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Observation is recommended even following a normal CT brain in warfarinised head injuries

Report by Simon Rendell: Senior emergency trainee

Search checked by Shahzadi Zeb: Clinical fellow in emergency medicine

Institution: Manchester Royal Infirmary, Manchester, UK

Clinical scenario

An elderly woman attends your emergency department following a mechanical fall. She takes warfarin for atrial fibrillation and has a small occipital haematoma. Her Glasgow coma score is 15; she has no amnesia and a normal neurological examination but did lose consciousness for a brief period. The international normalised ratio (INR) comes back within the therapeutic range at 2.9 and a CT scan is requested according to the National Institute for Health and Clinical Excellence guidelines.

The scan is reported as normal, and her social circumstances are adequate in that she lives with her husband who can keep an eye on her. You wonder, though, whether it is safe to discharge her or if there is a possibility of delayed intracranial haemorrhage due to her coagulopathy. You …

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