Assessment of Injuries
There is little difference in the investigation of injuries between younger and older patients except perhaps for a lower threshold for imaging – especially CT in minor head trauma, of c-spine, and of hip and pelvis in someone with change in weight bearing (eg new severe hip pain even if weight bearing.) The potential benefits of diagnosing occult injuries far outweigh the long-term consequences of added radiation exposure. There are NO long-term consequences of radiation exposure in this age group.
There is currently no body of evidence to guide decisions around imaging and treatment of head injuries. The Canadian Head CT Rules (link to PDF Poster and scholarly article) suggest that everyone over 65 with even minor head trauma is a candidate for CT imaging. Clearly some clinical judgement is required. However the standard of care is difficult to establish.
Good practice is…
Even with a normal CT, a late subdural or developing contusion is quite possible.
Even with a normal physical exam, a late subdural or developing contusion is quite possible.
Discussion: Assessment of Injuries
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we have no specific protocol. the Canadian CT head rule is used
usually we scan over 65 if there is a history of head trauma or confusion
repeat CT and place in observation status.
Admit and observe, consider repeat CT in 24-48 hours if cognition off of baseline or history of loss of consciousness with injury
Longer monitoring with baseline evaluation and frequent subsequent evaluations, head CT
use canadian or nexus cth. scan over 65.
head CT C-collar, bed alarm
CT scan
CT head/neck
ok
C collar, CT head and cervical spine. Often the recommendation for delayed repeat CT head at 6 hours
there is no specific protocol. we are not a trauma hospital, so every physician does whatever they think is best in a particular situation. luckily our hospitalists are pretty nice and we have a good rapport w them, so if we ask them to watch someone overnight for a repeat cth the next day, they often will. reversal is pretty rare in general barring some active catastrophic bleeding event.
ok
En mi centro siempre mantenemos un alto índice de sospecha de lesiones ocultas, también nos guiamos por el uso de la escala Canadiense de trauma trauma espinal y cráneo para objetividad el uso de estudios de imagen.
in our emergency department we always maintain a high index of suspicion for occult cervical injuries.
better to CT than not
c-collar
high index of suspicion for acute and delayed ICB
CT scan; if on blood thinners and/or elevated INR, admit for repeat imaging
CT
Bloods including electrolytes, FBC, inflammatory markers
VBG
ECG
CTB
septic screen including CXR, urine MCS
Head CT and Trauma silvers
scan away
head ct, c collar, bed alarm
CT head neck for all patients aged over 65 with any head injury
I agree, until I turn 65 and then I think it’s probably not indicated 😉
Typically low threshold for CT head in those over 65 years, but perhaps all patients do not need to be CTed. Of course the clinical threshold is lower, but no studies to tell us risk factors.
A FALL IS NOT JUST A FALL IN THE ELDERLY
CT head neck for all patients aged over 65 with any head injury
head CT, discharge if normal
Scanning most geriatric trauma.
Liberal use of CT, assess c-spine and include in imaging if any midline TTP, return precautions if reliable and or has caregiver
OurED use TBI risk if moderate-severe ,Or mild-high risk do the CT scan
Patient age > 65 yr is the one criteria of mild TBI high risk
I definitely have a low threshold to do CT head and neck when there is a fall in an elderly person with HI, and esp if on blood thinners.
CT for anyone on warfarin, NOAC or clopidogrel
It’s always good to complete a CT scan elderly clients when indicated. The results shouldn’t be examined in isolation.
CT any head injury over 65
If over 65, head injury, on oral anticoags
thanks
dont work in ed
If on anticoagulant – CT head with any trauma. Otherwise, CT head if neuro deficits or visible trauma to head
ok
C collar CT
SMR and transport to ER, haven’t figured out how to fit CT machine in ambulance just yet
c-collar, investigate distracting injuries accordingly
C collar use
as a medic, c-collar because we have protocols
Extremely low threshold for CT in elderly trauma
Follow SMR, and suspect fractures for those over 65
n/a
o
n/a
n/a
n.a
nice to know
n/a
hyperventilate a head injury pt if their unconcious
c collar
c-collar
leave the collar on
CT for any suspicion of closed head injuries.
I think it is a good practice if anyone over the age of 65 with a suspected head injury to have a ct regardless of the medications they are on.
