A Fall, an Anticoagulant, and a Headache
An 82-year-old woman on apixaban for atrial fibrillation is brought in by her daughter after a mechanical fall at home 6 hours ago. She struck the back of her head but did not lose consciousness. She now reports a gradually worsening bifrontal headache and has vomited twice. Glasgow Coma Scale is 15, pupils equal and reactive, no focal limb weakness, and no neck stiffness. BP 156/88, HR 78, SpO2 97%. Her last apixaban dose was this morning. Renal function is mildly reduced with an eGFR of 48 mL/min/1.73 m2. The triage nurse suggests she can wait in the minor injuries area because her GCS is normal and she is walking and talking.
1. Evaluate the triage decision and identify the features that should change her disposition.
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The triage decision is unsafe. A normal GCS and the ability to walk and talk do not exclude a significant intracranial injury, particularly in an anticoagulated older adult. The key risk features are: age over 65, anticoagulation with apixaban, a direct blow to the occiput, a headache that is worsening rather than settling, and recurrent vomiting. Vomiting and progressive headache after head trauma raise concern for raised intracranial pressure from an intracranial hemorrhage, including subdural, epidural, or intraparenchymal bleeding, and anticoagulation markedly increases the risk of delayed or expanding hemorrhage. The absence of focal deficits and neck stiffness is reassuring but not exclusionary; posterior fossa and frontal lesions can present with headache and vomiting before focal signs. The mildly reduced eGFR matters because apixaban has renal clearance and accumulation increases bleeding risk, and it also affects dosing decisions and reversal planning. The correct disposition is a monitored area with urgent non-contrast head CT, not the minor injuries waiting room. While awaiting imaging, obtain IV access, check full blood count, coagulation studies including INR, renal function, and group and save, and perform frequent neurological observations including GCS, pupils, and limb power. If she deteriorates or the CT shows hemorrhage, immediate senior emergency and neurosurgical involvement is required, along with consideration of reversal agents for apixaban, such as andexanet alfa or prothrombin complex concentrate per local protocol, because the last dose was recent and drug levels may be significant.
2. The CT shows a small acute subdural hematoma without midline shift. She remains GCS 15. Explain the factors that determine whether she can be managed conservatively or needs neurosurgical referral, and what monitoring you would insist on.
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A small subdural hematoma without midline shift in a GCS 15 patient can often be managed conservatively, but the decision is not based on size alone. Favorable features here are the small volume, absence of midline shift, preserved consciousness, and lack of focal deficit. Features that would push toward urgent neurosurgical referral include any neurological deterioration, a hematoma that enlarges on repeat imaging, midline shift or effacement of basal cisterns, hydrocephalus, a coagulopathy that cannot be corrected, or the presence of a posterior fossa collection. Anticoagulation is the pivotal modifier: apixaban effect must be assessed and, if clinically significant, reversed according to local protocol, because ongoing anticoagulant effect increases the risk of expansion. Renal impairment slows clearance and prolongs exposure, so repeat imaging and a lower threshold for reversal are reasonable. I would insist on admission to a unit with neurological observation capability, hourly GCS, pupil checks, and limb power for at least the first 24 hours, with clear escalation criteria written in the notes. Repeat non-contrast CT within 6 to 12 hours, or sooner if any change, is standard because delayed expansion is well described. Blood pressure should be controlled to reduce rebleeding risk while maintaining cerebral perfusion, and analgesia and antiemetics should be given. Discuss the case with neurosurgery early even if transfer is not planned, document that discussion, and involve the family in understanding the observation plan. Restarting apixaban requires a multidisciplinary decision balancing stroke and bleeding risk, and should not be done automatically.