Head Injury on an Anticoagulant
A 79-year-old man is brought in at 18:40 after a ground-level fall at home, striking the back of his head on a tile floor. He did not lose consciousness and walked to the car. He takes apixaban for atrial fibrillation and lisinopril for hypertension. On arrival: GCS 15, pupils equal and reactive, HR 78 and irregular, BP 168/88, RR 16, SpO2 97% on room air, T 36.8 C. He has a 3 cm boggy hematoma on the occiput and mild neck stiffness but no midline tenderness. He reports a 'mild headache' and says he feels fine. The CT scanner is available; the department has no in-house neurosurgery after 19:00 and a transfer would take 2 hours by ground.
1. Decide whether this patient needs immediate CT and observation or can be discharged with instructions. Justify using the specific risk factors.
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Decision: immediate non-contrast head CT and monitored observation; discharge is not appropriate.
Justification from the case:
- Anticoagulation: apixaban, a direct oral anticoagulant, substantially raises the risk of delayed intracranial hemorrhage after head strike, even with a normal exam.
- Age 79: advanced age is an independent risk factor for intracranial injury and poor outcome.
- Mechanism and findings: occipital impact with a boggy hematoma and neck stiffness indicates meaningful energy transfer; 'boggy' suggests ongoing soft-tissue bleeding.
- Normal GCS does not exclude injury: a lucid interval is characteristic of epidural hematoma, and anticoagulated patients can deteriorate hours later.
- Operational constraint: no in-house neurosurgery after 19:00 and a 2-hour transfer means any deterioration is a crisis; earlier imaging buys time for transfer decisions.
Actions:
- CT head now; document time of injury, last apixaban dose, and renal function (affects reversal agents).
- Continuous neuro checks (GCS, pupils, motor) every 15 minutes initially, then per protocol.
- Keep him NPO, maintain normotension and normocapnia, elevate head of bed, and avoid hypotensive episodes.
- Notify the physician of the anticoagulant and confirm reversal plan availability (e.g., andexanet alfa or prothrombin complex concentrate per formulary) before any transfer.
- C-spine precautions until cleared clinically and radiographically.
2. Two hours later his GCS drops from 15 to 12 and he vomits once. The CT showed a small occipital contusion. What is your interpretation and immediate action plan?
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Interpretation: acute neurological deterioration - a new or expanding intracranial hemorrhage until proven otherwise. A small contusion on the initial scan does not explain a 3-point GCS drop; anticoagulated patients can develop delayed expansion, and vomiting signals rising intracranial pressure.
Immediate actions:
- Airway: protect from aspiration, suction, position laterally if safe with C-spine precautions, and prepare for intubation if GCS falls further or airway reflexes are lost.
- Call the physician and activate the stroke/neuro pathway; repeat CT immediately.
- Neuro assessment: recheck pupils, motor strength, and GCS; report changes in a structured format.
- Physiologic targets: maintain SpO2, avoid hypoxia and hypercapnia, keep systolic BP in the range ordered (often 140-160 for intracranial hemorrhage), and avoid hypotension.
- Prepare for transfer: because there is no in-house neurosurgery, begin arranging transfer now rather than after the repeat scan; gather records, imaging, anticoagulant history, and reversal status.
- Reversal: confirm with the physician whether reversal has been given and whether repeat dosing is needed.
- Documentation: time-stamped serial exams and every notification, since deterioration after a 'normal' exam is a high-risk event.