OBJECT: The direct thrombin inhibitor dabigatran has recently been approved in 
the US as an alternative to warfarin. The lack of guidelines, protocols, and an 
established specific antidote to reverse the anticoagulation effect of 
dabigatran potentially increases the rates of morbidity and mortality in 
patients with closed head injury (CHI). Confronted with this new problem, the 
authors reviewed their initial clinical experience.
METHODS: The authors retrospectively reviewed all cases of adult patients (age ≥ 
18 years) who sustained CHI secondary to ground-level falls and who presented to 
the authors' provisional regional Level I trauma center between February 2011 
and May 2011. The authors divided these patients into 3 groups based on 
anticoagulant therapy: dabigatran, warfarin, and no anticoagulants.
RESULTS: Between February 2011 and May 2011, CHIs from ground-level falls were 
sustained by 5 patients while on dabigatran, by 15 patients on warfarin, and by 
25 patients who were not on anticoagulants. The treatment of the patients on 
dabigatran at the authors' institution had great diversity. Repeat CT scans 
obtained during reversal showed 4 of 5 patients with new or expanded hemorrhages 
in the dabigatran group, whereas the warfarin group had 3 of 15 (p = 0.03). The 
overall mortality rate for patients sustaining CHI on dabigatran was 2 (40%) of 
5, whereas that of the warfarin group was 0 (0%) of 15 (p = 0.05).
CONCLUSIONS: It is critical for physicians involved in the care of patients with 
CHI on dabigatran to be aware of an elevated mortality rate if no treatment 
protocol or guideline is in place. The authors will soon implement a reversal 
management protocol for patients with CHI on dabigatran at their institution in 
an attempt to improve efficacy and safety in their treatment approach.