Download A4Medicine Mobile App
Empower Your RCGP AKT Journey: Master the MCQs with Us! 🚀
Anticoagulant use (e.g., warfarin, DOACs) is increasingly common in older adults with cardiovascular conditions, but it significantly raises the risk of intracranial hemorrhage (ICH) after head trauma. Studies show that anticoagulated patients face a fourfold to fivefold higher mortality risk from traumatic brain injuries (Pang et al., 2015). Consequently, primary care clinicians must remain vigilant when assessing head injuries in these individuals, promptly arranging CT imaging and monitoring for delayed hemorrhage (Fuller et al., 2019; Marques et al., 2019).
NICE guidelines recommend a 24-hour observation period after any head injury in anticoagulated patients, followed by repeat CT imaging if necessary (Chenoweth et al., 2018). In severe cases, clinicians should evaluate the need for anticoagulation reversal, carefully balancing bleeding risks against possible thromboembolic events (Miller et al., 2015).
| Section | Recommendation Summary |
|---|---|
| 1.1 Decision Making & Capacity |
- 1.1.1: Follow NICE’s guideline on shared decision making (NICE, 2023). - 1.1.2: For people ≥16 who may lack capacity, see NICE’s guideline on decision making and mental capacity. |
| 1.2.1 Public Advice | Encourage anyone with a head injury (for themselves or someone else) to seek urgent medical advice, regardless of injury severity. |
| 1.2.2 Remote Advice → 999 |
Immediate emergency transport if 1) Unconscious / reduced consciousness 2) Focal neurological deficit 3) Suspected complex skull fracture or penetrating injury 4) Any seizure(s) since injury 5) High-energy head injury 6) No safe alternative transport |
| 1.2.3 Remote Advice → ED |
Refer to ED if 1) Loss of consciousness (now recovered) 2) Amnesia (before/after injury) 3) Persistent headache 4) Vomiting 5) Any previous brain surgery 6) Bleeding/clotting disorders 7) On anticoagulant or antiplatelet (not aspirin alone) 8) Drug/alcohol intoxication 9) Safeguarding concerns 10) Irritability/altered behavior (especially in under 5s) 11) Persistent diagnostic concern by helpline staff |
| 1.2.4 Community Health → ED |
Refer to ED (ambulance if needed) if 1) GCS <15 on initial assessment 2) Any loss of consciousness 3) Focal neurological deficit 4) Suspected complex skull fracture or penetrating injury 5) Amnesia (before/after injury) 6) Persistent headache 7) Vomiting (use judgment under 12s) 8) Seizure(s) since injury 9) Any previous brain surgery 10) High-energy head injury 11) Bleeding/clotting disorders 12) Anticoagulant/antiplatelet (not aspirin alone) 13) Drug/alcohol intoxication 14) Safeguarding concerns 15) Any persistent diagnostic concern |
| 1.2.5 Other Concerns |
Consider ED referral if • Irritability/altered behavior (esp. under 5s) • Visible trauma still concerning • No one to observe at home • Continuing worry by patient/family |
| 1.2.6 – 1.2.8 Transport |
- Ensure a competent adult accompanies the person. - Decide on ambulance vs. private/public transport based on clinical condition. - Alert receiving hospital by phone; send written summary if non-emergency. |
| 1.2.9 Training | Train community healthcare professionals (GPs, nurses, dentists, ambulance crews) to recognize and act on these risk factors. |
| 1.3 Glasgow Coma Scale |
- Document Eye (E), Verbal (V), Motor (M) scores separately; total GCS as “X/15.” - In preverbal children, use ‘grimace’ for V. - For known low baseline GCS (e.g., dementia), adjust accordingly. |
In conclusion, the intersection of anticoagulant therapy and head injury presents a complex challenge for primary care clinicians. Understanding the increased risks associated with anticoagulation, adhering to established guidelines for assessment and management, and maintaining a high index of suspicion for complications are essential for optimizing patient outcomes in this vulnerable population.
