What is the appropriate emergency department workup for an elderly patient with a scalp hematoma following a fall?

From the Guidelines

The emergency department workup for an elderly patient with a fall resulting in a scalp hematoma should include a thorough neurological assessment, vital signs monitoring, and appropriate imaging, with a CT scan of the head without contrast being the imaging modality of choice to rule out intracranial hemorrhage, skull fractures, or brain contusions, as recommended by the American College of Radiology 1.

Key Components of the Workup

• Complete history focusing on the mechanism of fall, loss of consciousness, anticoagulant use, and symptoms like headache, vomiting, or confusion
• Physical examination to assess the hematoma size, neurological status using the Glasgow Coma Scale, and evaluate for other injuries
• Laboratory tests, including complete blood count, coagulation studies (especially if on anticoagulants), and electrolytes to identify contributing factors to the fall

Management and Admission Criteria

• Management typically involves close monitoring, pain control with acetaminophen (500-1000mg every 6 hours as needed), and cold compresses to the hematoma
• Anticoagulant reversal may be necessary if significant bleeding is present, with four-factor prothrombin complex concentrate (4F-PCC) being the preferred agent for warfarin reversal 1
• Admission criteria include abnormal imaging findings, persistent neurological deficits, inability to ambulate safely, inadequate home support, or anticoagulant use with significant hematoma

Discharge and Follow-up

• For discharge, ensure the patient has adequate home support, clear return precautions, and follow-up arrangements
• The decision to discharge should be made on a case-by-case basis, taking into account the patient's overall condition and the risk of delayed intracranial hemorrhage, which is rare but can occur in patients on anticoagulant or antiplatelet therapy 1

From the Research

Emergency Department Workup for Elderly Fall Scalp Hematoma

• The workup for elderly patients with a fall scalp hematoma in the emergency department may involve a combination of physical examination, laboratory tests, and imaging studies 2, 3, 4, 5, 6.
• Patients taking anticoagulant or antiplatelet agents may require more urgent evaluation and treatment, as they are at higher risk for intracranial hemorrhage 2, 4, 5, 6.
• The use of a novel level III trauma protocol has been shown to be effective in quickly identifying intracranial hemorrhages in elderly patients without activating the trauma team for every elderly patient presenting to the ED with a potential head injury after a fall 4.
• The decision to perform a CT scan in patients with head injuries taking warfarin should be individualized, taking into account the patient's symptoms, Glasgow Coma Scale score, and international normalized ratio (INR) 5.
• Patients with a normal initial cranial computed tomography scan may not require a second CT scan, unless they are taking warfarin or have an INR greater than 2.0 6.

Key Considerations

• Elderly patients with a fall scalp hematoma should be evaluated for signs of intracranial hemorrhage, such as headache, confusion, or focal neurologic deficits 2, 3.
• Patients taking anticoagulant or antiplatelet agents should be evaluated for signs of bleeding, such as bruising or petechiae 2, 4, 5, 6.
• The use of vitamin K, fresh frozen plasma, and platelet transfusion may be necessary to arrest the progression of intracranial hemorrhage in patients taking anticoagulant or antiplatelet agents 2.

Imaging Studies

• CT scans are commonly used to evaluate patients with head injuries, including those with a fall scalp hematoma 2, 4, 5, 6.
• The decision to perform a CT scan should be based on the patient's symptoms, physical examination, and laboratory results 5.
• Patients with a normal initial CT scan may not require a second CT scan, unless they are taking warfarin or have an INR greater than 2.0 6.