At our ER, we routinely perform CT head scans on patients who are treated with anticoagulants and who are admitted with minimal to mild head injuries (GCS 14 – 15). The vast majority of these patients are elderly (> 75 yo) with balance issues. And more often than not the trauma mechanism is "stumbled", "felt dizzy, unsteady and fell" or "has postural hypotension and a known tendency towards syncopes". Regardless of the outcome of the CT, we observe the patients in-hospital for approx. 24 hours. However a positive scan is followed by a repeat CT 6 hours after the scan and (unless surgical evacuation is required) a control CT after 4-6 weeks (of course earlier if the patient develops symptoms) with the patient temporarily discontinuing the anticoagulant. But, the majority of the patients have negative first scan.
This decision is based on the Scandinavian Neurotrauma Commitee Guidelines on management of mild to moderate head injuries: https://www.researchgate.net/figure/Scandinavian-Neurotrauma-Committee-guidelines-19_fig2_286374512
I gather this is similar to the updated NICE guidelines from 2019: https://www.nice.org.uk/guidance/cg176/chapter/1-Recommendations#patients-having-warfarin-treatment
But recently I've been questioning the rationale or rather the evidence behind routinely performing CT scans on every patient who uses anticoagulants, but presents with and maintains GCS 14-15.
Obviously a patient on anticoagulants has an increased risk of bleeding, but my very quick pubmed-search didn't reveal any precise estimates on how high this risk is?
And does this risk warrant performing scans en masse?
And if these patients are being observed in-hospital regardless, wouldn't it be more clinically sound to perform a scan if they develop symptoms or decline in GCS etc?
Just thinking out loud here. What are your thoughts? What do you practice at your hospital?
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