What imaging and labs should be ordered for an 83-year-old male veteran who presents to the Emergency Room (ER) with a history of fall, possible loss of consciousness, severe back pain, leg weakness, and abdominal bloating?

Emergency Imaging and Laboratory Workup for Elderly Fall Patient with Neurological Symptoms

For an 83-year-old male veteran with history of fall, possible loss of consciousness, severe back pain, leg weakness, and abdominal bloating, a comprehensive CT imaging protocol including head, cervical spine, thoracolumbar spine, and abdomen/pelvis with IV contrast should be ordered immediately.

Initial Imaging Workup

Head and Spine Imaging

1. Non-contrast CT Head

   • Essential to evaluate for intracranial hemorrhage, especially given history of fall with possible loss of consciousness 1
   • Should be performed before any contrast studies

2. CT Cervical Spine

   • Indicated due to fall mechanism and possible loss of consciousness
   • Patient meets NEXUS criteria (focal neurologic deficit - leg weakness) 1

3. CT Thoracolumbar Spine

   • Critical given the severe back pain and leg weakness
   • Vertebral fractures can present with abdominal symptoms and may be missed without appropriate imaging 2
   • Meets criteria for thoracolumbar imaging (back pain, abnormal neurologic signs) 1

Abdominal Imaging

1. FAST (Focused Assessment with Sonography in Trauma)

   • Should be performed immediately upon arrival to rapidly assess for free intraabdominal fluid 1
   • High specificity but limited sensitivity for detecting free fluid (<500ml) 1

2. CT Abdomen/Pelvis with IV contrast

   • Essential for comprehensive evaluation of abdominal complaints and potential injuries 1, 3
   • Will help identify source of abdominal bloating and potential causes of back pain
   • Can detect solid organ injuries, hollow viscus injuries, and retroperitoneal pathology 1, 3

Laboratory Studies

1. Complete Blood Count (CBC)

   • To assess for anemia from occult bleeding
   • Leukocytosis may indicate infection or inflammation

2. Comprehensive Metabolic Panel (CMP)

   • Evaluate renal function prior to contrast administration
   • Assess electrolyte abnormalities that could contribute to weakness
   • Liver function tests to evaluate for abdominal pathology

3. Coagulation Studies (PT/INR, PTT)

   • Essential in elderly patients who may be on anticoagulants
   • Critical if intracranial hemorrhage is suspected

4. Urinalysis

   • To rule out urinary tract infection which can cause altered mental status in elderly
   • Evaluate for hematuria which may indicate genitourinary trauma

5. Cardiac Enzymes (Troponin)

   • To evaluate for cardiac etiology of fall or syncope
   • Elderly patients may have atypical presentations of cardiac events

Clinical Considerations and Pitfalls

• Beware of occult injuries: In elderly patients, significant injuries may present with minimal symptoms due to decreased pain sensation and altered physiologic response 1

• Consider vertebral compression fractures: These can present with abdominal pain and are often missed in initial evaluations 2

• Monitor for delayed deterioration: Elderly patients with traumatic injuries may have delayed presentations of serious pathology, requiring close monitoring 1, 3

• Medication review: Polypharmacy is common in elderly veterans and may contribute to falls and symptoms 1, 4

• Avoid relying solely on negative FAST: A negative FAST does not rule out significant intraabdominal injury and should not delay definitive CT imaging 1

Special Considerations for Elderly Veterans

• Elderly veterans have higher rates of comorbidities that increase fall risk and complicate recovery 4, 5

• Age at time of injury is a significant predictor of mortality following traumatic injuries 5

• Consider admission for observation even with negative initial imaging if clinical suspicion remains high 1, 3