In a 72-year-old patient who had a fall last week and another fall today with a normal skull X‑ray, should I obtain an urgent non‑contrast CT scan of the head?

Yes, obtain a non-contrast CT head scan now for this 72-year-old patient with recurrent falls.

You should obtain an urgent non-contrast CT scan of the head for this patient, as skull X-rays are inadequate for detecting intracranial hemorrhage, and older adults who fall are at significant risk for traumatic intracranial bleeding that requires detection to prevent mortality.

Why CT is Essential in This Case

Skull X-rays Are Insufficient

Skull X-rays only detect fractures and provide no information about intracranial hemorrhage (ICH), which is the critical concern in older adults who fall. The 2023 ACEP guidelines emphasize that older patients are particularly prone to closed head injury from falls, and the presence of ICH carries significant morbidity and mortality 1.

Age-Related Risk Factors

At 72 years old, this patient falls into the high-risk category:

• Older adults (>65 years) have a 3.2% rate of clinically important intracranial bleeding after falls 2
• Falls from standing height are the most frequent cause of traumatic intracranial bleeding in this age group 2
• The risk increases substantially with recurrent falls, suggesting underlying instability or medical issues

Critical Clinical Assessment Points

Before or during CT ordering, evaluate these specific factors that influence management:

Medication History (HIGHEST PRIORITY)

• Anticoagulants (warfarin, NOACs like apixaban, rivaroxaban, dabigatran): ICH risk 3.9% vs 1.5% in non-anticoagulated patients 1
• Antiplatelet agents (clopidogrel, ticagrelor): Similar elevated risk as anticoagulants 1
• Aspirin: May require longer observation even with negative initial CT 1

The 2023 ACEP guidelines state: "the threshold for initial imaging after minor head trauma in patients on either anticoagulants or antiplatelet agents is very low because of the consequences of potentially missing an early hemorrhage" 1.

Neurological Examination

Document specifically:

• Glasgow Coma Scale (GCS): Any score <15 mandates CT and likely admission
• Focal neurological deficits: Weakness, sensory changes, cranial nerve abnormalities
• Consciousness disturbance: Any altered mental status
• New vomiting episodes: Associated with ICH 3, 4
• Amnesia: Either retrograde or anterograde 3

Mechanism and Injury Details

• Witnessed loss of consciousness: Significantly increases ICH risk 3
• Direct head impact: History of striking head on ground/object
• Scalp hematoma or laceration: Visible external trauma

Common Pitfalls to Avoid

1. Do NOT rely on skull X-rays alone - They miss all intracranial pathology
2. Do NOT assume "minor" falls are safe - Ground-level falls cause the majority of traumatic ICH in elderly 2
3. Do NOT delay imaging in anticoagulated patients - Even with normal exam, delayed hemorrhage can occur up to 6% of cases 1
4. Do NOT discharge without clear return precautions - Even with negative CT, up to 5% may develop delayed ICH 1

If CT is Negative

For patients on anticoagulants/antiplatelets:

• The 2023 ACEP guidelines found delayed ICH is rare (0.6% for warfarin, 0% for clopidogrel in one Class II study) after negative initial CT 1
• Most can be safely discharged with clear return precautions if neurologically intact
• Consider 4-6 hour observation period, though benefit is debated 1
• Repeat CT is generally not required if patient remains neurologically normal 1, 5

For patients NOT on anticoagulants/antiplatelets:

• Risk of delayed ICH is very low (0.006%) with normal CT and normal exam 5
• Safe discharge with return precautions

Additional Considerations for Recurrent Falls

Since this is the second fall in one week, address:

• Underlying cause: Cardiac arrhythmia, orthostatic hypotension, medication side effects, gait instability
• Frailty assessment: Clinical Frailty Scale score ≥5 increases ICH risk 2
• Fall prevention: Physical therapy, home safety evaluation, medication review
• Consider admission for comprehensive evaluation if no clear reversible cause identified

The ACR Appropriateness Criteria (2021) supports that head CT is the appropriate initial imaging modality for acute head trauma evaluation 5, making it the clear choice over skull X-rays in this clinical scenario.