Always need to consider the likelihood od closed head injuries, so dont take a normal presentation for granted
uhuh
those on anti-coagulants are more at risk, high incident of suspicion of injury
r/u head bleed and fractures, send home to responsible care giver with H/I routine. follow up with family dr. come back if any concerns
ok
CT brain and geriatrics assessment if CT head is negative.
ok
clear discharge information, return if worsening symptoms, confusion, neuro sx
Be thorough in what you do and communicate with nurses/doctors.
Be thorough in your findings.
c-collar and take them to the hospital
We like to drive them to the hospital for assessment by a doctor.
c collar , CT , neuro assessment , vital signs
With Canadian C-Spine rule, most elderly pt over 65 are being brought into the ED by EMS with C-collars in place. Physician assessment and judgement will rule in or out the need for a CT.
Majority of elderly patients who have fallen have a c collar applied and a CT scan performed
The experience has been positive. Most receive cervical collars as well as have CT scans performed and are monitored accordingly
N/A
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.
nonje
CT scan if trauma to the head.
consider admission if on anticoagulation even if normal head CT depending on the situation
Ct head with any impact to head post fall especially if on anticoag
low threshold for ct head/c spine. I have also not been routinely reversing if normal CT head- it’s a good thought. Seems like risk benefit discussion with patient.
neg CT, nl neuro exam, someone to watch them and reliable, go home. Any of those not there, admit.
image c spine as well, admit for repeat head ct imaging 12 hours later if on anticoagulant.
low index to scan, same as above
Be aware of blood thinners, and if patient has any signs of head trauma, especially with confusional state or shows any signs of decrease in cognition then a CT brain is requested. Take into consideration age as well.
Always be concerned for concomitant cervical injury
CT scan, monitor for manifestations of head injury
Special consideration for blood thinners
Collar and CT
–
M
ok
CT head, may consider holding anticoagulants if on them. d/c with Observation by family
CT HEAD IN ALL HEAD INJURIES IN GERIATRIC POPULATION WHO ARE ANTICOAGULATED. OTHERWISE, PE AND IF SUSPICION HIGH OR MECHANISM HIGH GET CT.
I am very liberal with CT scanning, especially if demented, unwitnessed fall, obvious head trauma, or any anticoagulant. I have seen two cases of fatal delayed intracranial bleeding, both involving coumadin with INR 3-4 range, both presented about 12 hours after the initial trauma. Both were seen in another ED at the time of the fall and had negative head CTs.
No experience in ED
c-collar
C collar help minimize further injuries
ok
k
Of the head. CT is usually ordered and Xray
case by case. But CT all anticoagulated, ALOC, HA, V, amnesia, intox
great information
In an ideal setting, CT would be done, however it is not readily available in my country so clinical judgement is used, however once patient’s family can afford, it is what we recommend.
I have a low threshold for Head CT scan in elderly patient (>65yrs), more espcially if on anticoagulants.
If the INR and CT scan are normal, most of my patients are discharged to the caregivers/ family members and the GP to follow-up with them. Those without adequate caregivers are admitted under the care of the surgeons for observation and further discharge because the ED does not have enough room to keep patients for 24hrs observatioon.
Same noted
ct head in all along with ct spine
For minor head injury, I use The Canadian Head CT Rules, however low threshold for head CT especially if on anticoagulants.
head ct and observation
Early head CT, identify if patient is on thinners or not, cervical collar
okay
ok
ok
ok
ok
Depending on MOI, cervical collar/c-spine immobilization may be needed. Assess LOC, mental status, neuro status.
Cspine stabilization until cleared with head ct and ct of spine, blood panel, meds reviewed
good review
.
Good Review
ook
ct br c spine
ct, immobilization
I have a very low threshold for completing head/c-spine CTs on elderly patients. I have seen too many cases where patient’s have normal physical exam and still have bleeds.
Good to know
.
We have increased suspicion of head injury if there are any changes in pt cognitive status or evidence of head trauma. The presence of blood thinners and/or increased INR makes the possibility of a head injury or slow developing bleed more likely. If vitals and pt presentation are normal it is necessary to have pt monitored at home by a competent caregiver with instructions on what to look for.
Ok
I tend to do a head CT on any patient who has either had a head injury (regardless of LOC or not) or cannot remember if they hit their head. I also maintain a low threshold for ordering a Head CT if they are anticoagulated
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–
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Head CT is commonly done.
Almost always CT head + CT c-spine.
ok
ok
Head CT, C-SPine CT, C-collar
radiology tests
great
ok
Head CT and possibly observation depending on other factors
ok
Regarding anticoagulation – with recommendations under certain circumstances if all studies look good to correct INR when the patient is on warfarin, and send home if a safe discharge plan can be made – this becomes useless when anticoagulation is with Factor Xa Inhibitors. I understand they have great advantages for conditions and patient, but they sure create uncertainty with injuries!!
