What is the indication for a 64-year-old gentleman who presented to the emergency department with a head trauma due to an unwitnessed fall?

From the Guidelines

A CT scan of the head is indicated for this 64-year-old gentleman who presented to the emergency department with head trauma from an unwitnessed fall, as his age is a high-risk factor according to the Canadian CT Head Rule 1. The scan should be performed urgently to evaluate for intracranial hemorrhage, skull fractures, or other traumatic brain injuries. Given his age and the unwitnessed nature of the fall, there is a higher risk of serious intracranial pathology, even if he appears clinically stable.

• The patient's age is a significant risk factor, as the Canadian CT Head Rule considers patients over 64 years old to be at high risk for clinically important brain injury 1.
• The New Orleans Criteria also consider age over 60 years as a high-risk factor, further supporting the indication for a CT scan 1.
• The patient should also have his cervical spine immobilized and evaluated, as head trauma can be associated with cervical spine injuries.
• While waiting for the CT, the patient should be monitored closely for neurological deterioration, including regular assessments of his Glasgow Coma Scale, pupillary responses, and vital signs.
• If the patient is on anticoagulants or antiplatelet medications, this information should be communicated to the radiologist and emergency physician, as these medications increase the risk of intracranial bleeding, with a relative risk of significant intracranial injury of 1.88 for patients on warfarin alone 1.
• The urgency of the CT scan is heightened if the patient demonstrates any concerning neurological symptoms such as decreased consciousness, vomiting, seizures, focal neurological deficits, or worsening headache. According to the most recent study from 2023, the NEXUS Head CT decision instrument has shown promise as a clinical decision tool, with a sensitivity of 100% and a specificity of 24.9% for predicting the need for neurosurgical intervention 1. However, the study also notes that the absence of all features of the Canadian CT Head Rule lowers the probability of a severe intracranial injury to 0.31%, which is still a significant risk considering the patient's age and presentation 1. Therefore, a CT scan of the head is the most appropriate course of action for this patient.

From the FDA Drug Label

Mannitol Injection is indicated for the following purposes in adults and pediatric patients. Therapeutic Use Reduction of intracranial pressure and brain mass. Reduction of high intraocular pressure. Diagnostic Use Measurement of glomerular filtration rate.

The indication for a 64-year-old gentleman who presented to the emergency department with a head trauma due to an unwitnessed fall is reduction of intracranial pressure and brain mass. Key considerations include:

• Contraindications: Active intracranial bleeding except during craniotomy 2
• Dosage: 0.25 to 2 g/kg body weight as a 15% to 25% solution administered over a period of 30 to 60 minutes 2

From the Research

Indication for Head CT Scan in a 64-year-old Gentleman with Head Trauma

• The patient presented to the emergency department with a head trauma due to an unwitnessed fall, which may indicate the need for a head CT scan to assess for potential injuries such as intracranial hemorrhage or skull fractures 3, 4, 5, 6, 7.
• Studies have shown that the incidence of combined cranial and cervical spine injuries in patients with blunt minor trauma is low, which may not justify routine combined CT examinations of the head and cervical spine 4.
• However, patients with traumatic intracranial hemorrhage (TIH) may require repeat head CT scans to assess for progression of TIH, although the utility of this practice has been brought into question 3.
• The decision to perform a repeat head CT scan should be based on clinical judgment, taking into account factors such as the patient's Glasgow Coma Scale (GCS) score, presence of neurologic symptoms, and history of anticoagulation 3, 5, 6.
• A study found that isolated falcotentorial subdural hematomas in blunt traumatic brain injury are typically small and do not increase in size on short-term follow-up CT, suggesting that repeat CT may not be necessary in these cases 5.
• Another study found that routine repeat head CT scans in medically managed patients with head injury may not be necessary, and that factors such as GCS score at admission, abnormal international normalized ratio (INR), midline shift, effaced basal cisterns, and multiple hemorrhagic lesions are associated with worsening of repeat CT, neurological deterioration, and/or need for neurosurgical intervention 6.
• A retrospective study found that the incidence of delayed intracranial haemorrhage in head injury is small, and that repeat CT scans should be performed based on clinical indication, such as worsening neurologic symptoms or increased intracranial pressure 7.