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DOAC Use and Head Trauma

Matthew DeLaney, MD and Matthieu DeClerck, MD
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Patients who take DOACs have an increased risk of ICH following minor head injury. While some of these patients may not need emergent neuroimaging, to date the literature strongly suggests that we have a low threshold to image any patient on a DOAC who presents with minor head trauma.

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Tabor D., PA-C -

I think if the patient has a mild head injury and reliable family at home, then the provider could have a discussion with the family about potential risks and discharge instructions to go to ER if any new or worsening symptoms are noted. If there's no family or reliable person to monitor then its a trip to the ER. I feel like a lot of this has to do with how well the patient appears overall and if the family is willing to be involved with shared-decision-making to manage some of the risk at home.

Mike W., MD -

But note that if a patient is on a DOAC or clopidogrel that PE is unreliable and they need a brain CT (even if exam is normal). Nishijima et al Annals of EM 2012

Mizuho M., DO -

Agree with Mike here. There are few things that I hold hard & fast on in medicine...this is one of them. Anticoag + minor head injury = CT HEAD period. If they want to AMA/refuse that is fine...Im usually a huge fan or shared decision making...but NOT in this scenario. Shared decision making is going to do nothing for you when it comes to their subdural. Ive seen WAY too many cases of this...all of my colleagues who have been involved in cases like this have lost in their litigation. You are screwed if they have a bleed...thats the bottom line.

Tabor D., PA-C -

Thank you for your reply. I have listened to you both for several years on the podcast and you continue to influence my clinical practice. I'll be sure to send anyone with a head injury on DOAC to the ER. My thought process was formed from my experience covering at a nursing home and over the years there would be some falls with people on DOAC. In discussion with the Physicians if a head injury was minor the patient would be put on nuero checks every 4 hours and closely monitored by Nursing staff. We never had anyone with any observable changes to indicate need for CT Scan. Overall head trauma in people on DOAC is not a patient we see too often in our Urgent Care, but I will be diligent about sending these patients to the ER for further care. Thanks for the clinical guidance.

Mike W., MD -

Appreciate the response - it is funny as this is counter intuitive to our teaching about the primacy of the H&P, but this specific issue is so serious, that extra testing is warranted - Tabor, we REALLY appreciate the comments and thoughts. Miz and I recorded a few additional thoughts (similar to the comments above) for the March summary/outro. Thx again!!
M

Mizuho M., DO -

Tabor - I just wanted to echo THANKS for the comments as well! We appreciate it and certainly its good for us to check ourselves often too! I can understand with your nursing home experience why you would have that perspective...totally fair. As an aside it makes me wonder if this is why "Mrs. Jones passing away in her sleep" happens in these SNF's?! haha...kidding aside...grateful for your feedback and moreover for listening to UC! ~Miz

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Hippo Urgent Care RAP - December 2019 Written Summary 273 KB - PDF

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