Skip to main content

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.


  • Medstudent says:

    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 says:

      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.

  • Zafar says:

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

    • admin says:

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

  • Ajay says:

    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 says:

      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.

  • Danielle says:

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

  • Pinaki Roy says:

    very good site

  • Jimmy says:

    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.

  • Tanja says:

    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.

  • Damon says:

    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!!

  • 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.

  • 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.

  • Fletcher says:

    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.

  • togel china says:

    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!

  • Ramona says:

    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

  • Riley says:

    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.

  • Catherine says:

    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.

  • George says:

    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.

  • Loretta says:

    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

  • Cathryn says:

    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.

  • Pingback: Google
  • Angelia says:

    bookmarked!!, I like your site!

Leave a Reply