Depending on the circumstances, we will perform CT scan of head and make sure there is not bleed and monitor their neurology checks on the patient. If patient is discharged home, we provide instructions of symptoms to watch for.
Same
Closed head injury in elderly obtain CT head with C-spine – often find occult cervical fx with no tenderness or complaint on exam.
head injury, ct labs
o
we activate traumas on those who are on coumadin and fall. most likely admission to do repeat head ct especially if ETOH is on board.
ok
low theshold ct. dont always reverse
low threshold for CT
true
elderly head injury = head ct
any head trauma neuro observation is needed, ct scan and GCS charting
ok
high suspicion and low threshold for CT
In my country, CT scan is not readily avaiable and thus the decision to have a CT scan for every patient with even minor head injury may be difficult. We therefore use clinical symptoms, history surrounding the incidence and our discretion as physicians to determine who will need CT. However, if the family is able and willing, CT scan is advised.
Good information
CT all falls
good
ok
okay
Working in a site without CT, we have some additional considerations when considering when to send someone for imaging. In the older population, we still maintain a lower threshold for recommending CT, but we have to have an additional discussion whether transfer to obtain this image is within the pt’s GOC while also discussing the potential consequences of not having the imaging/intervention thereafter recommended.
We generally observe for 12-24 hours after last anticoagulant dose.
I am curious, in rural areas where CT is minimum 3 hours away, not feasible or even possible for elderly to get to CT
We generally place a C-collar for any neck pain after a fall of someone greater than 65 and even without an overt head injury, we will do a head CT for most patients who report a fall if they are over 75.
same practice.
practice is varied. If INR >3 have low threshold for hospitalization and consider repeat imaging in 12-24 hours.
We typically admit most of these pt’s
head CT sometimes even with mechanical fall depending on a situation
low threshold for scanning the elderly pt
we are the same
head ct
Not sure protocol, still a student. Looking forward to learning about this.
,
has no experience with patient head trauma
I am a student, I am not sure will look into this
.
wear aspen collar at all times
cervical collar, ct scan
lab values and CT head and neck
ok
agree with many of the comments above. low threshold but we don’t actively reverse patients with minor HI with negative CT. just warn patients and families of close observation and red flags
We have a low threshold for obtaining a head CT in the elderly population. We obtain head CT scans on most everyone > 65 years even if they are asymtomatic.
have not been in practice long enough
haven’t been practicing long enough yet
CT and home if normal. We don’t typically reverse anticoagulation in all patients, seems more likely to create stroke risk, and would be of minimal benefit. The incidence of delayed bleeding is very low
CT head, labs if med hx indicates
ct head order
Head CT
CT head, may consider holding anticoagulants if on them
BEEERS!
I don’t have any experience in ED
CT head for all patients with a fall + head strike. Canadian CT guidelines
CT, assess medications ie anticoagulants, if family able to observe patient may send home otherwise admit for observation
CT head, may consider holding anticoagulants if on them. d/c with Observation by family
ct head readily available so low threshold to scan
follow MIPS based off canadian head CT
ct
ct
interesting
brain ct, monitor vitals, c collar, x rays of c-spine.
If head trauma, CT. If ok, d/c home with supervision.
CTB, neuroobs..home if all RF cleared and discharge plan in place
CT age 65 or older, or anyone with anticoagulation, others based on discretion
Keep them overnight for observation dince we dont have a ct scan on site
Tricky working in smaller community with limited CT access. The prevalence of antiplt drugs and anticoagulants in the elderly almost makes it inevitable that CT head testing is needed; the increased risk of bleed up to 30 days post head injury even in the presence of a negative initial CT is problematic.There are recommendations that an unwitnessed fall in the elderly in patient should be a presumed head injury and warrant a head injury too. Again, the threshold to scan is really low, and I wonder if clinical 12-24 hour monitoring is sufficient.
our standard is CT head then obs for 23h +/- repeat head CT is no HA and neuro at baseline
low threshold for imaging in elderly
not sure if this was made explicit, but the Canadian CT head rules excluded with “minimal head injuries” (ie no loss of consciousness, amnesia to the head injury event or witnessed disorientation) thus the decision to scan patients over 65 with minimal head injuries is not informed by this clinical decision making rule, only judgement alone.
