2. Management of Patients with Traumatic Brain Injury on Anticoagulant and Antiplatelet Therapy

Management of Patients with Traumatic Brain Injury on Anticoagulant and Antiplatelet Therapy

Date: 03/2026 | Supersedes: 08/2024 | Location: MH Katy

Patients on warfarin, any anti-platelet, or DOAC may be discharged home after an observation period of 6 hours (from the time of injury) if ALL of the following criteria are met:

  • No findings of intracranial bleeding on initial CT Head
  • No signs of neurological deterioration during the 6 hour observation period
  • INR <3.5 in warfarin-therapy patients
  • Patient has no other injuries that warrant admission

Patients will be observed in the hospital for 23 hours and repeat head CT obtained in 6 hours if ANY of the following criteria are met:

  • Findings of intracranial bleeding on CT Head (BIG 2 or 3)
  • Neurological deterioration during the 6 hour observation period (obtain repeat CT Head)
  • INR ≥ 3.5 in warfarin-therapy patients
  • Inability to obtain a neurological examination despite normal baseline CT Head

Reversal of Anticoagulant or Antiplatelet Medications

  • See Anticoagulant and Antiplatelet Reversal policy for specific reversal therapies.
  • Antiplatelet drugs
    • Platelet transfusion should not be given unless:
      • Patient has progression of TBI on repeat CT Head
      • Patient is to undergo a neurosurgical intervention
    • Patients undergoing a Neurosurgical intervention or who have progression of TBI on repeat CT Head should receive a platelet transfusion if they were taking aspirin or ADP inhibitor (clopidogrel, ticagrelor, cangrelor, ticlopidine, prasugrel)
      • Patients on NSAIDs or GP IIb/IIIa inhibitors (triofiban, eptifibatide) do not require platelet transfusion even if having a neurosurgical intervention
    • Consider a single dose of DDAVP (0.4 microgram/kg)
  • Anticoagulants
    • In general, reversal of anticoagulants should be guided clinically and not by lab values.
    • Patients should be reversed when:
      • On warfarin and INR ≥3.5
      • Patient will be undergoing Neurosurgical intervention
      • Patient has severe TBI (BIG 3)