Evidence Based Medicine| Volume 46, ISSUE 3, P410-417, March 2014

Download started.


Can Anticoagulated Patients be Discharged Home Safely from the Emergency Department after Minor Head Injury?

Published:December 20, 2013DOI:



      Anticoagulated patients have increased risk for bleeding, and serious outcomes could occur after head injury. Controversy exists regarding the utility of head computed tomography (CT) in allowing safe discharge dispositions for anticoagulated patients suffering minor head injury.

      Clinical Question

      What is the risk of delayed intracranial hemorrhage in anticoagulated patients with minor head injury and a normal initial head CT scan?

      Evidence Review

      Four observational studies were reviewed that investigated the outcomes of anticoagulated patients who presented after minor head injury.


      Overall incidence of death or neurosurgical intervention ranged from 0 to 1.1% among the patients investigated. The studies did not clarify which patients were at highest risk.


      The literature does not support mandatory admission for all anticoagulated patients after minor head injury, but further studies are needed to identify the higher-risk patients for delayed bleeding to determine appropriate management.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Emergency Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Faul M.
        • Xu L.
        • Wald M.M.
        • Coronado V.G.
        Traumatic brain injury in the United States: emergency department visits, hospitalizations and deaths 2002–2006.
        Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Atlanta, GA2010
        • Pieracci F.M.
        • Eachempati S.R.
        • Shou J.
        • Hydo L.J.
        • Barie P.S.
        Use of long-term anticoagulation is associated with traumatic intracranial hemorrhage and subsequent mortality in elderly patients hospitalized after falls: analysis of the New York State Administrative Database.
        J Trauma. 2007; 63: 519-524
        • Batchelor J.S.
        • Grayson A.
        A meta-analysis to determine the effect of anticoagulation on mortality in patients with blunt head trauma.
        Br J Neurosurg. 2012; 26: 525-530
        • Dossett L.A.
        • Riesel J.N.
        • Griffin M.R.
        • Cotton B.A.
        Prevalence and implications of preinjury warfarin use: an analysis of the National Trauma Databank.
        Arch Surg. 2011; 146: 565-570
        • Faul M.
        • Xu L.
        • Wald M.M.
        • Coronado V.G.
        Traumatic brain injury in the United States: emergency department visits, hospitalizations, and deaths.
        Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Atlanta, GA2010
        • Eliastam M.
        Elderly patients in the emergency department.
        Ann Emerg Med. 1989; 18: 1222-1229
        • Stiell I.G.
        • Wells G.A.
        • Vandemheen K.
        • et al.
        The Canadian CT Head Rule for patients with minor head injury.
        Lancet. 2001; 357: 1391-1396
        • Haydel M.J.
        • Preston C.A.
        • Mills T.J.
        • Luber S.
        • Blaudeau E.
        • DeBlieux P.M.
        Indications for computed tomography in patients with minor head injury.
        N Engl J Med. 2000; 343: 100-105
        • Mower W.R.
        • Hoffman J.R.
        • Herbert M.
        • Wolfson A.B.
        • Pollack Jr., C.V.
        • Zucker M.I.
        Developing a decision instrument to guide computed tomographic imaging of blunt head injury patients.
        J Trauma. 2005; 59: 954-959
        • Li J.
        • Brown J.
        • Levine M.
        Mild head injury, anticoagulants and risk of intracranial injury.
        Lancet. 2001; 357: 771
        • Gittleman A.M.
        • Ortiz A.O.
        • Keating D.P.
        • Katz D.S.
        Indications for CT in patients receiving anticoagulation after head trauma.
        AJNR Am J Neuroradiol. 2005; 26: 603-606
        • Brewer E.S.
        • Reznikov B.
        • Liberman R.F.
        • et al.
        Incidence and predictors of intracranial hemorrhage after minor head trauma in patients taking anticoagulant and antiplatelet medication.
        J Trauma. 2011; 70: E1-E5
        • Cohen D.B.
        • Rinker C.
        • Wilberger J.E.
        Traumatic brain injury in anticoagulated patients.
        J Trauma. 2006; 60: 553-557
        • Fabbri A.
        • Vandelli A.
        • Servadei F.
        • Marchesini G.
        Coagulopathy and NICE recommendations for patients with mild head injury.
        J Neurol Neurosurg Psychiatry. 2004; 75: 1787
        • Vos P.E.
        • Battistin L.
        • Birbamer G.
        • et al.
        EFNS guideline on mild traumatic brain injury: report of an EFNS task force.
        Eur J Neurol. 2002; 9: 207-219
        • Ingebrigtsen T.
        • Romner B.
        • Kock-Jensen C.
