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

From the Guidelines

A 64-year-old gentleman presenting to the emergency department with head trauma from an unwitnessed fall should undergo an immediate CT head scan, as the risk of significant intracranial pathology is higher in elderly patients, even with minor mechanisms of injury, and early detection of treatable conditions such as subdural hematomas is crucial. The indication for CT head in this case is based on several risk factors, including age over 60 years, an unwitnessed fall (suggesting possible loss of consciousness), and head trauma 1.

Key Considerations

• The patient's age and mechanism of injury increase the risk of significant intracranial pathology, making immediate imaging necessary 1.
• The presence of anticoagulant or antiplatelet therapy further increases the risk of intracranial hemorrhage, supporting the need for expedited imaging 1.
• While awaiting the scan, the patient should be closely monitored for neurological deterioration using the Glasgow Coma Scale (GCS) at regular intervals, with neurological observations continuing for at least 24 hours.
• Blood tests, including full blood count, clotting profile, and alcohol levels, may be appropriate, especially if the patient is on anticoagulant therapy.

Management Approach

• The patient should be assessed for other injuries, particularly cervical spine injuries, which commonly accompany head trauma.
• Clear discharge instructions with return precautions are warranted due to the potential for delayed intracranial hemorrhage, although the incidence is rare in patients with a normal initial head CT and who are neurologically intact 1.
• The decision to withhold anticoagulant or antiplatelet medication should be made on a case-by-case basis, weighing the risk of repeat trauma against the risk of intracranial hemorrhage.

Evidence Support

• The American College of Emergency Physicians (ACEP) Clinical Policy from 2008 provides guidelines for the use of noncontrast head CT in patients with head trauma, including those with loss of consciousness or post-traumatic amnesia, and those without these symptoms but with other risk factors such as age over 60 years, coagulopathy, or severe headache 1.
• Recent studies, including the one by Nishijima et al., support the notion that delayed intracranial hemorrhage after blunt head trauma in neurologically intact patients on anticoagulant or antiplatelet therapy is rare, and most patients can be safely discharged after a brief observation period and a normal initial head CT 1.

From the Research

Indications for a 64-year-old gentleman with head trauma

The patient's presentation to the emergency department with a head trauma following an unwitnessed fall requires careful evaluation. The following points should be considered:

• The patient's age and potential comorbidities, such as dementia, stroke, or smoking, which may increase the risk of repeat falls or new injuries 2
• The use of clinical decision rules, such as the Florida Geriatric Head Trauma CT Clinical Decision Rule, to determine the need for computed tomography (CT) scans in older adults with head trauma 3
• The implementation of protocols, such as the level III trauma protocol, to quickly identify intracranial hemorrhages in elderly patients without activating the trauma team for every elderly patient presenting to the ED with a potential head injury after a fall 4
• The importance of assessing co-morbidities and complications, as well as the use of anticoagulant/antiplatelet medication, in older adults presenting with head injury 5
• The use of symptoms and signs, such as physical examination findings suggestive of skull fracture, Glasgow Coma Scale (GCS) score, vomiting episodes, and decline in GCS score, to aid in determining which adults with minor trauma have severe intracranial injuries visible on CT 6

Key considerations

• The patient's age and comorbidities should be taken into account when evaluating the need for CT scans or other diagnostic tests
• Clinical decision rules and protocols can help guide the evaluation and management of older adults with head trauma
• A thorough assessment of the patient's symptoms and signs is crucial in determining the risk of severe intracranial injuries
• The use of anticoagulant/antiplatelet medication should be carefully considered in older adults presenting with head injury

Diagnostic evaluation

• A CT scan may be indicated in older adults with head trauma, particularly if they have a high risk of severe intracranial injuries based on clinical decision rules or protocols 3, 4
• The patient's GCS score, vomiting episodes, and decline in GCS score should be carefully monitored and documented 6
• The presence of physical examination findings suggestive of skull fracture or other signs of trauma should be carefully evaluated 6