The table below summarizes the recommendations for adult patients on anti-thrombotic agents with intracranial hemorrhage (both spontaneous and traumatic). This will be focused on ED management.
Positive responses to "red flag" screening questions for back pain warranted further investigation, though the positive predictive value was poor. Negative responses to screening "red flag" questions were useless as a screening tool for ruling out serious disease, such as fracture, infection, malignancy, or cauda equina.
Among patients with ICH, those on non-vitamin K oral anticoagulants had a lower in-hospital risk of mortality compared to warfarin (26.5% vs 32.6%). Compared to warfarin, those on NOACs were more likely to be discharged home (+3.3%), be functionally independent (+2.5%), and have the ability to ambulate independently at discharge (+1.8%).
Patients with acute stroke from occluded intracranial internal carotid artery (ICA) or proximal middle cerebral artery (MCA) presenting from 6-24 hours from onset benefitted from endovascular thrombectomy when clinical deficits of stroke were greater than expected based on infarct volume on diffusion-weighted MRI or perfusion CT.
A negative c-spine CT had 99.9% NPV for clinically significant c-spine injury in intoxicated patients. The Western Trauma Association recommends c-spine clearance, even in intoxicated patients, if gross motor function is normal, no neurologic complaints, and negative c-spine CT per experienced radiologist. Be careful out there, and get institutional buy-in if you plan to put this into practice.