information, weigh it and communicate a choice? A head injury and possible cognitive impairment may affect this; document the assessment.
- Risk of discharge: anticoagulated elderly patients with head injury are at risk of delayed intracranial haemorrhage. If CT is normal and she is observed for an appropriate period with a responsible adult, discharge may be considered in some pathways - but she lives alone.
- Social factors: living alone increases the risk of deterioration being missed. Arrange a responsible adult, a follow-up plan, and clear safety-netting (return for headache, vomiting, drowsiness, weakness, confusion).
- If she lacks capacity or is unsafe: escalate to senior colleagues and consider admission or a formal social care assessment; involve the family or next of kin.
- Document the discussion, the decision and the reasons.