        Scandinavian guidelines for initial management of minimal, mild, and moderate head injuries. The Scandinavian Neurotrauma Committee.
        J Trauma. 2000; 48: 760-766
        • Kaen A.
        • Jimenez-Roldan L.
        • Arrese I.
        • et al.
        The value of sequential computed tomography scanning in anticoagulated patients suffering from minor head injury.
        J Trauma. 2010; 68: 895-898
        • Peck K.A.
        • Sise C.B.
        • Shackford S.R.
        • et al.
        Delayed intracranial hemorrhage after blunt trauma: are patients on preinjury anticoagulants and prescription antiplatelet agents at risk?.
        J Trauma. 2011; 71: 1600
        • Menditto V.G.
        • Lucci M.
        • Polonara S.
        • Pomponio G.
        • Gabrielli A.
        Management of minor head injury in patients receiving oral anticoagulant therapy: a prospective study of a 24-hour observation protocol.
        Ann Emerg Med. 2012; 59: 451-455
        • Nishijima D.K.
        • Offerman S.R.
        • Ballard D.W.
        • et al.
        Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and preinjury warfarin or clopidogrel use.
        Ann Emerg Med. 2012; 59: 460-468
        • Temple R.J.
        A regulatory authority's opinion about surrogate endpoints.
        in: Nimmo W.S. Tucker G.T. Clinical measurement in drug evaluation. John Wiley & Sons, New York1995: 3-22
        • Fleming T.R.
        • DeMets D.L.
        Surrogate end points in clinical trials: are we being misled.
        Ann Intern Med. 1996; 125: 605-613
        • Guyatt G.H.
        • Oxman A.D.
        • Kunz R.
        • et al.
        GRADE guidelines 2. Framing the question and deciding on important outcomes.
        J Clin Epidemiol. 2011; 64: 395-400
        • Li J.
        Admit all anticoagulated head-injured patients? A million dollars versus your dime. You make the call.
        Ann Emerg Med. 2012; 59: 457-459
        • Pieracci F.M.
        • Eachempati S.R.
        • Shou J.
        • Hydo L.J.
        • Barie P.S.
        Degree of anticoagulation, but not warfarin use itself, predicts adverse outcomes after traumatic brain injury in elderly trauma patients.
        J Trauma. 2007; 63: 525-530
        • Franko J.
        • Kish K.J.
        • O’Connell B.G.
        • Subramanian S.
        • Yuschak J.V.
        Advanced age and preinjury warfarin anticoagulation increase the risk of mortality after head trauma.
        J Trauma. 2006; 61: 107-110
        • Hansen M.L.
        • Sørensen R.
        • Clausen M.T.
        • et al.
        Risk of bleeding with single, dual, or triple therapy with warfarin, aspirin, and clopidogrel in patients with atrial fibrillation.
        Arch Intern Med. 2010; 170: 1433-1441
        • Shireman T.I.
        • Howard P.A.
        • Kresowik T.F.
        • Ellerbeck E.F.
        Combined anticoagulant-antiplatelet use and major bleeding events in elderly atrial fibrillation patients.
        Stroke. 2004; 35: 2362-2367
        • Johnson S.G.
        • Witt D.M.
        • Eddy T.R.
        • Delate T.
        Warfarin and antiplatelet combination use among commercially insured patients enrolled in an anticoagulation management service.
        Chest. 2007; 131: 1500-1507
        • Carpenter C.R.
        • Griffey R.T.
        • Stark S.
        • Coopersmith C.M.
        • Gage B.F.
        Physician and nurse acceptance of technicians to screen for geriatric syndromes in the emergency department.
        West J Emerg Med. 2011; 12: 489-495
        • Sternberg S.A.
        • Wershof Schwartz A.
        • Karunananthan S.
        • Bergman H.
        • Mark Clarfield A.
        The identification of frailty: a systematic literature review.
        J Am Geriatr Soc. 2011; 59: 2129-2138
        • Carpenter C.R.
        • DesPain B.
        • Keeling T.N.
        • Shah M.
        • Rothenberger M.
        The six-item screener and AD8 for the detection of cognitive impairment in geriatric emergency department patients.
        Ann Emerg Med. 2011; 57: 653-661
        • Han J.H.
        • Wilson A.
        • Ely E.W.
        Delirium in the older emergency department patient: a quiet epidemic.
        Emerg Med Clin North Am. 2010; 28: 611-631
        • Carpenter C.R.
        Evidence-based emergency medicine/rational clinical examination abstract. Will my patient fall?.
        Ann Emerg Med. 2009; 53: 398-400
        • Caterino J.M.
        • Murden R.A.
        • Stevenson K.B.
        Functional status does not predict complicated clinical course in older adults in the emergency department with infection.
        J Am Geriatr Soc. 2012; 60: 304-309
        • Hastings S.N.
        • George L.K.
        • Fillenbaum G.G.
        • Park R.S.
        • Burchett B.M.
        • Schmader K.E.
        Does lack of social support lead to more ED visits for older adults?.
        Am J Emerg Med. 2008; 26: 454-461