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Head Injury on Anticoagulation — MRCEM SBA MCQ

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MediumEmergency MedicineHead Injury on AnticoagulationMRCEM SBAUKMLAPARA

A 75-year-old man with known atrial fibrillation, well-controlled on apixaban, presents to the Emergency Department after a fall. He hit his head but had no loss of consciousness. GCS is 15/15, neurological examination is normal. CT head is unremarkable. What is the most appropriate advice regarding his anticoagulation?

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Correct answer: C — Continue apixaban as usual

This is a minor head injury in a patient taking a DOAC, with GCS 15, normal neurological examination and no intracranial haemorrhage on CT. In this setting, apixaban should be continued as usual. There is no indication to reverse anticoagulation or switch to warfarin, and routinely withholding apixaban after a normal CT exposes an older patient with atrial fibrillation to avoidable thromboembolic stroke risk. Appropriate management is discharge with standard head-injury safety-net advice, including return if headache, vomiting, confusion, drowsiness, seizure, weakness or other neurological symptoms develop.

Reference: BMJ Practice Pointer: Head injury in older people taking anticoagulants, 2025. https://www.bmj.com/content/389/bmj-2024-080736