Anticoagulation, a Fall, and a Head Strike on a Busy Ward
Mrs. Lindqvist, 79, is admitted with atrial fibrillation and a lower respiratory tract infection. She takes apixaban 5 mg twice daily, which she received at 08:00. At 14:20 she is found on the floor beside her bed; she says she felt dizzy standing up to reach the call bell and did not lose consciousness. She has a 3 cm boggy swelling over the left occiput but no visible laceration. Vital signs: HR 88 irregular, BP 128/74, RR 18, SpO2 96% on room air, blood glucose 6.8 mmol/L. She is alert and oriented, moves all limbs, and complains only of a mild headache. Her last creatinine was 96 micromol/L. The ward is short-staffed and the bed alarm was not on. The physician is in theatre for another 90 minutes.
1. Prioritize your immediate assessment and actions, and justify why the anticoagulant changes the urgency.
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Immediate priority: assess for intracranial bleeding after head strike in an anticoagulated older adult, while also assessing for other injury and the cause of the fall.
Actions in order:
- Do not move her until you have checked for cervical spine tenderness, limb deformity, and pain; then assist her up safely with help and a hoist if needed.
- Full neurological observation set: Glasgow Coma Scale, pupil size and reaction, limb power, and repeat vital signs including a lying-and-standing blood pressure when safe, because the dizziness suggests orthostatic hypotension.
- Apply a cold pack to the swelling, document its size and appearance with a measured description, and mark the margin so progression can be judged.
- Escalate now. A 90-minute wait for the covering physician is not acceptable for a head injury on a direct oral anticoagulant. Contact the on-call physician or the theatre team, and use the rapid-response pathway if her neurological status changes.
- Anticipate an urgent CT head and coagulation studies; ask whether reversal agents are available and who authorizes them.
- Institute frequent neurological observations per head-injury protocol and keep her supervised.
Why the anticoagulant matters: apixaban blunts clotting, so an intracranial bleed can expand with few early signs, and the classic lucid interval can mislead. A boggy swelling over the occiput is a direct sign of impact force. Headache after a head strike in this patient is not a minor complaint.
2. The physician asks whether the apixaban dose needs adjusting given her age. How do you reason about this, and what information do you gather before answering?
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This requires assembling the specific dose-reduction criteria rather than reasoning from age alone.
Gather: her age, weight, and serum creatinine (to calculate creatinine clearance), her full medication list including antiplatelets, NSAIDs, or interacting drugs, her renal function trend, and the indication and duration of therapy. Confirm the exact product and its approved dosing criteria, because apixaban reduction criteria differ from those of other direct oral anticoagulants and are not interchangeable.
Reasoning: age by itself does not determine the dose. The reduction criteria generally combine at least two of advanced age, low body weight, and impaired renal function, and the thresholds are product-specific. Her creatinine of 96 micromol/L may correspond to a substantially reduced clearance in a small older woman, so calculate rather than eyeball. Also consider the acute illness: dehydration and infection can reduce clearance transiently.
What you should not do: adjust or hold the anticoagulant on your own judgement. Your role is to supply accurate data, flag the concern, and ask the prescriber to confirm the dose against the criteria and document the rationale. If the dose is changed, verify the new order, check the administration record, and educate the patient about bleeding precautions before discharge.
3. Describe the post-fall documentation and the quality-improvement response to the missing bed alarm.
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Documentation should be factual, timed, and complete enough for another clinician to reconstruct the event.
Record: the time she was found and the position she was in; her account in her own words; whether loss of consciousness occurred; the witnessed or unwitnessed nature of the fall; findings of the head-to-toe and neurological assessment with times; the size, colour, and texture of the swelling; vital signs and glucose; the time each clinician was notified and their response; interventions applied; and the patient's and family's understanding. Complete an incident report through the designated system - the report supplements but never replaces the clinical record, and it is not referenced in the notes as a substitute for them. Do not speculate about cause in the chart; describe what you observed.
Quality improvement: the absent bed alarm is a system signal, not simply an individual lapse. Review whether the alarm was ordered, whether the equipment worked, and whether staffing made hourly rounding unrealistic. Propose concrete changes: a fall-risk assessment repeated after any change in condition or medication, a bedside checklist confirming alarms are on for high-risk patients at each shift handover, hourly rounding with the four Ps (pain, position, toileting, possessions), and a review of orthostatic blood pressure measurement for patients starting or continuing antihypertensives. Feed the event into the ward's incident review and track whether alarm compliance improves.