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Minor head injury in a person taking a direct-acting oral anticoagulant — MSRA MCQ

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Hardall topics relevant for this examMinor head injury in a person taking a direct-acting oral anticoagulantMSRA

A 78-year-old man attends the GP surgery 10 hours after tripping on a rug at home and striking his left temple on a table edge. He did not lose consciousness and has no amnesia, vomiting, seizure, headache, focal neurological symptoms or neck pain. He is alert with a GCS score of 15; neurological examination is normal. There is a small superficial scalp abrasion only. He takes apixaban 5 mg twice daily for non-valvular atrial fibrillation. He lives alone, has no nearby family, and says he would be reluctant to re-attend hospital if symptoms developed overnight. What is the most appropriate management now?

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Correct answer: D — Refer immediately to the emergency department for CT head within 1 hour of identifying anticoagulant use

He has a head injury while taking a DOAC. Although he has no loss of consciousness, amnesia, vomiting, focal deficit or reduced GCS, NICE advises considering CT head in anticoagulated adults with no other CT indication. This is particularly appropriate here because he presents more than 8 hours after injury and cannot be reliably observed or expected to return promptly if he deteriorates. In this situation, CT should be performed within 1 hour of identifying anticoagulant use. A is inappropriate because absence of symptoms does not by itself exclude intracranial bleeding in a person taking apixaban, and he lacks reliable home supervision. B uses the correct investigation but the wrong timing: the 8-hour target applies when presentation is within 8 hours of injury. C does not substitute for imaging and unnecessarily interrupts stroke-prevention therapy without evidence of haemorrhage. D delays imaging beyond the recommended urgent timeframe. ([nice.org.uk](https://www.nice.org.uk/guidance/ng232/chapter/Recommendations?utm_source=openai))

Reference: NICE NG232: Head injury: assessment and early management, recommendation 1.5.13 (18 May 2023) — https://www.nice.org.uk/guidance/NG232/chapter/recommendations NICE NG232: Rationale and impact — criteria for CT head scanning (18 May 2023) — https://www.nice.org.uk/guidance/ng232/chapter/Rationale-and-impact