Head Injury on Apixaban With a Negative Initial CT
A 72-year-old man taking apixaban 5 mg twice daily for atrial fibrillation falls at home and strikes his forehead. He has no loss of consciousness but has a persistent headache and one episode of vomiting. On arrival, GCS is 15, pupils are equal, and there is a small scalp hematoma but no focal neurologic deficit. Noncontrast head CT at 2 hours after the fall shows no hemorrhage. His last apixaban dose was 6 hours ago. Creatinine is 1.0 mg/dL, platelets 210,000/microL, and INR is 1.1. He lives alone, feels well, and wants to go home. The emergency department is busy, and a bed for observation is available but would require 24 hours. He has no reliable ride until tomorrow morning.
1. What is the appropriate disposition, and what is the role of anticoagulation reversal?
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Observe him for at least 24 hours with neurologic checks. He is on a direct oral anticoagulant, has a headache and vomiting after head strike, and lives alone. A negative CT at 2 hours lowers but does not eliminate the risk of delayed intracranial hemorrhage, especially with ongoing anticoagulation. A repeat noncontrast CT should be obtained if he develops worsening headache, vomiting, drowsiness, focal deficit, or before discharge according to local protocol.
Do not reverse apixaban prophylactically. Reversal with andexanet alfa or prothrombin complex concentrate is reserved for confirmed intracranial hemorrhage, life-threatening bleeding, or emergency surgery where hemostasis is essential. His INR is not useful for monitoring apixaban. Check renal function and the timing of the last dose, because impaired clearance prolongs exposure. The absence of blood on the first CT is not a reason to ignore the mechanism and symptoms.
2. How would you handle his request to go home, and what safety counseling would you give?
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Explain that his headache, vomiting, age, anticoagulant use, and lack of a reliable ride make discharge unsafe right now. Offer observation and a repeat CT if symptoms change. If he has decision-making capacity and insists on leaving, document the discussion, provide strict return precautions, arrange a responsible adult to stay with him, and ensure follow-up within 24 hours. Do not simply send him home alone.
Counsel him to avoid alcohol, driving, and strenuous activity. Give written instructions to return immediately for worsening headache, repeated vomiting, drowsiness, confusion, weakness, numbness, or vision change. Confirm that he understands why the first scan does not end the risk. Arrange medication review and falls prevention after the acute episode.