CT of the head, blood work, xray
head CT routine with patients over 65, discharge home if normal and patient has appropriate support, however is geriatric population admission is more common as there are concerns about safety and reason for fall.
Agreed
CT Head. DC home if normal. Probably wound reverse therapeutic INR if no bleeding.
yes
Low index of suspicion in presence of DOAC or warfarin
head CT
CTscan
Doing a CT scan of the brain and cognitive testing and screening tools
good information
head ct
yes
i don’t know I would have to investigate
ct or xray
helpful
k
head CT
Head CT
how about MRI
ok
everyone gets a ct
low threshold for CT
Head ct if fits criteria
We do a lot of head Ct scan. It is available rapidly and easily. Not harmful to the patient and that way patient have shorter hospital stay, for their benefit
CT head, ? need for repeat imaging in anticoagulated
Aucune règle claire qui clarifie quels patients n’ont pas besoin de ct. Donc, beaucoup de ct sont fait.
most get CT – many on anti-coagulated but dont have a med list and are poor historians
Elderly patients with head trauma of high or low intensity must receive a ct brain to ensure no intracerebral bleeds
most get ct
low threshold for imaging
case by case
I will be wary of clopidogrel (rather tha aspirin alone) as it has higher incidence ofICH.I will CT all Nh residents with warfarin/NOACS unless advanced care guidelines.
reversal only if ICH .If INR high but CTB noral , I will observe and follow up the INR with stopping.
Head CT, if fits in criteria
CT scan
better to do a CTB and C spine
CT
Usually CT if over the age of 65, C-collar and if any suspicion of injury also image spine, check meds for anticoagulants
Usually CT
Low threshold for CT head. If INR is >3, we usually hold a dose or two of warfarin (depending on the INR). If very high (>6) we would consider reversing with Vitamin K.
Low threshold for Ct head –
Reverse INR only if signs of bleeding – if patient on warfarin, ensure they are therapeutic
Scheduled follow up if can be discharged home safely, otherwise, admit for observation
ok
Low threshold for CT head in this group. If anticoagulated, even ASA, then get CT.
low threshold for CT head in patients over age 65.
frequently Ct for trauma
ok
head CT
T scan to older than 65
Normal ct, god bye
same as scottp
we use Canadian CT head rule (NICE guideline)
all on anticoagulants get CT head
those on dual antiplatelet also get CT head
those on aspirin only or no antiplatelets do not all get CT head. Clinical judgement applied
We acutally don’t have a specific protocol that we follow other than the standard candian CT head or NICE guidelines. In saying this it seems that we tend to scan more than we don’t but I don’t feel this necessarily should be the way it should be. Should the question of whether to scan or not also include what are we going to do with the patient if there is a bleed. Realistically will it change management? Majority of times, probably not?
Rpt CT head in 48 hrs.
over 65 gets CT head. Anticoagulated with head trauma either observed or d/c with qualified caregiver
We use CT scan for every pt who is anti-coagulated or on dual anti-platelets; most pts on aspirin. Use clinical judgement for the rest.
Elderly patient >75 with head injury — CT Brain
Short stay or admission for observation
Before discharge — mechanism of fall — physiotherapist/occupational therapist involvement
we use nice guidelines
even with this use clinical gestalt with low threshold to scan
Never worked directly in an ER, therefore not in a position to comment
we may not use FFP – since we now have PCC
CT scan is used liberally
Over 75 possible HI discussions surrounding the outcomes of CT prior to scan. If it has been decided that no active treatment would follow CT results regardless of outcomes then you question why you are doing CT in the first place.
We use NICE guidelines
….
Not sure Can CT head rules are being reported properly here … Not everyone who is older then 65 and has head trauma fits the rule. Before one even gets to the rule elements, one has to have inclusion criteria ie: blunt trauma to the head resulting in LOC, definite amnesia or witnessed disorientation, GcS 13-15 and trauma w/I 24h and not have exclusion criteria … then one can see if person fits rule, otherwise the rule was not meant for this population. If one doesn’t consider the inclusion and exclusion criteria of the rule then everyone 65 and over who gets a small bump to the head would need a ct …
Agreed. Additionally, I think the literature suggests that delayed ICH in patients on warfarin is rare (I think less than 4%, and even fewer have clinically significant bleeds), and profoundly rare in patients who aren’t anticoagulated. Thus, I think the statement that delayed bleeds are “quite possible” is a bit exaggerated.
Canadian CT rules
ok
I think if the patient is coagulopathic, particularly if old (but even if young) a CT head is almost unavoidable with any presentation involving head injury.
