BEST PRACTICE RECOMMENDATION FOR MINOR HEAD TRAUMA
Minor Head Trauma Guidelines – Indications for Head CT in Adult Trauma Patients with Minor
Head Trauma
Initial Effective Date:
Last Renewed:
Subject:
PURPOSE
To standardize the management of patients with minor head trauma.
ATTN:THESE ARE GUIDELINES FOR CARE, NOT PHYSICAN ORDERS
GUIDELINES:
1) Immediate Head CT Indicated:
a) Evidence or History of Trauma and:
i. GCS < 15
ii. Focal Neurological Deficit
iii. Patients taking anticoagulants, antiplatelet agents (see attached list), or has bleeding disorder.
2) Head CT Indicated:
a) Patients WITH LOC (LOC defined as: A state of impaired consciousness in which one shows no
responsiveness to environmental stimuli but may respond to deep pain with involuntary movements) and
i. Headache
ii. Emesis
iii. Age > 60
iv. Drug/Alcohol Intoxication
v. Anterograde Amnesia/ Short-term Memory Deficits
vi. Physical evidence of significant trauma above clavicles (significant abrasions, contusions, and/or
ecchymosis)
3) Head CT Indicated:
a) Patient WITHOUT LOC and:
i. Severe Headache
ii. Suspected Basilar Skull Fracture
iii. Dangerous Mechanism of Injury (ejection from moving vehicle, pedestrian struck by vehicle, fall > 3
ft or 5 steps)
4) Observation:
a) Obtain CT or Repeat CT if worsening or no resolution of symptoms
i. 6 hours of observation if ONLY criteria met is intoxication
ii. 6 hours of observation if ONLY criteria met is GCS <14 that returned to normal within 2 hours of
injury.
Medications Triggering Anti-Coagulation Head Trauma Alert
WARFARIN – COUMADIN* & JANTOVEN*
DABIGATRAN – PRADAXA*
RIVAROXABAN – XARELTO*
APIXABAN – ELIQUIS*
Other Antiplatelets or Anticoagulants to consider as possible risk for Physician Review
ABCIXIMAB - REOPRO
ASPIRIN*
ARGATROBAN
BIVALIRUDIN – ANGIOMAX
CLOPIDOGREL – PLAVIX*
DALTEPARIN – FRAGMIN
DESIRUDIN – IPRIVASK
DIPYRIDAMOLE – PERSANTINE*
DIPYRIDAMOLE/ ASA – AGGRENOX*
EPTIFIBATIDE - INTEGRILIN
ENOXAPARIN – LOVENOX*
FONDAPARINUX – ARIXTRA
HEPARIN
PRASURGREL – EFFIENT*
TICAGRELOR – BRILINTA*
TICLODIDPINE – TICLID
TINZAPARIN – INNOHEP
TIROFIBAN - AGGRASTAT
* MOST COMMONLY ENCOUNTERED AS HOME MEDICATIONS
Note: Patients on Warfarin, Pradaxa, Xarelto, or Eliquis that sustain a head injury should
receive a CT of the head STAT. Patients on other anticoagulants or antiplatelet therapy
require urgent evaluation by the physician to determine if a head CT is indicated and if it
should be performed stat (10 minutes) or urgent (within 30 minutes) of arrival.
ANTICOAGULANTS AND ANTIPLATELETS BY CLASS
VITAMIN K ANTAGONIST
WARFARIN – COUMADIN*
ANTIPLATELET
CLOPIDOGREL – PLAVIX*
DIPYRIDAMOLE – PERSANTINE
DIPYRIDAMOLE/ ASA – AGGRENOX*
PRASUGREL – EFFIENT*
TICAGRELOR – BRILINTA*
TICLODIPINE – TICLID
DIRECT THROMBIN INHIBITORS
ARGATROBAN
BIVALIRUDIN – ANGIOMAX
DABIGATRAN – PRADAXA*
FACTOR Xa INHIBITORS
RIVAROXABAN – XARELTO*
APIXABAN – ELQUIS*
DALTEPARIN – FRAGMIN
DESIRUDIN – IPRIVASK
ENOXAPARIN – LOVENOX
FONDAPARINUX – ARIXTRA
HEPARIN
GLYCOPROTEIN IIB/IIIA INHIBITOR
ABCIXIMAB - REOPRO
EPTIFIBATIDE - INTEGRILIN
TIROFIBAN - AGGRASTAT
* MOST COMMONLY ENCOUNTERED AS HOME MEDICATIONS
ADULT Coagulopathy/Head Trauma –
Vitamin K antagonist Coumadin (Warfarin)
PATIENT ON COUMADIN WITH EVEN MINOR HEAD TRAUMA, OBTAIN STAT CT HEAD AS STANDING ORDER
(SMDO)
1. PT/INR 1
2. STAT Blood to Blood Bank
3. Alert Phyisican
Head CT Negative
Coumadin
1.- INR less than 1.4=4 hour
observation in ED
Head CT Positive for Intracranial
Hemorrhage (ICH)
RAPID INR REVERSAL
2.- INR greater 1.4-5= 23 hour
observation; repeat CT in am
3.- INR >5 consider FFP ;give
vitamin K, 23 hour observation,
repeat CT, INR in AM.
1.- Call receiving facility to arrange transfer,
if transferring- STAT by most rapid route
available
2.- Refer to your own network order sets for
anticoagulation reversal management:
4.- Consider TEG
Do not delay transport (greater than 15
minutes) to wait for FFP
IF ADMITTED:
1.- Consider 23 hour obs hospital
admission if no other trauma –this does
not require transfer to a higher level of
care with a normal CT
2.- Repeat CT head in 16-23 hours
3.- Repeat INR in 16-23 hours
Change in Mental Status at any time
Repeat Head CT STAT
ADULT Coagulopathy /Head TraumaDirect Thrombin Inhibitor –DTI- (Dabigatran, Pradaxa) and Factor Xa Inhibitors
(Rivaroxaban)
Patient on a Direct Thrombin Inhibitor, Factor Xa Inhibitor, or other anticoagulant in
this category with even minor head trauma, obtain STAT CT Head as standing order (
SMDO)
1.- PT/INR, PTT; Thrombin Time and APTT
2.- STAT Blood to Blood Bank
3.- Alert Physician
4.- Consider TEG
Head CT Negative
1.- Consider 23 hrs obs
hospital admission if no other
trauma
2.- Does not warrant transfer
to a higher level trauma
center if only has a
coagulopathy or potential for
bleeding
3. Consider specific antidote
for agent if profoundly
anticoagulated
4. Repeat CT head in 16-23
hours.
Change in Mental Status at any
timeRepeat Head CT STAT
Head CT Positive for Intracranial
Hemorrhage (ICH)
1.- IF TRANSFERRING , call receiving facility
to arrange transfer- STAT by most rapid route
available
2.-There is no known reversal agent for DTI
3.- Refer to your own network order sets for
anticoagulation management: