The Anticoagulated Ground-Level Fall With a Negative Head CT

The decision hinges on three factors, not on the CT alone.

Risk. A negative initial CT does not fully exclude delayed intracranial hemorrhage in a patient on a direct oral anticoagulant plus an antiplatelet; reported rates are low (roughly 1% or less) but the consequence in an 82-year-old with atrophy is catastrophic. Her disorientation to day may be baseline or may be early injury - that ambiguity raises, not lowers, the concern.

Capacity to observe. Home observation by a daughter who does not live there is not neurologic monitoring. What is required is serial neuro checks (typically every 1–2 hours) for a defined window, a low threshold for repeat CT with any change, and instructions to return immediately for vomiting, drowsiness, or worsening headache.

Constraints. No inpatient bed does not equal no care: use the ED observation unit or a protocolized extended-stay pathway, escalate to the house supervisor and the on-call trauma surgeon, and consider transfer to the trauma center if monitoring cannot be delivered locally.

Action. Recommend 24-hour observation with scheduled neuro checks and a repeat CT before discharge if any change occurs. Do not give reversal agents for a negative scan. If she refuses, document capacity, shared decision-making with the daughter present, and explicit return precautions.

This is a neurologic deterioration in an anticoagulated patient - treat it as an expanding intracranial hemorrhage until imaging says otherwise.

1. Airway and physiology first. Suction, position to protect the airway, apply oxygen, and prepare for intubation if GCS continues to fall. Avoid hypoxia and hypotension - each independently worsens outcome.
2. Immediate repeat non-contrast CT. Do not wait for a full neuro exam or for labs.
3. Notify the trauma surgeon and neurosurgeon now, and initiate transfer to the trauma center in parallel with imaging rather than after it. The 45-minute distance is the clock that matters.
4. Reverse anticoagulation per protocol. For apixaban, andexanet alfa or four-factor PCC depending on formulary; the indication is now confirmed or strongly suspected intracranial bleeding, not prophylaxis. Hold aspirin. Do not wait for a coagulation panel to guide a DOAC reversal - the standard assays do not reflect apixaban effect.
5. Secondary-injury prevention: head of bed 30 degrees, normocapnia, normothermia, normoglycemia, isotonic fluids only, avoid hypotonic solutions.
6. Document the timeline - arrival, first CT, first change, repeat imaging, reversal, transfer request - because this sequence will be reviewed as a system delay if outcomes are poor.

The injury is the symptom; the fall is the diagnosis. A discharge plan that stops at "follow up with primary care" will produce a readmission.

• Medication review: the combination of an anticoagulant and an antiplatelet for atrial fibrillation alone warrants a conversation with her cardiologist about whether aspirin is indicated (CHA2DS2-VASc scoring, bleeding risk). Deprescribing is a fall-and-bleed intervention. Review sedatives, antihypertensives, and anything causing orthostasis.
• Mobility: physical therapy assessment before discharge, not after; a walker she already owns is not evidence she uses it correctly.
• Home safety: bathroom grab bars, raised toilet seat, night lighting, removal of throw rugs, review of footwear.
• Bone health and vision: she fell from standing height and fractured nothing, but she is at high risk; vitamin D, osteoporosis screening, and a vision check belong in the plan.
• Contingency plan: who checks on her, how often, and what specifically prompts a 911 call.
• Teach-back: confirm she and the daughter can state the return precautions in their own words before she leaves.