What investigations are warranted for an elderly patient in long-term care with a scalp hematoma (subcutaneous collection of blood) post fall, with no significant improvement in size two weeks after the traumatic incident, and no new neurological symptoms?

From the Guidelines

Yes, investigations should be done for an elderly patient in long-term care with a persistent scalp hematoma two weeks after a fall. I recommend obtaining a non-contrast CT scan of the head to rule out serious complications such as subdural hematoma, which can develop slowly in elderly patients due to age-related brain atrophy and fragile bridging veins 1. While the absence of new neurological symptoms is reassuring, elderly patients may not present with classic symptoms of intracranial bleeding. The persistent size of the hematoma after two weeks is concerning and warrants evaluation. Additionally, basic blood work including complete blood count, coagulation studies (PT/INR, PTT), and a medication review should be performed to identify any bleeding disorders or medication effects (such as anticoagulants or antiplatelets) that might contribute to poor resolution. If the patient is on anticoagulants like warfarin, rivaroxaban, or apixaban, their dosing may need temporary adjustment based on findings. The investigation is particularly important in long-term care settings where falls are common and patients often have multiple comorbidities that can complicate recovery from seemingly minor trauma. According to the American College of Radiology, noncontrast head CT is usually appropriate for the initial imaging of patients with acute head trauma that is mild (GCS 13–15) when imaging is indicated by clinical decision rule 1. Given the patient's age and the presence of a persistent scalp hematoma, it is essential to prioritize their safety and rule out any potential complications. The recent study by 1 suggests that delayed ICH after blunt head trauma in neurologically intact patients on anticoagulant or antiplatelet therapy is rare, but clear discharge instructions with return precautions are still warranted. In this case, the patient's persistent scalp hematoma and potential for underlying complications justify further investigation, despite the low risk of delayed ICH. Key considerations include:

• The patient's age and potential for age-related brain atrophy and fragile bridging veins
• The presence of a persistent scalp hematoma
• The potential for underlying complications, such as subdural hematoma
• The need for basic blood work and medication review to identify any bleeding disorders or medication effects
• The importance of clear discharge instructions with return precautions.

From the Research

Investigations for Scalp Haematoma

• The patient has a scalp haematoma post fall and had a trauma incident two weeks ago without much improvement to the size of the hematoma, but no new neurological symptoms have appeared.
• According to 2, noncontrast computed tomography (CT) has become the accepted standard of care for the initial evaluation of patients with suspected subdural hematoma due to its widespread availability, rapid acquisition time, and noninvasive nature.
• However, 3 suggests that repeat CT scans may not be necessary for patients with mild traumatic brain injury and isolated falcotentorial subdural hematoma, as these hematomas are unlikely to increase in size on short-term follow-up CT.
• The decision to perform a CT scan should be based on clinical decision rules, such as the Canadian Computed Tomography Head Rule, which has been found to be reliable in determining indications for head CT scanning following minor head injuries 4.
• It is also important to consider the patient's overall clinical condition, including their age, medical history, and presence of any neurological deficits, when deciding whether to perform further investigations 5, 6.

Considerations for CT Scanning

• CT scanning should be used judiciously, taking into account the patient's individual risk factors and clinical presentation, to avoid unnecessary radiation exposure and reduce the number of "unnecessary" CT scans 4, 6.
• The use of clinical decision rules, such as the Canadian CT Head Rule, can help reduce the number of CT scans performed in minor head injury by 35% 6.
• However, the decision to perform a CT scan is often influenced by nonclinical factors, including patient anxiety, provider confidence and experience, and patient expectations, which can lead to overuse of CT scanning 6.