In our April 16, 2007 Tip of the Week we discussed falls with injury, with particular emphasis on what the first responder to a fall needs to do. We pointed out that the responder needs not only to assess the patient for injuries but also to do an assessment of the reason for the fall. Having a checklist to help the medical responder is a good way to ensure that the injuries are attended to and the cause of the fall is considered.
In response to the fall, there are a number of other tools that can be useful in the assessment of potential injuries. Many of these are already used in your emergency rooms. Good examples are the Canadian CT Head Rule, the New Orleans Criteria (for head injury), or the Ottawa C-spine Rule. Most of these rules and their algorithms can be downloaded for use on a PC (such as the Medical Algorithms Project) or handheld PDA (such as EM Rules).
The Canadian CT Head Rule is an excellent rule for determining which patients should get a CT scan of the head after minor trauma. However, it does not apply to patients who have a bleeding disorder or who are on anticoagulants. The following case is a good example of some of the unique considerations in anticoagulated patients.
An elderly patient with a cardiac condition was on full-dose heparinization while an inpatient and had an unwitnessed fall in the hospital one evening. He did not lose consciousness and was alert and fully oriented when the medical resident examined him after the fall. He had a mild ecchymosis on his right forehead but no focal neurological signs and no evidence of trauma elsewhere on the body. Because the patient was fully anticoagulated, the resident ordered an emergency head CT scan, which was normal. No changes were made in his heparin regimen. The following morning the patient was more somnolent than usual and a repeat CT scan showed a sizeable subdural hematoma that required surgical evacuation.
We’ve included this case because it shows that the timing of a CT scan may be important in the patient who is anticoagulated. The accumulation of a subdural hematoma after minor head trauma may be slow in a patient on anticoagulants. So particularly in a patient who is already hospitalized and being monitored regularly, one might consider delaying the head CT for several hours if the initial neurological examination is normal. However, that implies that the “neuro checks” will indeed be carried out as ordered. We’ve often seen in that past that there is a tendency for “neuro checks” to be overlooked when the patient is asleep – which is exactly when neuro checks are most important!
The same may apply to bleeding in other spaces in patients fully anticoagulated. A good example is retroperitoneal bleeding, which may present with no signs until a drop in hemoglobin is found or flank ecchymoses are noted.
Heparin, coumadin, and other anticoagulants are all high risk medications and your organizations should have comprehensive guidelines and protocols for their use. Joint Commission’s 2008 National Patient Safety Goals include taking steps to reduce the risk of harm in patients on anticoagulants. While the focus of that goal is to help ensure that patients are adequately and safely anticoagulated and avoid the frequent adverse drug events often associated with coumadin or other anticoagulants, a comprehensive policy should include recommendations about minor trauma in the anticoagulated patient as well.