However, if the patient is >65, I think you have to really be careful about the inclusion criteria of the CT head rules (minor head injury with initial GCS 13-15, Amnesia to the head injury event, Confusion). If the patient does not meet any of these criteria, the rules should not even be applied regardless of age.
very low threshold for CT head as per Canadian CT Head Rules
reverse elevated INR if present
k
This is such a tricky one, if in a centre without a CT.
CT Head liberally. Relatively low threshold to CT C-Spine if complaining of neck pain, since X/R are not very sensitive and histories can be very poor. We have to call in the tech for imaging after midnight, so will often hold the patient in ED for observation till CT in the morning.
We usually get Head CT because it is easy and fast
UK NICE guidelines apply for me: CT for those over 65 with LoC or amnesia (other more definite indications trigger a CT earlier in the NICE guideline e.g. focal deficit)…but how do you assess LoC and amnesia with impaired cognitive function? We tend to use the CT in the elderly fairly liberally, especially as the radiation risk is not an issue.
Thanks for the link to guidelines/article
CT
If they are on warfarin – CT
CT brain is now so readily available 24 hours in our institution that very low threshold to scan. Virtually all get a scan if they have hit their head whether on anti-coagulants or not.
May not scan some of the high level care patients who would not be neurosurgical candidates after discussion with the family
High index of suspicion is the key…
Canadian C Spine rule
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Follow the Canadian CT Head rules.
suspect TBI until proven otherwise
high level of suspicion, scans and other diagnostics, investigate cause of trauma as well
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Scan them all!
We see a lot of elderly patients with ICH secondary to TBI and anticoagulation. CT head very important in this population!
What do Unicorns eat for breakfast?
Lucky Charms.
Important to acknowledge to patients and families that a normal head CT does not predict bleed risk in the subsequent days, though multiple studies of anticoagulated patients (warfarin, not NOAC) indicate bleed rates of ~1% in the 1-2 days following a negative head CT after blunt trauma. The question then becomes should anticoagulated blunt head injury patients be admitted after a negative CT for observation or should they be discharged home. Lee et al. have estimated that the societal healthcare cost per life-saved to admit ALL of these patients exceeds $1 million (U.S. not Canadian :)), which is probably more than most nation’s can bear. So who to admit?
UK NICE guidelines, but with a much lower threshold for CT and admission. Admission also guided by social circumstances and support/isolation at home.
CT brain routinely done for all elder patients with head injury > 65
Our centre also has a lower threshold for CT head in older patients with head injury
not applicable
j
low threshold for CT, caregiver consultation for preceding events and home care, when in doubt even if CT normal patient is kept or admitted for observation, neurosurgery consult or MRI the next day
We follow the UK NICE guidelines for head trauma, we also have a lower threshold for doing CT scans in the elderly with minor head injury. We also neuro-watch them for at least 12 hours if on initial assessment we do not think a CT is warranted. For those we discharge every effort is made to liaise with a caregiver or relative. If patient does not have good social support they re admitted for observation for at least 24 hours and social workers are contacted from the ward.
actualmente tomografia y resonancia magnetica
in all patients whit more than 65 years old and head trauma we prefer to do a CT scan
prior to discharge from de emergency service, and those patients whit abnormal neurologic exam or those that are somnolent, we repeat de ct sac prior to discharge
only tomography or radiographs and no management protocols
Daily basis. One of the most common complaints in trauma centers…
excelente información
We tend to use the UK Nice guidelines of CT in head trauma. Very similar to the Canadian Head CT rules. I have a low threshold for scanning the elderly. Most of this population are on antiplatelet or anticoagulant therapy and many are poor historians. If the CT Brain is normal I may still neurowatch them for 12-24 hrs depending on the mechanism of injury, if I suspect a subdural and their GCS and social support. The ED is not the ideal place for neurowatch especially since the nurses aren’t trained to do neurochecks but our neurosurgery ward only has 6 beds so I might as well keep the patients in the department.
CT C-spine is another kettle of fish. We only have a one functioning 16 slice CT machine. The C-spine images are poor quality sometimes. But the lateral C-spine x rays can be very inadequate at times due to the rigid collar and positioning and radiographers not attempting different methods to obtain a better view.
in elderly who are on anticoagulants,with a history fall, and no LOC and have un remarkable neuro exam, admission for observation as oppose to sending them out for head CT works for us. we use this approach because we do not have CT scanner on site.
