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Lesson

Anticoagulated Trauma

11 min Trauma Skip to quiz

Objective: Treat head or torso trauma in a patient on a blood thinner as high risk, even when the exam looks normal. Do not stay on scene. Do not skip a hospital that can scan the patient and reverse the drug.

Why this matters

The patient walked to a chair. The Glasgow Coma Scale (GCS) is 15, so the exam looks normal. The family says the patient takes a blood thinner. Do not cancel the trauma response because the exam looks normal.

Anticoagulants raise the chance of bleeding inside the skull hours later. Direct oral anticoagulants (DOACs) such as apixaban, rivaroxaban, and dabigatran do not have a clotting test you can run in the field. A normal exam does not clear this patient.

Key points
  • Ask every trauma patient and every fall patient about anticoagulants, antiplatelet drugs, and the last dose if anyone knows it. Photograph the bottles.
  • GCS 15 does not clear an anticoagulated head injury. Repeat the neuro exam during transport. Vomiting, a worse headache, or a new deficit means this patient needs the hospital sooner.
  • Go to a hospital that can do a CT and can reverse the drug or operate. A clinic that cannot scan or reverse the drug is not enough.
Verbalize
  • Anticoagulant is __. Last dose is known or unknown.
  • The exam can look normal. This patient still needs a CT.
  • This is not a lift back into a chair.
  • We are bringing the medication bottles.

Clinical sequence

  1. Run MARCH as usual: massive hemorrhage, airway, respirations, circulation, then hypothermia and head injury. Then do a neuro exam and check glucose.
  2. Get the medication history. Ask about warfarin, a DOAC, heparin, and antiplatelet drugs. Ask the last dose and why they take it.
  3. If the mechanism involves the head or torso and the patient takes an anticoagulant, go to a trauma center, or the equivalent in your protocol, even if they look well.
  4. Do not give a drug that can worsen bleeding just for comfort unless your protocol allows it. Tranexamic acid (TXA) is a protocol question. It is not a reversal drug for a DOAC. See the TXA lesson. This site does not list a milligram dose.
  5. Notify early. A useful sentence is: ground-level fall, apixaban, GCS 15, headache. That sentence changes how fast they get a CT.

Teaching points

  • The list: warfarin, apixaban, rivaroxaban, edoxaban, dabigatran, enoxaparin, heparin, and dual antiplatelet drugs. If a family member says "blood thinner," treat that as true until you know otherwise.
  • There is no reliable field clotting test for DOACs. A report that the level is therapeutic is still a reason for a CT. An INR does not clear apixaban, rivaroxaban, or dabigatran.
  • Older adults who fall from standing while on an anticoagulant are a classic under-triage. See the geriatric trauma lesson.
  • Reversal drugs such as prothrombin complex concentrate, andexanet, and idarucizumab are hospital drugs. Your job is to recognize the risk, protect the airway if they decline, and choose the right hospital.

Common errors

  • Accepting a refusal, or canceling trauma, only because the GCS is 15.
  • Leaving the medication list on the kitchen table.
  • Giving intramuscular ketorolac for hip pain to a patient on apixaban.

Practice

One-minute check

An 88-year-old fell from standing, takes apixaban, has a GCS of 15 and a small scalp hematoma, and wants to stay home. What do you say about risk, destination, and refusal? If they come with you, what do you bring?

Related: Geriatric Trauma, Traumatic Brain Injury.

Sources & Further Study

Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.

Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.

Check Your Understanding

Questions drawn only from this lesson. After you check, the key is highlighted. Education practice — not a certification exam.

1. An older adult on apixaban after a ground-level fall with GCS 15:
2. DOACs (direct oral anticoagulants such as apixaban, rivaroxaban, dabigatran) in the field:
3. The most useful thing to bring to the ED is:
4. TXA (tranexamic acid) in anticoagulated trauma:
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