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Case Presentation:

• 55-year-old male with a past medical history of ESRD (on dialysis) and antiphospholipid antibody syndrome (on warfarin) presents to the ED after falling off his bed.

• He landed on his right hip, has dislocated it four times in the last five months, and states “it feels like it’s dislocated again”.

• It was an unwitnessed fall; he denies loss of consciousness and denies hitting his head.

• His vitals on presentation are: BP: 140/91, HR 69, RR 16, O2 92%, T 36.9.

• On exam, he is frail and chronically ill appearing, with a central catheter for dialysis. He has marked deformity of his right hip, with his right leg shorter than his left. He is alert and oriented, has no other signs of trauma, and has no complaints on ROS aside from leg pain.

• His INR is 1.5 and other basic labs are within his historical normal limits.

Clinical Question:

Does an elderly patient on oral anticoagulation (OAC) with GCS 15 after a ground-level fall (GLF) require a head CT?

Background Information:

• The elderly and those with chronic medical conditions, such as atrial fibrillation, are more likely to require OAC.[i]

• Patients on OAC are at a higher risk of mortality after falls and can have up to a 10x increase in the rate of intracranial hemorrhage.[ii],[iii]

• The Canadian Head CT/Trauma rule is a clinical decision tool designed to standardize the management of patients with minor head injury.[iv]

• The study identified 7 risk factors (5 high-risk and 2 medium-risk) that should warrant head imaging.

• Notably, patients deemed too low of a risk (no LOC, amnesia, or disorientation) or too high (those with bleeding disorders or on OAC) were excluded from enrollment.

• A 2005 validation study concluded that the decision rule was 100% sensitive for identifying both those needing neurosurgical intervention and for detecting clinically important brain injury.[v]

• Moreover, compared with another validated decision rule, its implementation resulted in a reduction in head CTs performed.

Literature Review:

• A 2018 meta-analysis identified 5 studies comprising 4,080 anticoagulated patients with GCS 15 following a head injury. The authors’ analysis generated an intracranial hemorrhage (ICH) incidence of up to 10.9%, the clear majority of whom were on warfarin.[vi]

• Spaniolas et al. found that in 57,302 patients with a GLF, mortality in the elderly was significantly higher than in the nonelderly (4.4% vs. 1.6%, p <0.0001) and the elderly were more likely to sustain intracranial injury (10.6% vs. 8.7%, p<0.0001).[vii]

• These statistics may be a bit misleading as elderly was defined as age greater than 70 and only 7% of the falls in the non-elderly cohort were by individuals under 65 years old.

• A 2017 retrospective study of patients greater than 55 years old with a GCS 15 after a GLF showed that of the 437 patients who received head CTs, 146 (33.4%) had a positive finding, 95 (21.7%) had a change in management, and 19 (4.3%) required neurosurgical invention.[viii]

• The inclusion criteria did not specifically require head trauma and OAC status was not analyzed.

• Consecutive adult patients who presented to the ED with a GLF were enrolled if they had a head CT performed and were on anti-platelet or OAC therapy.

• The average enrollment age was 78.3+11.9 years, in line with the understanding that the elderly are more likely to be anticoagulated.

• In 180 patients on OAC, in whom (179) 99.4% were awake and alert, only 3 (1.7%) showed ICH on head CT, with a similar 30-day mortality.

• In the OAC cohort, 78 (43.3%) patients stated they did not hit their head.

Recommendations:

• Patients on OAC with head trauma after a ground-level fall should receive a head CT.6

• While Ganetsky et al. showed a low likelihood of ICH after ground-level fall, this conclusion was “unanticipated and counterintuitive, as most literature and teaching suggests a higher rate”.9

• As most statistics of ICH after a fall are based on trauma registries, the criteria in which patients were enrolled provides credibility to the study’s results, despite its somewhat paradigm shifting conclusion.

• Many aspects of this study dilute its ability to establish a new standard level of care (ex: retrospective nature, sample size, single center) in assessing the need for head CT for those on OAC after a GLF.

• There should be a low threshold to scan the elderly on OAC after a GLF due to the risks of bleeding and the resultant likelihood that identification of a bleed would result in a change in clinical management.

Case Resolution

• While the patient in question was not chronologically elderly, his chronic medical condition rendered him frail for his age. Thus a head CT was ordered.

• The patient refused the scan and his hip was reduced under procedural sedation without complication.

• He also refused observation stay with physical therapy follow-up in the morning and was discharged home.

References:

1. Robert-Ebadi H and Righini M. Anticoagulation in the Elderly. Pharmaceuticals (Basel). 2010 December; 3(12); 3543-3569.

2. Inui T, Parina R, Chang D, Inui T, Coimbra R. Mortality after ground-level fall in the elderly patient taking oral anticoagulation for atrial fibrillation/flutter: A long-term analysis of risk versus benefit. Journal of Trauma and Acute Care Surgery. 2014 March; 76(3); 642-650.

3. Hart R, Boop B, Anderson D. Oral Anticoagulants and Intracranial Hemorrhage. Stroke. 1995 August 1. 26(8); 1471-1477.

4. Steill IG, Wells GA, Vandemheen K, Clement C, Lesiuk H, Laupcais A, McKnight RD, Verbeek R, Brison R, Cass D, Eisenahuer MA, Greenberg GH, Worthington J. The Canadian CT Head Rule for patients with minor head injury. The Lancet. 2001 May 5. 357 (9266); 1391-1396.

5. Stiell IG, Clement CM, Rowe BH, Schull MJ, Brison R, Cass D, Eisenhauer MA, McKnight RD, Bandiera G, Holroyd B, Lee JS, Dreyer J, Worthington JR, Reardon M, Greenberg G, Lesiuk H, MacPhail I, Wells GA. Comparison of the Canadian CT Head Rule and the New Orleans Criteria in patients with minor head injury. JAMA. 2005 Sept 28; 294(12); 1511-1518.

6. Mihas H, Welsher A, Turcotte M, Eventov M, Mason S, Nishijima DK, Versmee G, Li M, de Wit K. (2018) Incidence of intracranial bleeding in anticoagulated patients with minor head injury: A systematic review and meta-analysis of prospective studies. British Journal of Haematology. 2018 July 20; Web accessed: Sept 28, 2018.

7. Spaniolas K, Cheng J, Gestring M, Sangosanya A, Stassen N, Bankey P. Ground Level Falls Are Associated With Significant Mortality in Elderly Patients. The Journal of Injury, Infection, and Critical Care. 2010 October. 69(4); 821-825.

8. Sartin R, Kim C, Dissanaike S. Is routine head CT indicated in awake stable older patients after a ground level fall? The American Journal of Surgery. 2017 December. 214 (6); 1055-1058.

9. Ganetsky M, Lopez G, Coreanu T, Novack V, Horng S, Shapiro N, Bauer K. Risk of Intracranial Hemorrhage in Ground-level Fall with Antiplatelet or Anticoagulant Agents. Academic Emergency Medicine. 2017 October. 24(10); 1258-1266.