Head Injury: Bleeding issues!

Updated: Dec 12, 2020

Over the last number of Trauma Forum's, repeatedly we have discussed 2 important aspects of Head Injury:

1. Emergency Management of Intracerebral Haemorrhage on an Oral Anticoagulant

"time is brain"

For any patient with a Head Injury on an Anticoagulant, an Urgent CT Brain is crucial, and we should aim to reverse their anticoagulant for Intracerebral Haemorrhage in less than 90 mins. The NICE guidelines on CT imaging for head injury can be found here:


Important to ask 3Ts:

  • Type of anticoagulant

  • Time the last dose taken

  • TAKE and send URGENT Bloods and alert the Blood bank and Haematology that you require urgent testing and reversal agent!: INR (if on Warfarin), FBC, Renal Profile, Type and Screen


Tailored to the specific anticoagulant, if it is a Vitamin K Antagonist {Vitamin K and Prothrombin Complex Concentrate (PCC)}, or Direct Oral Anticoagulant (PCC and Tranexamic Acid for Apixaban, Rivoraxaban and Edoxaban). For Dagibatran - Idarucizumab and Tranexamic acid.

Further local information can be found on the Maternet: "Guideline for the Treatment of Anticoagulant - Associated Intracerebral Haemorrhage:


Further reading: American College Cardiology 2020 Guidelines


2. When to commence VTE prophylaxis?

Patients who have a Traumatic Brain Injury are at significantly higher risk for venous thromboembolism (VTE), with rates as high as 20-30%.

  • PROPHYLAXIS for VTE should be considered within the first 72 hours.

Earlier initiation of pharmacologic prophylaxis (<72 hours) appears to be safe in patients at low risk for progression of intracranial bleeding and have a stable repeat head CT scan.

The Modified Berne-Norwood criteria shown below shows considerations for low, medium and high risk Traumatic Brain injury VTE prophylaxis:

Further reading: American College of Surgeons: Best practices in Management of Traumatic Brain Injury


Thanks for reading and looking forward to sharing more Trauma Forum learning!



Emergency Medicine

Trauma Forum Co-ordinator

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