Head injury and blood thinners-When to Scan

Subscribe to Resus

Get the latest updates on our Conferences PLUS our Webcasts and Education Newsletters. And it's FREE!

  • We respect your privacy
  • This field is for validation purposes and should be left unchanged.

Register Now:

Sorry, we couldn't find any posts. Please try a different search.

Head injury in the anticoagulated patient can be a challenge. Below is the approach I use. I then read a 2012 paper from the Annals of Emergency Medicine, which gives us the evidence on what our approach might be.

Here’s the scenario. A 56 yo male is brought to the emergency department following a mechanical fall at work. He has hit his head. He hasn’t lost consciousness, his GCS is 15, but has had a significant fall from a standing height. You find that he has a history of cardiac disease and is on clopidogrel. Do you CT scan this patient’s brain? If so, when? Do you admit for observation as he is on a blood thinner.

Here’s a second scenario. A 68 yo woman is brought to the emergency department following a mechanical fall, from a standing height and a head strike. She lost consciousness for 2-3 seconds. On assessing the patient you find that she is on warfarin for atrial fibrillation. Does she need a scan? When? Should be be admitted for observation? Should the warfarin be reversed?

My approach to CT’s is simple. I use my own ‘HAAGLE’ formula(as I used to have to haggle with the radiology registrar to get a head CT). It applies to the lower risk head injury, not the major head injury; they’re straightforward; just scan them all.

Here it is: (Only one of these is needed to trigger a scan)

HHeadache that the physician considers significant

AAmnesia- ante or retrograde in nature of > 30 minutes

AAnticoagulated- and this includes warfarin and clopidogrel. I also include aspirin

GGCS of < 15 at any time

LLoss of consciousness at any time

EEmesis of > 2 episodes

In terms of when to scan; I do so when the patient comes in. There is certainly evidence that bleeds can occur later in the elderly, however most will have a bleed when they come in?

A recent article by Nishijima et al Ann Emerg Med 2012;59(6):460-468,can help us.  The authors looked at ‘Immediate and delayed traumatic intracranial haemorrhage in patients with head trauma and pre injury warfarin or clopidogrel use’

It was a prospective observational study of 1064 patients. Patients were followed for two weeks after their initial presentation.

Of the total group of 1064 patients , 768 were on warfarin and 296 were on clopidogrel.

Immediate intracranial haemorrhage was present in:

  •      12% of those receiving clopidogrel vs 5.1% of those receiving warfarin.

Delayed intracranial haemorrhage ie., within 2 weeks was present in:

  •      0% on clopidogrel vs 0.6% of patients on warfarin

This study indicates that a CT on patient arrival to the emergency department is still very reasonable. It also indicates that a very small percentage of patients have a delayed bleed. It is therefore appropriate, unless there are other concerns to discharge these patients, without a repeat head CT, however with strict instructions, because delayed bleeding can occur. There is also no need to reverse anticoagulation if it is therapeutic.

Dr Peter Kas

Emergency Physician, Educator. Key Interests: Resuscitation, Airway, Emergency Cardiology, Clinical Examination. Creator resus.com.au.

108 Comments

  1. Medstudent on 14/12/2012 at 10:28 am

    Thank you Dr. Kas for this blog. You mentioned that you don’t need to reverse anticoagulation if it is therapeutic, what are situations that you would stop it immediately?

    • admin on 05/03/2017 at 10:04 am

      I seem to have missed this comment. Sorry. What I meant was that if the CT is normal, they need no adjustment in their dose, as long as it’s therapeutic. If the patient had a very high INR i.e. I would stop it. If the patient had a bleed, not only would you stop it, but reverse it.

  2. Zafar on 16/03/2017 at 11:28 am

    So what you mean scan heads of all patients on Anticoagulant and ant platelets.No need to use Canadian minor head injury rule .

    • admin on 16/03/2017 at 5:08 pm

      Hi Zafar
      The simple answer is yes. The Canadian Minor Head Injury Rule CANNOT be applied if the patient is anticoagulated.

  3. Ajay on 29/04/2017 at 12:38 pm

    Interesting. I have never scanned anybody just because they were on Aspirin unless they had other factors, for example LOC etc as you mentioned. During the last 20yrs not a single patient came back with any significant symptoms or bleeding. Just my experience…………..

    • admin on 30/04/2017 at 9:38 am

      Hi Ajay
      I think you’re right, the literature only discusses warfarin and clopidogrel. Aspirin is my addition, but I think your right, I haven’t found too many either. The saver is that most people I see are on both aspirin and clopidogrel, so I haven’t scanned that many only aspirin patients.

  4. Danielle on 12/07/2019 at 6:22 am

    Isn’t it dangerous to give a patient admitted with s subdural hematoma a blood thinner to prevent dvt?

  5. Pinaki Roy on 02/08/2019 at 2:17 pm

    very good site

  6. bienvjprg on 30/08/2021 at 3:53 am

    Head injury and blood thinners-When to Scan – Resus
    bienvjprg http://www.g023l886zezjm5hb6186wl72yd8nb8l6s.org/
    [url=http://www.g023l886zezjm5hb6186wl72yd8nb8l6s.org/]ubienvjprg[/url]
    abienvjprg

  7. Jimmy on 17/09/2021 at 10:10 am

    Hey I know this is off topic but I was wondering
    if you knew of any widgets I could add to my blog that automatically tweet my
    newest twitter updates. I’ve been looking for a plug-in like this for quite some time and was hoping maybe you would have some experience with something like this.
    Please let me know if you run into anything. I truly enjoy reading your blog and I look forward to your new updates.

  8. Bioneo Farms CBD Review on 17/09/2021 at 10:13 am

    Regards for this post, I am a big big fan of this
    website would like to go on updated.

    Look at my web page :: Bioneo Farms CBD Review

  9. Mega Male Enhancement Pills on 17/09/2021 at 10:22 am

    I have not checked in here for some time because I thought it was getting boring,
    but the last several posts are great quality so I guess I’ll add you back to my everyday
    bloglist. You deserve it friend 🙂

    my web page; Mega Male Enhancement Pills

  10. Max Melt Keto on 17/09/2021 at 10:27 am

    Fastidious response in return of this question with
    firm arguments and describing the whole thing concerning
    that.

    Review my page … Max Melt Keto

  11. https://polywebhost.com on 17/09/2021 at 10:48 am

    Hey just wanted to give you a brief heads up and let you know a few of the images aren’t
    loading properly. I’m not sure why but I think its a linking issue.
    I’ve tried it in two different internet browsers and both show the same results.

    Here is my web-site Erectesto XL Reviews (https://polywebhost.com)

  12. Hello there! This blog post couldn?t be written any better!
    Looking at this post reminds me of my previous roommate!

    He constantly kept preaching about this. I will send this information to him.

    Fairly certain he will have a good read. I appreciate you for sharing!

    Also visit my blog post; Max Melt Keto Reviews (http://www.comptine.biz/modules.php?name=Your_Account&op=userinfo&username=AkilahSwai)

  13. A1 Keto BHB Reviews on 17/09/2021 at 11:09 am

    You have brought up a very good points, regards for the post.

    my web blog – A1 Keto BHB Reviews

  14. Liliana on 17/09/2021 at 11:16 am

    Thank you, I have recently been searching for info about this subject for
    a long time and yours is the greatest I’ve came upon so far.
    But, what in regards to the conclusion? Are you certain concerning the source?

    Feel free to surf to my blog – Extreme Keto EFX [Liliana]

  15. polywebhost.com on 17/09/2021 at 11:26 am

    Howdy! This blog post couldn’t be written much better! Looking through this post reminds me of my previous roommate!
    He continually kept preaching about this.
    I most certainly will send this article to him.
    Fairly certain he’s going to have a very good read.
    I appreciate you for sharing!

