What precautions should be taken and why is a CT (Computed Tomography) scan ordered for a patient with head trauma resulting from a fall?

Management of Head Trauma from Falls: Precautions and CT Scan Indications

A CT scan is essential for patients with head trauma from falls to detect potentially life-threatening intracranial injuries, especially in those with risk factors including loss of consciousness, vomiting, headache, age over 60, drug/alcohol intoxication, memory deficits, trauma above the clavicle, seizures, focal neurological deficits, or coagulopathy.

Initial Assessment and Precautions

Clinical Evaluation

• Assess Glasgow Coma Scale (GCS) score, pupillary size and reactivity, which are key predictors of neurological outcome at 6 months 1
• Document each component of GCS (Eye-Verbal-Motor) separately, with particular attention to motor response which remains robust even in sedated patients 1
• Perform repeated neurological examinations to detect secondary deterioration 1
  • For moderate TBI (GCS 9-13): Check every 30 minutes for first 2 hours, then hourly for 4-12 hours
  • For mild TBI (GCS 14-15): Monitor according to risk factors present

Prevention of Secondary Brain Injury

• Maintain systolic blood pressure >110 mmHg to prevent secondary cerebral insults 1
• Prevent and promptly correct hypoxemia (SaO₂ <90%), which significantly worsens neurological outcomes 1
• The combination of hypotension and hypoxemia is particularly dangerous with a 75% mortality rate 1
• Investigate and correct other systemic factors that may cause secondary cerebral insults 1

Transfer Considerations

• Severe TBI patients should be managed by a pre-hospital medical team and transferred as soon as possible to specialized centers with neurosurgical facilities 1
• Management in a specialized neuro-intensive care unit is associated with improved outcomes, even for patients not requiring neurosurgical procedures 1

CT Scan Indications

Mandatory CT Scan Criteria

• Severe TBI (GCS ≤8): Immediate brain and cervical CT scan without delay 1
• Moderate TBI (GCS 9-13): Systematic and prompt brain and cervical CT scan 1

Mild TBI (GCS 14-15) with Risk Factors

• CT scan is indicated with any of the following 1:
  • Loss of consciousness or posttraumatic amnesia plus one or more of:
    • Headache
    • Vomiting
    • Age >60 years
    • Drug or alcohol intoxication
    • Short-term memory deficits
    • Physical evidence of trauma above the clavicle
    • Posttraumatic seizure
    • GCS <15
    • Focal neurological deficit
    • Coagulopathy
  • Even without loss of consciousness, CT should be considered with:
    • Focal neurological deficit
    • Vomiting
    • Severe headache
    • Age ≥65 years
    • Signs of basilar skull fracture
    • Dangerous mechanism of injury (fall from >3 feet/5 stairs)
    • Anticoagulant therapy 1, 2

Special Considerations

• Patients on anticoagulants have higher risk of intracranial hemorrhage after head trauma 2
• Patients with seizure-related falls have significantly higher rates of intracranial hematomas (90.9%) compared to falls from other causes (39.8%) 3
• Secondary neurological deterioration (decrease of ≥2 points in GCS) should prompt immediate repeat CT scan 1

Why CT Scan is Ordered

• CT is the first-line imaging modality for acute head trauma due to its availability and speed 1, 4
• Up to 15% of patients with head trauma and GCS 15 will have acute lesions on CT scan 1
• CT can detect treatable lesions before secondary neurological damage occurs 4
• CT effectively identifies:
  • Scalp injuries
  • Skull fractures
  • Extra-axial hematomas (epidural, subdural)
  • Parenchymal injuries
  • Lesions requiring immediate neurosurgical intervention 5, 4
• CT is compatible with multiple monitoring devices often used in trauma patients 5

Limitations and Follow-up

• MRI is more sensitive for detecting subtle parenchymal injuries but less practical in acute settings 5
• If CT does not explain clinical status, MRI may be warranted 5
• Follow-up imaging is best done with MRI as it's more sensitive to parenchymal changes 5

Outcome Considerations

• Less than 1% of mild TBI patients will have lesions requiring neurosurgical intervention 1
• However, 5-15% of mild TBI patients may have compromised function 1 year after injury 1
• Implementation of protocols focused on monitoring and prevention of secondary insults significantly reduces mortality 1