From the Guidelines
For a 66-year-old female with a head injury from a fall two weeks ago, immediate medical evaluation is strongly recommended, preferably in an emergency department, to assess for potential complications such as intracranial hemorrhage or delayed subdural hematoma, which can be more common in older adults due to age-related brain atrophy. The evaluation should include a thorough neurological examination, cognitive assessment, and brain imaging—typically a CT scan, as suggested by the American College of Radiology Appropriateness Criteria for head trauma 1. This approach is crucial because clinical decision rules like the New Orleans Criteria and the Canadian CT Head Rule have been validated for their sensitivity in identifying patients who require neurosurgical intervention after mild head trauma 1.
Given the patient's age and the mechanism of injury, the risk of delayed complications necessitates a careful assessment. The patient should be evaluated for symptoms such as persistent headache, confusion, weakness, vision changes, or balance problems, which could indicate delayed complications. Treatment depends on the findings but may include close observation, symptom management with acetaminophen (500-1000mg every 6 hours as needed) for headache, and possibly a short course of rest followed by gradual return to activities.
The recent clinical policy from the American College of Emergency Physicians (ACEP) provides guidance on the management of adult patients presenting with mild traumatic brain injury, emphasizing the importance of considering anticoagulant and antiplatelet use in the decision-making process for imaging and observation 1. However, the policy also notes that delayed intracranial hemorrhage after blunt head trauma in neurologically intact patients on anticoagulant or antiplatelet therapy is rare and tends not to be clinically significant, suggesting that patients with a normal initial head CT and who are neurologically intact can be safely discharged with clear instructions for return precautions 1.
Follow-up care should include monitoring for post-concussive symptoms and cognitive changes, with consideration for rehabilitation services if deficits persist. Additionally, the patient should undergo a fall risk assessment to prevent future injuries, which may include medication review, vision testing, and home safety evaluation. This comprehensive approach prioritizes the patient's morbidity, mortality, and quality of life outcomes, ensuring that any potential complications from the head injury are promptly identified and managed.
From the Research
Evaluation and Treatment for Head Injury
The recommended evaluation and treatment for a 66-year-old female who suffered a head injury from a fall two weeks ago can be guided by the following points:
- Computed Tomography (CT) Scan: A CT scan is often the initial imaging modality used to evaluate head injuries, especially in emergency settings 2. Given the patient's age (66 years) and the mechanism of injury (fall), a CT scan may be indicated to rule out intracranial lesions, as the risk of such lesions is higher in older adults 2.
- Indications for CT Scan: The decision to perform a CT scan can be based on criteria such as the Japan Coma Scale (JCS) score, presence of accessory symptoms (headache, nausea/vomiting, loss of consciousness/amnesia), and age ≥60 years 2.
- Magnetic Resonance Imaging (MRI): While CT is typically the first-line imaging modality, MRI can provide more detailed information about the brain and may be useful in certain cases, especially if the CT scan is normal but clinical suspicion of injury remains high 3, 4.
- Antiemitic Treatment: For patients experiencing nausea and vomiting after a head injury, antiemetic medications like ondansetron or metoclopramide can be considered. Ondansetron may be preferred due to its similar efficacy to metoclopramide but with fewer side effects, such as drowsiness and anxiety 5.
- Monitoring and Follow-Up: Close monitoring of the patient's neurological status and follow-up appointments are crucial to assess for any worsening of symptoms or development of new symptoms that may indicate a complication of the head injury.
Considerations for Older Adults
Older adults, like the patient in question, may have a higher risk of complications from head injuries due to age-related changes and potential comorbidities. Therefore, a thorough evaluation, including imaging studies as indicated, and close monitoring are essential components of their care. The use of imaging techniques such as CT and MRI, as well as the administration of appropriate medications for symptoms like nausea and vomiting, should be guided by evidence-based practices 2, 6.