    Here is my webpage: GrownMD CBD [polywebhost.com]

  16. Tanja on 17/09/2021 at 11:59 am

    My relatives always say that I am killing my time here at
    net, however I know I am getting knowledge daily by reading such good posts.

  17. Bioneo Farms Pure CBD on 17/09/2021 at 12:31 pm

    Hey there I am so glad I found your weblog, I really found
    you by accident, while I was researching on Aol
    for something else, Regardless I am here now and would just like
    to say kudos for a tremendous post and a all round exciting blog (I also love
    the theme/design), I don’t have time to read it all at the moment but I have book-marked
    it and also included your RSS feeds, so when I have
    time I will be back to read a great deal more, Please do keep up the superb work.

    My web page … Bioneo Farms Pure CBD

  18. Ultra Quick Keto Burn Reviews on 17/09/2021 at 12:35 pm

    Thanks on your marvelous posting! I really enjoyed reading it, you’re a great
    author.I will remember to bookmark your blog and definitely will come back in the future.
    I want to encourage yourself to continue your great posts, have a nice morning!

    Also visit my homepage; Ultra Quick Keto Burn Reviews

  19. Branden on 17/09/2021 at 12:51 pm

    I like this website very much so much excellent info.

    My web page Grown MD CBD (Branden)

  20. Extreme Muscle XXL Review on 17/09/2021 at 12:59 pm

    Greetings! Very helpful advice in this particular post!
    It’s the little changes that produce the largest changes. Thanks a lot for sharing!

    my web blog Extreme Muscle XXL Review

  21. Pure CBD Softgels Review on 17/09/2021 at 3:28 pm

    I was studying some of your blog posts on this internet site and I think this internet site is really instructive!
    Continue posting.

    Here is my web site :: Pure CBD Softgels Review

  22. www.fles.hlc.edu.tw on 17/09/2021 at 4:13 pm

    For newest information you have to go to see
    web and on web I found this site as a finest site for most up-to-date updates.

    Feel free to surf to my website – Renew Brite Teeth Whitening (http://www.fles.hlc.edu.tw)

  23. Damon on 17/09/2021 at 7:47 pm

    Great blog you’ve got here.. It’s difficult to find excellent
    writing like yours these days. I seriously appreciate individuals like you!
    Take care!!

  24. http://sc.sie.gov.hk on 18/09/2021 at 2:54 am

    Hello, Neat post. There is a problem together with your site in internet explorer, would
    check this? IE nonetheless is the market chief and a good component of people will
    pass over your great writing because of this problem.

  25. Link Slot deposit pulsa tanpa potongan on 18/09/2021 at 5:19 am

    Everdy weekend i used to go to see this web site, as i want enjoyment, as this thіs ᴡebsite conations ցenuinely nice funy data too.

    Have a look at my weƄѕite – Link Slot deposit pulsa tanpa potongan

  26. data togel china on 18/09/2021 at 5:52 pm

    Excellent article. Keep writing such kind
    οf informаtion on youг site. Im гeally impressed bby your ѕite.

    Hey there, You’ve done a fantastiс job.
    I’ll ԁefijnitely digg it and personally suggest to my friends.
    I’m syre they’ll be benefited from this sitе.

  27. Fletcher on 18/09/2021 at 10:43 pm

    With havin so much written content do you ever run into any problems of
    plagorism or copyright violation? My website has a
    lot of exclusive content I’ve either created
    myself or outsourced but it appears a lot of it is popping it up all over the internet without my agreement.
    Do you know any solutions to help prevent content from being
    stolen? I’d really appreciate it.

  28. togel china on 19/09/2021 at 1:53 am

    This is a vеry good tip espеcially to those freshh to the bⅼogosphere.

    Short bbut very precise info… Thanks for sharing this
    one. A mus read article!

  29. Ramona on 19/09/2021 at 8:17 am

    I know this if off topic but I’m looking into starting my own blog and was
    curious what all is needed to get setup? I’m assuming having a blog like yours would cost a pretty penny?
    I’m not very web savvy so I’m not 100% certain. Any recommendations or advice would be greatly appreciated.

