What is the recommended initial evaluation and management for a 92-year-old female who presents with a headache after a fall, with unknown loss of consciousness, and lives in an assisted care facility?

From the Guidelines

The initial evaluation for a 92-year-old female with headache after a fall should include a comprehensive neurological assessment and immediate CT scan of the head to rule out intracranial hemorrhage, as recommended by the most recent guidelines 1. The patient's age, unknown loss of consciousness, and presentation with headache after a fall warrant a high degree of suspicion for serious head injuries, such as subdural hematoma. According to the 2021 update of the ACR Appropriateness Criteria for head trauma 1, a noncontrast head CT is indicated in patients with head trauma and loss of consciousness or posttraumatic amnesia, especially if they have a headache, are over 60 years old, or have coagulopathy.

Given the patient's age and clinical presentation, a thorough physical examination should assess for external signs of trauma, neurological deficits, and mental status changes. Laboratory tests, including complete blood count, coagulation profile, and metabolic panel, are recommended, especially if the patient is on anticoagulants. Vital signs, including blood pressure, heart rate, oxygen saturation, and temperature, should be monitored closely.

The cause of the fall should be investigated, including medication review, orthostatic vital signs, and cardiac evaluation. Pain management can include acetaminophen 650mg every 6 hours as needed, avoiding NSAIDs due to bleeding risk. If the CT scan reveals intracranial bleeding, neurosurgical consultation is warranted immediately. Hospitalization for observation for at least 24 hours is recommended due to the patient's age and unknown loss of consciousness.

The guidelines from the American College of Emergency Physicians (ACEP) in 2008 1 and the geriatric emergency department guidelines in 2014 1 also support the importance of thorough evaluation and consideration of CT scan in elderly patients with head trauma. However, the most recent guidelines from 2021 1 provide the most up-to-date recommendations for imaging and decision-making in adult mild traumatic brain injury.

Key considerations in the evaluation and management of this patient include:

• Comprehensive neurological assessment
• Immediate CT scan of the head
• Laboratory tests, including complete blood count, coagulation profile, and metabolic panel
• Thorough physical examination
• Investigation of the cause of the fall
• Pain management with acetaminophen
• Hospitalization for observation for at least 24 hours
• Neurosurgical consultation if intracranial bleeding is suspected.

From the Research

Initial Evaluation and Management

The initial evaluation and management of a 92-year-old female who presents with a headache after a fall, with unknown loss of consciousness, and lives in an assisted care facility, should follow a systematic approach to identify potential head injuries.

• The patient's age and mechanism of injury are important factors to consider when evaluating the need for computed tomography (CT) scanning 2.
• The Canadian CT Head Rule may be applied to guide the decision for CT imaging, although it was derived from patients with minor head injury who had loss of consciousness or witnessed disorientation 2.
• A normal CT scan does not exclude the possibility of intracranial pathology, and magnetic resonance imaging (MRI) may be considered if there is a high index of suspicion for injury 3.

CT Scan Guidelines

• The Canadian CT Head Rule recommends CT scanning for patients with minor head injury who have a high-risk mechanism of injury, regardless of loss of consciousness or disorientation 2.
• The rule was found to be 100% sensitive for the presence of intracranial hemorrhage in a cohort of patients with minimal head injury, although it had low specificity 2.
• Other studies suggest that CT scanning may not be necessary for all patients with minor head injury, and that clinical decision rules can help reduce unnecessary imaging 4, 5.

Considerations for Elderly Patients

• Elderly patients are at higher risk for intracranial injury due to falls, and CT scanning may be more frequently indicated in this population 2.
• The presence of a headache after a fall should prompt further evaluation, including CT scanning, to rule out intracranial hemorrhage or other injuries 6, 3.
• The patient's overall clinical condition, including vital signs and neurological examination, should guide the decision for CT scanning and further management 6.