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Walking on Thin Ice on Blood Thinners

By Currents Editor posted 03-12-2020 09:56


By Peter J. Papadakos, MD, FCCM, FAARC 

As neurocritical care providers, we are confronted with an increased number of individuals who are on blood thinners who are involved in falls during the winter months.  Many will become neurocritical care patients with major subdural hematomas (SDH).

Admissions for traumatic SDH increased 154% from 17,328 in 1993 to 43,996 in 2006.  The mortality associated with acute subdural hematomas has been reported to range from 36-79%, with many survivors not regaining previous levels of functioning, especially after acute subdural severe enough to require surgical drainage.  Several studies have shown an increase in favorable outcome in younger patients.  Age younger than 40 years old was associated with a mortality rate of 20%, whereas age 40-80 years was associated with a mortality rate of 65%.  Younger patients were usually involved in major trauma, and older patients were involved in simple falls.

The cost of subdural hematoma has also increased in the past 20 years.  These costs do not reflect the added costs of rehab and placement of patient’s post-acute care. 

What has also increased in our society is the rate of blood thinners being used by the general population.  The number of diseases where they are prescribed include atrial fibrillation, coronary artery disease, deep vein thrombosis, ischemic stroke, hypercoagulable states, mechanical heart valves, pulmonary embolism and stent, to name a few.

The combination of widespread use of these drugs and an active aging population will thus mean an increased risk of falls on these agents and an increased number of severe subdurals.  Many neuro ICU teams are aware of an increased admission rate during winter months where patients are involved in falls on ice and snow. 

shoes.jpgOne of the key roles we have in neurocritical care advocacy is patient education. We should advocate for patient education to prevent falls.  One of the major winter safety educational initiatives is walk like a duck or penguin program.  We should place posters and educational materials in our hospitals and waiting rooms to educate patients and families.  Another easy, cheap and prudent aid to use in areas of the country with ice and snow issues are ice cleats.  These traction cleats are available in sporting goods stores and online for less than $20. 

Neuro ICU teams should partner with hospital administration and the media to educate the public.  Local media are always looking for such public interest stories, especially during episodes of winter storms.  Neurocritical care staff members should also reach out to senior groups to give public information lectures on winter safety while on blood thinners.  These simple steps may both decrease severe subdural hematomas and greatly impact our patients’ lives.

My advice to my own friends and neighbors in the Snowbelt is to wear cleats and walk like a duck while enjoying the outdoors.


Claiborne Johnston, Pierre Amarenco, et al. for the THALES investigators.Ticagrelor and Aspirin or Aspirin Alone in Acute Ischemic Stroke or TIA. N Engl J Med   2020;383:207-17.
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