We do have a low threshold for doing CT in older patients
Good information. 🙂
Tricky area
nice
xx
kkk
frequent neurovitals, decrease stimulation, CT head and bw
head injury protocol, c-cpine collar, ct scan, transfer to trauma centre with neuro sx depending on case
significant brain bleeds get transferred to a trauma centre
I do not think that we CT heads as much as we should in the elderly. Many of them appear “fine” and we treat them as we would a younger and much less at risk individual. Some work convincing radiologists would be helpful for more appropriate investigation.
CT head rules, higher index for those on anticoagulants
I have a hard not doing a CT head on someone elderly. I think I CT most elderly folks who have a head injury if they are on any anti coagulation, which seems to be almost everyone
Without good follow up by the FD or anticoagulation clinic to hold warfarin for a few days to reduce the risk of post bleed might mean practically that they stay sub therapeutic for weeks.
Therefore we tend not to reverse them or hold warfarin if CT is normal, but give strict instructions on returning to ER if any change in mental stays, headache etc. I agree not clear answer on this
Cervical Collar,CTScan Head.
follow the new NICE guidelines
order CT head
In LTC I may forego the CT depending on the patient’s and family wishes. Many families and patients have specific requests especially in the context of cognitive impairment. They have orders such as “do not transfer out”. The staff has explained the risk of falls and SDH esp in the context of anti-coagulation. Families often find the trip to the ER itself too stressful on their loves ones and opt for comfort measures.
This is an issue I often struggle with. For me to get a head CT requires an ambulance transfer to a larger city hospital that’s 1.5 hrs away. My town then looses an ambulance (we only have 2) for the next 4 hours. With these constraints, I often forgo ordering a head CT for minor trauma if there was no LOC, no neurological deficits, and close follow-up and monitoring is available. It’s not ideal, but I have to work within our system.
What are the chances of an elderly patient going on to develop a contusion or late subdural in the setting of minor trauma, normal CT and therapeutic INR (2-3)? Is the risk greater than that of resident going on to have stroke with anticoagulation reversed? Most falls in LTC are not transferred to ER and investigated with CT head (even those on anticoagulation, unless concerning signs/symptoms develop). Should LTC residents with falls then be taken off anticoagulation?
I tend to do a head CT on any patient who has either had a head injury (regardless of LOC or not) or cannot remember if they hit their head. I also maintain a low threshold for ordering a Head CT if they are anticoagulated.
I don’t reverse a patient’s INR if it is in target range and they have had a minor head injury with a negative CT head. I understand if you are suggesting that they should ease up on their doses of warfarin for a couple days, but are you suggesting actively reversing people if they are therapeutic and have a normal CT head to reduce the risk of a late bleed? I think that reversing warfarin then trying to get it back up to target and get it tested again is quite difficult for the patient and their families (they will need lots of testing that is difficult to get in our community).
What is your suggestion if they are on a newer anticoagulant? Hold for a few days? Evidence has shown that we can safely hold anticoagulation for up to 5 days (ie. for dental procedures).
I’m curious what are other people doing?
Great questions and comments! There are no evidence-based guidelines in this area at all. So patient-specific experience-driven geriatric-aware clinical judgement will always prevail. The idea behind actively reversing people — perhaps those perceived to be at higher risk (frailer, less social support, lower indication for anti-coagulation e.g. parox a fib; or with a more significant trauma) is to try to prevent a delayed bleed. We know that older people are at increased risk of spontaneous SDH even without trauma — certainly much more so after a major head blow. Doctors and patients need to be aware that even if the Head CT is normal tonight, the risk of bleeding is still heightened for several days to come. With the newer irreversible anticoagulants, my practice would be to hold them for several days. If the indication for anticoagulation is a. fib., surely the risk of atrial clot formation can’t become substantial for at least a week with anticoagulation. Difficult questions.
Had the same question/thoughts. I’ve never seen and have never reversed a therapeutic range INR in a minor HI elderly with initial negative CT (regardless of indication for anticoagulation). I can’t imagine being able to admit all these patients for observation as beds are tight as is. If I reverse with Vit K, then it will be weeks until they are therapeutic again which makes me wonder if harm is outweighed by benefit. I think d/c with reliable caregiver who understands higher risk of future bleed/re-bleed is the way to go…
agree
if no subdural no blood dyscrasia and available caregivers then patient is dischargedhomme, otherwise supervised for 24 hrs then dc with CCAC
head injury routine , cervical collar , blood panel and ct brain scan