Code 3 Workshop

Paramedic Education
Home/All lessons/Trauma/Anticoagulated Trauma: The Bleed You Cannot See
Lesson

Anticoagulated Trauma: The Bleed You Cannot See

11 min Trauma Skip to quiz

Objective: Treat anticoagulant plus head or torso trauma as high-risk even when the exam is reassuring, and do not delay a trauma or stroke-capable CT for a long scene.

Why This Is Hard

They walked to the chair. GCS 15. The family says “he’s on a blood thinner.” Crews cancel trauma because ATLS look-normal. BTF prehospital TBI and ACS geriatric trauma teaching: anticoagulants raise the risk of delayed intracranial hemorrhage. DOACs (apixaban, rivaroxaban, dabigatran) do not have a field INR. You cannot “clear” this on a porch.

On this truck
  • Ask every trauma and every fall: anticoagulants, antiplatelets, last dose if known. Photograph the bottles.
  • GCS 15 does not clear an anticoagulated head. Serial exams in the truck. Vomiting, headache, or a new deficit upgrades the clock.
  • Destination: a hospital that can CT and reverse or operate. Not every clinic with an x-ray.

Street Sequence

  1. MARCH as always. Then neuro exam and glucose.
  2. Medication history: warfarin, DOAC, heparin, antiplatelet, last dose, why they take it.
  3. If head/torso mechanism plus anticoagulant: trauma-center (or protocol equivalent) even if they look well.
  4. Do not give anything that worsens bleeding “for comfort” without a protocol. TXA is a protocol question — see the TXA lesson; it is not a DOAC reversal agent.
  5. Notify: “ground-level fall, apixaban, GCS 15, headache.” That sentence changes the CT queue.

Field Rules (Education)

  • The list: warfarin, apixaban, rivaroxaban, edoxaban, dabigatran, enoxaparin, heparin, dual antiplatelets. “Blood thinner” from a family member counts until proven otherwise.
  • INR is not a truck test for DOACs. A “therapeutic” story is still a CT story.
  • Geriatric standing-height falls plus anticoagulants are a classic under-triage. See geriatric trauma.
  • Reversal (PCC, andexanet, idarucizumab) is hospital. Your job is recognition, protection of the airway if they decline, and the right door.
Say out loud
  • Anticoagulant is __ — last dose unknown/known
  • Exam can lie — still a CT destination
  • Not a lift-assist
  • Bringing the bottles

Field Pitfalls

  • Canceling because they want to refuse and GCS is 15.
  • Leaving the medication list on the kitchen table.
  • Giving IM ketorolac for the hip pain in a patient on apixaban.

Practice

60-second drill

88-year-old, ground-level fall, apixaban, GCS 15, small scalp hematoma, wants to stay home. What do you say about risk, destination, and refusal? What goes with you if they come?

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

Street decisions from this lesson only. 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 (apixaban, rivaroxaban, dabigatran) in the field:
3. The most useful thing to bring to the ED is:
4. TXA in anticoagulated trauma:
← Penetrating Neck Trauma Trauma category →