Head CT for 79-Year-Old Female After Fall Without Head Impact
A head CT scan is not indicated for a 79-year-old female who has fallen without head impact, unless specific risk factors are present such as focal neurologic deficits, anticoagulation therapy, or altered mental status.
Assessment of Need for Head CT After Fall
Key Risk Factors That Would Warrant Head CT:
- Focal neurologic deficit - neurologic symptoms or signs that would suggest intracranial injury 1
- Anticoagulation therapy - patients on blood thinners have higher risk of intracranial bleeding 1
- Altered mental status or decreased level of consciousness - suggests possible brain injury 1
- Signs of elevated intracranial pressure - including severe headache, vomiting, or visual disturbances 1
- Significant deterioration of consciousness - any decline in alertness or responsiveness 1
Additional Considerations for Elderly Patients:
- Age >60 years alone is not sufficient to warrant head CT without other risk factors 2
- The diagnostic yield of CT in elderly patients after falls without neurologic symptoms is low (only 7.6% in one study) 2
- Male sex is associated with higher risk of traumatic lesions on CT (RR = 2.19) 2
Evidence-Based Approach
When CT is NOT Indicated:
- Fall without loss of consciousness 1
- No impact to the head 1
- Normal neurological examination 1
- No anticoagulant therapy 1
- No headache or vomiting 1
When CT IS Indicated:
- According to the American College of Emergency Physicians guidelines, head CT should be considered in patients with head trauma if there is:
- Age >60 years PLUS one or more of: headache, vomiting, drug/alcohol intoxication, short-term memory deficits, physical trauma above clavicle, seizure, GCS <15, focal deficit, or coagulopathy 1
- The combination of risk factors significantly increases the likelihood of finding clinically relevant pathology 3
Clinical Decision Rules
Canadian CT Head Rule:
- The Canadian CT Head Rule has been validated and can reduce unnecessary CT scans by 37% while maintaining high sensitivity for clinically important brain injuries 1, 4
- A study implementing this rule in elderly patients from residential care facilities showed a 20% reduction in CT scans with no adverse outcomes 4
New Orleans Criteria:
- More sensitive (97.7%-99.4%) but less specific (3.0%-5.6%) than the Canadian CT Head Rule 1
- Would recommend CT for any elderly patient with headache, vomiting, age >60 years, intoxication, memory deficits, trauma above clavicle, or seizure 1
Common Pitfalls to Avoid
- Overreliance on age alone: While age >60 is a risk factor, it should not be the sole determinant for ordering CT 2
- Ignoring anticoagulation status: Some studies suggest anticoagulation may not significantly increase risk, but most guidelines still recommend CT for anticoagulated patients after falls 2, 1
- Missing subtle neurological deficits: Careful neurological examination is essential as some patients may not have obvious clinical signs predicting focal pathology 1
- Unnecessary radiation exposure: CT scans expose patients to radiation and incur healthcare costs when not clinically indicated 4