    Many thanks

  30. Riley on 19/09/2021 at 1:34 pm

    Admiring the time and effort you put into your website and detailed information you present.
    It’s nice to come across a blog every once in a while that isn’t the same outdated rehashed
    material. Wonderful read! I’ve bookmarked your site and I’m including your RSS feeds to my Google account.

  31. Catherine on 19/09/2021 at 3:42 pm

    Attractive component to content. I just stumbled
    upon your website and in accession capital to assert that I acquire in fact enjoyed account your blog posts.
    Any way I will be subscribing on your augment or even I achievement you get right of entry to persistently rapidly.

  32. bắn cá w88 on 20/09/2021 at 12:11 am

    Nice response in return of this query with eal arguments and describing everything
    concerning that.

    Feel free to visit my blog post … bắn cá w88

  33. George on 20/09/2021 at 1:23 am

    Excellent goods from you, man. I’ve understand
    your stuff previous to and you are just extremely fantastic.
    I actually like what you have acquired here,
    certainly like what you’re stating and the way in which
    you say it. You make it entertaining and you still care for to keep it smart.
    I can not wait to read much more from you. This is really a wonderful site.

  34. Loretta on 20/09/2021 at 10:26 am

    You really make it appear so easy with your presentation however
    I in finding this matter to be really something which I feel I would by no means understand.

    It seems too complex and very wide for me. I’m having a
    look forward in your next post, I will attempt to get the hang of
    it!

  35. Cathryn on 20/09/2021 at 11:14 am

    I think everything wrote made a ton of sense.
    But, think on this, suppose you composed a catchier title?
    I mean, I don’t wish to tell you how to run your website,
    however what if you added a headline that makes people want more?

    I mean Head injury and blood thinners-When to Scan – Resus is kinda vanilla.

    You might glance at Yahoo’s front page and note how they write news titles to grab people interested.
    You might add a related video or a picture or two to grab readers excited about everything’ve written. Just my opinion,
    it might make your website a little livelier.

  36. Google on 26/09/2021 at 2:27 pm

    Google

    Just beneath, are a lot of absolutely not associated web pages to ours, however, they may be surely worth going over.

  37. Google on 26/09/2021 at 10:52 pm

    Google

    Please stop by the web-sites we follow, like this one particular, because it represents our picks through the web.

  38. Macbook akku auswechseln pfäffikon on 01/10/2021 at 1:51 am

    Macbook akku auswechseln pfäffikon

    […]Every once in a when we select blogs that we study. Listed below are the most up-to-date web pages that we pick out […]

  39. Pinball Machines for Sale on 01/10/2021 at 3:09 am

    Pinball Machines for Sale

    […]the time to study or go to the subject material or web pages we’ve linked to beneath the[…]

  40. Masai Mara safari hotels on 01/10/2021 at 6:27 am

    Masai Mara safari hotels

    […]here are some links to web sites that we link to since we believe they may be really worth visiting[…]

  41. Livestock for sale on 01/10/2021 at 12:02 pm

    Livestock for sale

    […]that would be the end of this write-up. Right here you will find some websites that we think you will enjoy, just click the links over[…]

  42. Macbook pro akku tauschen rapperswil on 01/10/2021 at 9:07 pm

    Macbook pro akku tauschen rapperswil

    […]Wonderful story, reckoned we could combine a handful of unrelated information, nonetheless truly worth taking a look, whoa did one particular understand about Mid East has got extra problerms also […]

  43. Uganda adventure safaris on 02/10/2021 at 2:06 pm

    Uganda adventure safaris

    […]Wonderful story, reckoned we could combine several unrelated data, nonetheless really worth taking a search, whoa did one master about Mid East has got much more problerms too […]

  44. best doc johnson sex toys on 02/10/2021 at 11:14 pm

    best doc johnson sex toys

    […]here are some links to sites that we link to due to the fact we think they are worth visiting[…]

