🩸 Dabigatran Reversal in Mild Traumatic Brain Injury

• Neurosurgical complications of direct thrombin inhibitors--catastrophic hemorrhage after mild traumatic brain injury in a patient receiving dabigatran

Patients on dabigatran (Pradaxa) who suffer a mild traumatic brain injury (GCS 13–15) are at increased risk of delayed intracranial bleeding. Prompt assessment and potential dabigatran reversal are essential.

• Immediate non-contrast head CT scan
• Assess:
  • GCS score
  • Neurological deficits
  • Timing and severity of trauma
  • Last dabigatran intake (within last 12–24h, most relevant)
• Renal function (creatinine clearance) to estimate drug clearance

• Administer idarucizumab (Praxbind) 5 g IV, in two consecutive 2.5 g bolus infusions (within 15 minutes)
• Monitor for signs of rebound anticoagulation

• Consider holding dabigatran
• Observe clinically for 12–24h
• Repeat head CT in 6–12h if:
  • Age >75
  • High-energy trauma
  • Antiplatelet co-medication
  • Comorbidities (renal failure, dementia)

• Outpatient observation may be considered after:
  • Neurology/neurosurgery consult
  • Patient/family informed consent
  • Structured discharge instructions

• Exact time and dose of last dabigatran intake
• Neurological examination + GCS
• CT findings
• Renal function
• Reversalindication and timing
• Plan for repeat imaging (yes/no, when)
• Disposition (admit vs discharge)

• Use Idarucizumab only in active or high-risk bleeding
• Ensure protocol is aligned with the emergency department and the ICU
• Educate staff on location and indications for reversal agents

• Anticoagulation reversal