An 82-Year-Old on Apixaban Who 'Feels Fine Now'
An 82-year-old woman arrives 90 minutes after a ground-level fall in her kitchen, where she struck the back of her head on a cabinet. She takes apixaban 5 mg twice daily for atrial fibrillation, plus lisinopril and metoprolol; her last dose was about 4 hours ago. She was briefly stunned but is now GCS 15 and oriented, with a 3 cm boggy occipital hematoma and one episode of vomiting at the scene. She reports a mild headache. Pupils are equal, there is no focal deficit, and she denies neck pain. Vitals: BP 162/88, HR 76, RR 18, SpO2 96%, glucose 118. She walked with a walker before the fall and lives alone. She asks to go home because 'I feel fine now.' Your hospital has CT and 24-hour laboratory service but no neurosurgery; the trauma center is 45 minutes away.
1. Does she need imaging, and does she need a trauma center? Build the argument from the specific findings rather than a general rule.
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Imaging: yes, now, without delay for anything except airway. She carries at least five independent risk features in a validated decision rule: age over 65, vomiting, a head strike with a boggy hematoma, a witnessed loss of consciousness, and anticoagulation. Any one of these would justify a noncontrast CT head; the combination makes observation without imaging indefensible. Her GCS of 15 and normal pupils do not exclude an intracranial hemorrhage, and a boggy occipital hematoma marks the impact site.
Cervical spine: her age alone is an imaging criterion in the NEXUS rule, and a ground-level fall with a head strike in an osteoporotic 82-year-old is a credible mechanism for a dens fracture. She has no midline tenderness, is not intoxicated, and has no distracting injury, but she was briefly stunned, so maintain spinal precautions until clinical clearance is documented and image the c-spine if there is any doubt.
Disposition: she needs a place that can obtain the CT, watch her for at least 24 hours with serial neurologic checks, and reverse anticoagulation or transfer immediately if the scan is positive. With no neurosurgery on site, the practical decision is either admit locally under a protocol with a defined transfer trigger, or transfer now if the CT is positive, the exam is marginal, or the local monitoring capability is thin. What is not acceptable on any pathway is discharge home after a negative-looking exam.
2. What does apixaban change about your workup, and what is the nurse's role in reversal?
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What it changes
- An INR is uninformative. A normal INR does not mean she is not anticoagulated, and requesting it should not delay anything. The laboratory data that matter are CBC, creatinine with eGFR, and liver function.
- Timing and weight become clinical data. Her last dose was about 4 hours ago, so she is near peak effect; record the exact dose, the last dose time, her weight, and her renal function, because reversal products are dosed on these.
- Hold the next dose and check for other hemostasis-impairing drugs (additional antiplatelets, NSAIDs).
- Delayed hemorrhage is the trap. In anticoagulated patients, a delayed intracranial bleed can appear 24-48 hours after an initially negative scan, so observation with serial neurologic checks is standard even when the first CT is clean.
Reversal: your role
Reversal is a provider and hematology decision made only after hemorrhage is confirmed or strongly suspected, using a specific factor Xa inhibitor reversal agent or off-label four-factor prothrombin complex concentrate per protocol. Vitamin K and fresh frozen plasma are not effective for apixaban; suggesting them wastes time. The nurse's job is to gather the timing, weight, and renal data rapidly, hold the next dose, expedite CT, and make sure no one treats a normal INR as reassurance.
3. What change at hour 4 would matter, and how do you handle her request to go home?
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Changes that matter (and the subtle ones)
- Any decline in GCS, new confusion, or new word-finding difficulty - often reported first as 'she's just not quite herself.'
- Escalating headache, a second episode of vomiting, or new drowsiness.
- A pupil change, new focal weakness, or a seizure.
- The Cushing triad (bradycardia with rising systolic pressure and irregular respirations) is late and ominous; do not wait for it.
- Increasing neck pain, or new pain with movement, prompting c-spine reassessment.
Handling 'I feel fine now'
- Acknowledge it directly, then translate the risk into specifics: her age, her blood thinner, the vomiting, and the fact that a bleed can develop hours after a normal exam.
- Assess decision-making capacity, not just her stated preference: can she restate the risk and the alternative?
- Notify the provider, involve a family member or her emergency contact, and offer admission with the concrete plan (repeat scan if anything changes).
- If she still refuses, follow the against-medical-advice process: document her understanding of the specific risks, provide strict return precautions and a responsible adult, and make sure she is not signing out before the CT is done. Letting her leave from the waiting room without imaging is the failure mode this case is designed to catch.