What is the appropriate emergency department workup for an elderly patient with a head injury due to a fall?

From the Guidelines

The emergency department workup for an elderly patient with a fall-related head injury should begin with a thorough neurological assessment, including Glasgow Coma Scale, pupillary response, and evaluation for focal deficits, and all elderly patients with head injuries should undergo CT scanning of the brain without contrast, even with minor trauma, as they have a higher risk of intracranial hemorrhage due to age-related brain atrophy and increased use of anticoagulants 1.

Key Components of the Workup

• Vital signs should be monitored closely, with particular attention to blood pressure and heart rate.
• Laboratory tests should include complete blood count, basic metabolic panel, coagulation studies (PT/INR, PTT), and blood alcohol level if indicated.
• If the patient is on anticoagulants like warfarin, direct oral anticoagulants, or antiplatelet agents, this should be documented and may influence management decisions.
• The workup should also include assessment of the cause of the fall, including evaluation for cardiac arrhythmias, orthostatic hypotension, medication side effects, or environmental hazards.

Special Considerations

• Extended observation (at least 24 hours) is often warranted even with normal initial imaging, as elderly patients can develop delayed intracranial hemorrhage.
• Repeat imaging should be performed if there is any neurological deterioration.
• Consultation with neurosurgery is recommended for any identified intracranial hemorrhage, and geriatric consultation may be beneficial for comprehensive fall risk assessment and prevention strategies.

Recent Guidelines

• The 2023 guidelines on the management of adult patients presenting to the emergency department with mild traumatic brain injury support the use of CT scanning in elderly patients with minor head trauma, even if they are on anticoagulant or antiplatelet therapy 1.
• The guidelines also emphasize the importance of assessing the cause of the fall and evaluating for cardiac arrhythmias, orthostatic hypotension, medication side effects, or environmental hazards.

From the Research

Emergency Department Workup for Elderly Fall Head Injury

• The evaluation of elderly patients with head injury in the emergency department is crucial to identify those with intracranial injury, as it is often overlooked 2.
• A novel level III trauma protocol (L3TP) has been developed to better evaluate and diagnose intracranial injury in elderly patients presenting with minor head trauma after a fall, which requires immediate assessment by the ED physician for high-risk patients 2.
• The L3TP has been shown to be effective in quickly identifying intracranial hemorrhage (ICH) in elderly patients without activating the trauma team for every elderly patient presenting to the ED with a potential head injury after a fall 2.

Indications for Head CT in Elderly Patients

• A decision-tree based on objective clinical severity criteria, such as focal neurological deficit and history of traumatic intracranial hemorrhage (tICH) on a previous CT scan, can detect the majority of tICH requiring surgical intervention 3.
• The presence of at least one of these risk factors is associated with the occurrence of tICH, and systematic head CT for elderly patients presenting minor head trauma could be irrelevant 3.
• Clinical decision rules are helpful to identify patients who require advanced imaging, and warfarin slightly increases the risk of traumatic intracranial bleeding, while antiplatelet medications may also increase the risk 4.

Use of Routine Repeat Cranial CT Scans

• Scheduled repeat head computed tomography after mild traumatic brain injury has been shown to have limited use for predicting the need for an intervention 5.
• A practice of selective repeat head CT scans in patients with traumatic brain injury admitted with a GCS score of 13 to 15 decreases use of the test and is associated with decreased hospital length of stay, without impacting discharge GCS scores 5.
• Patients with head injury, normal GCS scores, and no focal neurologic deficits, and who are receiving anticoagulants, may not necessarily require emergency CT 6.