Anticoagulated minor head injury with a normal early CT
A 74-year-old woman presents 2 hours after a mechanical fall at home, striking the occiput on a tiled floor. She takes apixaban 5 mg twice daily for atrial fibrillation; the last dose was 8 hours ago. Her eGFR is 42 mL/min/1.73 m². She had no loss of consciousness, but has a mild headache and one episode of vomiting in the ambulance. GCS is 15, pupils equal, no focal neurology, and there is a small occipital hematoma. Non-contrast CT head at 2 hours is reported as normal by the on-call radiologist. She lives alone; her daughter is 2 hours away. The hospital has no neurosurgical unit; the nearest is 60 km away. Anti-Xa activity is not available overnight. She is keen to go home.
1. Using a risk-stratification approach, decide whether she can be discharged, admitted for observation, or transferred. Explain the factors that drive your decision and what you would document.
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Risk stratification in head injury on anticoagulation is not a single rule. Her normal CT at 2 hours and GCS 15 are reassuring, but she has several risk factors for delayed intracranial haemorrhage: age over 65, apixaban, vomiting, and a mechanical fall with occipital impact. The absence of anti-Xa testing means I cannot estimate the degree of anticoagulation. Many European pathways would recommend observation for at least 24 hours with a repeat CT before discharge, especially when the patient lives alone. I would not give reversal agents for a normal CT and GCS 15; reversal is reserved for bleeding or a falling GCS. I would admit to an observation unit, document the shared decision, and give written head-injury advice. If the daughter can stay and the patient is fully orientated, a supported discharge with a 24-hour observation plan may be considered, but only if return is rapid and reliable.
2. At 6 hours she vomits again and becomes drowsy, GCS 14. What is your immediate management, and how does the absence of a neurosurgical unit change it?
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Vomiting and a fall in GCS from 15 to 14 suggests expanding intracranial pathology, even if the first CT was normal. I would repeat the non-contrast CT immediately, protect the airway, and check glucose and pupils. If the repeat CT shows haemorrhage, I would contact the neurosurgical centre and discuss reversal. For apixaban, andexanet alfa is specific if available; otherwise four-factor prothrombin complex concentrate is used off-label, with local haematology advice. The absence of a neurosurgical unit lowers my threshold for early transfer: I would stabilise airway and blood pressure, start reversal if indicated, and arrange urgent transfer rather than wait for deterioration. I would not perform a lumbar puncture. The key reasoning is that a delayed bleed after a normal early CT is uncommon but treatable, and the clinical change is more important than the first scan.
3. If repeat imaging remains normal at 24 hours and she is GCS 15, how would you plan discharge? What would you do if she refused admission?
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If she remains GCS 15 and the 24-hour repeat CT is normal, discharge is reasonable only with a responsible adult, written advice, and clear return criteria. I would document that she lives alone and that the daughter will stay for 24 hours, or arrange a telephonic check. If she refuses admission, I would assess capacity, explain the small but real risk of delayed bleeding, and offer a compromise: a 12-hour observation in the emergency department or a family-supported plan with a repeat CT. I would not simply discharge because the CT is normal. The reasoning is that autonomy must be respected if she has capacity, but the clinician must ensure the refusal is informed and that safety-netting is robust.