A Normal GCS After a Ground-Level Fall on Apixaban
At 06:40, you are called to a mosque for a 79-year-old woman who fell from standing height while leaving morning prayer. She did not lose consciousness. She now reports a mild occipital headache and vomited once in the ambulance. She takes apixaban 5 mg twice daily for atrial fibrillation; her last dose was 8 hours ago. Examination: GCS 15, pupils 3 mm equal and reactive, no focal weakness, no neck pain. There is a 4 cm boggy occipital hematoma. Vital signs: BP 152/84, HR 88 and irregular, RR 18, SpO2 97% on room air, glucose 7.2 mmol/L, temperature 36.8°C. She is alert and says she wants to stay home and sleep it off. Her son is present and agrees. The nearest hospital is 10 minutes away and has CT but no neurosurgery; the trauma center is 30 minutes away with 24/7 neurosurgery. Traffic is moderate.
1. What is your disposition decision, and how do you justify it to the patient and family?
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This is a high-risk minor-mechanism head injury. Age over 65, apixaban use, vomiting, occipital hematoma, and headache all raise the probability of intracranial hemorrhage, and GCS 15 does not exclude it. Apixaban effect lasts at least 24-48 hours and may require reversal at a trauma center. She has capacity and can refuse, but she does not have the information to weigh a life-threatening bleed. Explain that a normal examination now does not rule out bleeding and that sleeping it off could allow an expanding hematoma to go unrecognized. Recommend transport to the trauma center with neurosurgery. If she refuses, involve on-line medical control and document capacity, risks, alternatives, and the refusal; arrange responsible adult supervision and a clear return plan. Do not treat the son's agreement as consent for her.
2. What would you monitor and do en route?
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Monitor GCS, pupils, motor function, blood pressure, heart rate, respiratory rate, and SpO2 every 5 minutes. Avoid hypoxia and hypotension, which worsen secondary brain injury; target SpO2 at least 94% and systolic BP at least 110 mmHg in an older adult with suspected TBI. If she deteriorates, support the airway with BVM and consider intubation for GCS 8 or less; avoid hyperventilation unless there are signs of herniation. Establish IV access and give isotonic crystalloid only for hypotension; avoid hypotonic fluids. Keep the head elevated 30 degrees if there is no shock. Reassess for neck pain or neurologic deficit; given a low-risk mechanism and no symptoms, spinal motion restriction is not mandatory, but maintain manual stabilization if any doubt. Notify the trauma center early.
3. How would you document the discussion if she continues to refuse?
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Document the initial GCS, pupils, vital signs, glucose, anticoagulant name and last dose, the discussion about risk, the patient's own words, and the son's response. If she refuses, use a structured refusal form, confirm she is alert and oriented, and state that she understands the risk of bleeding and death. Document that you offered transport to the trauma center and that she declined. If she lacks capacity, transport under implied consent and local policy. Notify medical control. Provide a written warning to return immediately for worsening headache, vomiting, drowsiness, weakness, or confusion.