  45. GUMTREE FARMING EQUIPMENT FOR SALE on 03/10/2021 at 2:16 am

    GUMTREE FARMING EQUIPMENT FOR SALE

    […]here are some hyperlinks to web pages that we link to mainly because we believe they’re really worth visiting[…]

  46. shipping containers for sale on 03/10/2021 at 8:52 am

    shipping containers for sale

    […]the time to study or check out the subject material or websites we’ve linked to below the[…]

  47. Serengeti African safari on 03/10/2021 at 6:27 pm

    Serengeti African safari

    […]although internet sites we backlink to beneath are considerably not related to ours, we really feel they may be basically really worth a go by, so have a look[…]

  48. ارقام بنات on 03/10/2021 at 9:43 pm

    ارقام بنات

    […]please stop by the websites we comply with, like this one, as it represents our picks from the web[…]

  49. Angelia on 06/10/2021 at 12:50 pm

    bookmarked!!, I like your site!

  50. izrada web sajtova on 07/10/2021 at 5:07 pm

    izrada web sajtova

    Izrada web sajtova, mobilnih aplikacija, portala i internet prodavnica

  51. www.myloweslife.com on 08/10/2021 at 10:27 am

    http://www.myloweslife.com

    […]below you’ll uncover the link to some web pages that we consider you need to visit[…]

  52. Buy Ketamine online on 10/10/2021 at 9:51 pm

    Buy Ketamine online

    […]check below, are some absolutely unrelated sites to ours, however, they’re most trustworthy sources that we use[…]

  53. Buy Viagra gold online on 11/10/2021 at 10:40 am

    Buy Viagra gold online

    […]here are some hyperlinks to sites that we link to since we believe they’re really worth visiting[…]

  54. GELATI STRAIN on 12/10/2021 at 11:31 am

    GELATI STRAIN

    […]although websites we backlink to below are considerably not connected to ours, we feel they’re basically really worth a go by, so have a look[…]

  55. taurus g3c on 13/10/2021 at 7:14 pm

    taurus g3c

    […]the time to read or take a look at the content material or web pages we have linked to beneath the[…]

  56. benelli nova 18 inch barrel on 13/10/2021 at 7:51 pm

    benelli nova 18 inch barrel

    […]usually posts some incredibly intriguing stuff like this. If you are new to this site[…]

  57. sig sauer emperor scorpion on 14/10/2021 at 7:56 am

    sig sauer emperor scorpion

    […]usually posts some pretty intriguing stuff like this. If you’re new to this site[…]

  58. sig p938 academy on 14/10/2021 at 8:11 am

    sig p938 academy

    […]very few sites that come about to become comprehensive beneath, from our point of view are undoubtedly nicely really worth checking out[…]

  59. mossberg patriot 308 for sale on 14/10/2021 at 7:53 pm

    mossberg patriot 308 for sale

    […]the time to study or go to the content or websites we have linked to below the[…]

  60. invaders from the planet moolah slot machine for sale

    […]usually posts some quite intriguing stuff like this. If you’re new to this site[…]

  61. buy ruger firearms online europe on 21/12/2021 at 6:14 am

    buy ruger firearms online europe

    […]here are some links to websites that we link to mainly because we feel they’re really worth visiting[…]

  62. heckler & koch mr556a1 on 22/12/2021 at 6:31 pm

    heckler & koch mr556a1

    […]here are some links to web sites that we link to mainly because we feel they are really worth visiting[…]

  63. tisas 1911 stainless on 23/12/2021 at 12:47 am

    tisas 1911 stainless

    […]one of our visitors lately encouraged the following website[…]

  64. uca.com.vn on 24/12/2021 at 3:23 pm

    uca.com.vn

    […]one of our visitors lately encouraged the following website[…]

  65. utsoo on 27/12/2021 at 6:50 am

    utsoo

    […]Every after inside a although we pick out blogs that we study. Listed beneath would be the newest web sites that we decide on […]

Leave a Comment