References
NICE. Head injury: assessment and early management. (Clinical Guideline; 2003, amended 2007, 2014, 2023)
NICE. Shared decision making. (Guideline; 2021, reviewed 2023)
NICE. Decision making and mental capacity. (Guideline; 2018, updated 2020, reviewed 2023)
Alrajhi, K., Perry, J., & Forster, A. (2015). Intracranial bleeds after minor and minimal head injury in patients on warfarin. Journal of Emergency Medicine, 48(2), 137–142. https://doi.org/10.1016/j.jemermed.2014.08.016
Chenoweth, J., Gaona, S., Faul, M., Holmes, J., & Nishijima, D. (2018). Incidence of delayed intracranial hemorrhage in older patients after blunt head trauma. JAMA Surgery, 153(6), 570. https://doi.org/10.1001/jamasurg.2017.6159
Fuller, G., Evans, R., Preston, L., Woods, H., & Mason, S. (2019). Should adults with mild head injury who are receiving direct oral anticoagulants undergo computed tomography scanning? A systematic review. Annals of Emergency Medicine, 73(1), 66–75. https://doi.org/10.1016/j.annemergmed.2018.07.020
Grewal, K., Atzema, C., Austin, P., Wit, K., Sharma, S., Mittmann, N., … & McLeod, S. (2021). Intracranial hemorrhage after head injury among older patients on anticoagulation seen in the emergency department: A population-based cohort study. Canadian Medical Association Journal, 193(40), E1561–E1567. https://doi.org/10.1503/cmaj.210811
Hadjigeorgiou, G., Anagnostopoulos, C., Chamilos, C., & Petsanas, A. (2014). Patients on anticoagulants after a head trauma: Is a negative initial CT scan enough? Report of a case of delayed subdural haematoma and review of the literature. Journal of Korean Neurosurgical Society, 55(1), 51. https://doi.org/10.3340/jkns.2014.55.1.51
Kerschbaum, M., Henssler, L., Ernstberger, A., Alt, V., Pfeifer, C., Worlicek, M., … & Popp, D. (2021). Influence of oral anticoagulation and antiplatelet drugs on outcome of elderly severely injured patients. Journal of Clinical Medicine, 10(8), 1649. https://doi.org/10.3390/jcm10081649
Liu, S., McLeod, S., Atzema, C., Austin, P., Wit, K., Sharma, S., … & Grewal, K. (2022). Delayed intracranial hemorrhage after head injury among elderly patients on anticoagulation seen in the emergency department. Canadian Journal of Emergency Medicine, 24(8), 853–861. https://doi.org/10.1007/s43678-022-00392-z
Mann, N., Welch, K., Martin, A., Subichin, M., Wietecha, K., Birmingham, L., … & George, R. (2018). Delayed intracranial hemorrhage in elderly anticoagulated patients sustaining a minor fall. BMC Emergency Medicine, 18(1). https://doi.org/10.1186/s12873-018-0179-0
Marques, R., Antunes, C., Machado, M., Ramos, R., Duarte, N., Oliveira, L., … & Sousa, N. (2019). Reappraising the need for a control CT in mild head injury patients on anticoagulation. European Journal of Trauma and Emergency Surgery, 47(5), 1461–1466. https://doi.org/10.1007/s00068-019-01172-8
Miller, J., Lieberman, L., Nahab, B., Hurst, G., Gardner-Gray, J., Lewandowski, A., … & Watras, J. (2015). Delayed intracranial hemorrhage in the anticoagulated patient. Journal of Trauma and Acute Care Surgery, 79(2), 310–313. https://doi.org/10.1097/ta.0000000000000725
Nash, T. (2024). Retrospective observational study of aged care facility residents presenting to ED post fall: A case for person‐centred shared decision making. Emergency Medicine Australasia, 36(4), 512–519. https://doi.org/10.1111/1742-6723.14391
Pang, C., Lee, S., & Yoo, H. (2015). Clinical factors and perioperative strategies associated with outcome in preinjury antiplatelet and anticoagulation therapy for patients with traumatic brain injuries. Journal of Korean Neurosurgical Society, 58(3), 262. https://doi.org/10.3340/jkns.2015.58.3.262
Savioli, G., Ceresa, I., Luzzi, S., Gragnaniello, C., Lucifero, A., Maestro, M., … & Bressan, M. (2020). Rates of intracranial hemorrhage in mild head trauma patients presenting to emergency department and their management: A comparison of direct oral anticoagulant drugs with vitamin K antagonists. Medicina, 56(6), 308. https://doi.org/10.3390/medicina56060308
