Management of Geriatric Patients on Anticoagulants After a Fall

Initial Assessment and Imaging

• All geriatric patients on anticoagulants who have fallen and hit their head should receive immediate CT imaging of the brain, regardless of symptoms, due to the high risk of intracranial hemorrhage associated with anticoagulation, as recommended by the American College of Emergency Physicians 1, 2
• Non-contrast CT brain should be performed urgently in these patients, as suggested by the American College of Emergency Physicians 1, 2

Laboratory Tests and Coagulation Studies

• Coagulation studies, including PT/INR and Anti-Factor Xa activity, should be performed in patients on anticoagulants, with Anti-Factor Xa activity being the preferred test for anticoagulant activity if available, according to the International Society on Thrombosis and Haemostasis 1
• Consider chromogenic anti-FXa assay calibrated for anticoagulants for accurate measurement of anticoagulant activity, as recommended by the International Society on Thrombosis and Haemostasis 1
• Obtain urgent complete blood count, renal function, and anti-Factor Xa activity if available, though treatment should not be delayed in emergency situations 1, 3

Management of Bleeding

• For life-threatening bleeding in patients on anticoagulants, consider administration of PCC (25-50 U/kg) and co-administer tranexamic acid (15 mg/kg or 1 g), as suggested by the Society of Critical Care Medicine 1, 4
• Patients taking anticoagulants should be evaluated for signs of bleeding, including visible blood, bruising, hematuria, melena, hematemesis, and bleeding from gums or nose, as this medication increases bleeding risk and can cause serious or fatal bleeding, according to the American College of Cardiology 5
• The following signs and symptoms are potential indicators of bleeding in patients taking anticoagulants:
• Bleeding in critical sites, such as intracranial, intraocular, spinal, retroperitoneal, intra-articular, pericardial, or intramuscular with compartment syndrome, is considered major bleeding, according to the American College of Cardiology and Critical Care 5, 4
• Hemodynamic instability, drop in hemoglobin, and requirement for blood transfusion are also criteria for major bleeding in patients taking anticoagulants, as recommended by the American College of Cardiology and Critical Care 5, 4
• For life-threatening bleeding, consider reversal with andexanet alfa or prothrombin complex concentrate, as recommended by the American College of Cardiology and Critical Care 5, 4, 1, 3

• The following dosing is recommended for andexanet alfa:

  Dose	Administration
  400 mg IV bolus	followed by 4 mg/min infusion for up to 120 minutes
  800 mg IV bolus	followed by 8 mg/min infusion for up to 120 minutes

  1, 5

• If andexanet alfa is unavailable, administer prothrombin complex concentrate (PCC) 25-50 U/kg 1, 3, 5
• Consider activated charcoal if anticoagulant was ingested within 2-4 hours 5
• For non-life-threatening bleeding, provide supportive care, local hemostatic measures, and consider delaying the next anticoagulant dose, with close monitoring for bleeding progression 5

Fall Prevention and Risk Assessment

• Patients on anticoagulants should have regular fall risk assessments using tools that evaluate previous falls, medication use, visual acuity, sensation, and mobility, as recommended by the European Heart Journal 6
• Age, heart failure, vascular disease, uncontrolled hypertension, and concomitant use of antiplatelet drugs or NSAIDs are also risk factors for falls in patients taking anticoagulants 6
• Implement fall prevention strategies for all patients on anticoagulants, including balance training, home safety evaluation, and vision assessment 5

Post-Bleeding Management

• After major bleeding, delay resumption of anticoagulation for at least 24-72 hours and reassess thrombotic vs. bleeding risk, as recommended by the American College of Cardiology 5
• If the last dose of anticoagulant was more than 24 hours ago in patients with normal renal function, reversal may not be necessary, but for impaired renal function, the drug effect may persist longer 7, 8
• Monitor patients closely for delayed bleeding complications, especially with head trauma, and consider renal function when assessing drug clearance and timing of last dose 8