Can a fall from a chair cause a fatal acute subdural hemorrhage (ASH)?

Can a Fall from a Chair Cause a Fatal Acute Subdural Hemorrhage?

Yes, a fall from a chair can cause a fatal acute subdural hemorrhage, particularly in older adults and those on anticoagulant medications, as low-impact mechanisms like ground-level falls can result in severe brain injury in vulnerable populations. 1

Risk Factors for Fatal Subdural Hemorrhage from Low-Energy Falls

Age-Related Factors

• Adults aged ≥65 years are at significantly higher risk of severe injury and death from low-energy falls 1
• Ground-level falls account for 34.6% of all deaths in patients aged ≥65 years 1
• Mortality risk increases further after age 74, with a 1.67 higher odds of death compared to those aged 65-74 years 1
• Physiologic response to injury differs in older adults, with occult hypotension present in 42% of elderly patients with "normal" vital signs 1

Anticoagulation and Bleeding Disorders

• Anticoagulation use significantly increases the risk of intracranial hemorrhage following even minor head injuries 1
• 30% of patients who died following ground-level falls were anticoagulated with aspirin, warfarin, clopidogrel, heparin, or multiple anticoagulants 1
• Patients on clopidogrel had particularly high mortality rates (OR = 14.7) after traumatic intracranial hemorrhage 1
• Rapid reversal of anticoagulation is critical to prevent hematoma expansion in patients with subdural hematomas 2

Mechanism of Injury

• Low-energy transfers (e.g., falls from chairs or ground-level falls) can result in serious injuries, especially in older adults 1
• Occipital impacts are particularly dangerous, accounting for 57% of falls on the same level 3
• The base of the skull is frequently involved (91%) in cranial fractures from falls 3
• Subdural hematomas were associated with cranial fractures in 75-91% of fatal falls 3

Pathophysiology and Outcomes

Acute Subdural Hematoma Development

• Acute subdural hematomas can develop rapidly after head trauma due to tearing of bridging veins between the brain and dural sinuses 1
• In elderly patients, brain atrophy creates more space for the brain to move during impact, increasing strain on bridging veins 1
• Non-contrast CT is the first-line imaging modality for diagnosing acute subdural hematomas 2

Mortality and Timing of Intervention

• Overall mortality for acute subdural hematoma ranges from 57-66% 4, 5
• Factors strongly influencing outcome include:
  • Age over 65 years 4
  • Initial neurological status 4
  • Postoperative intracranial pressure 4
  • Time from injury to surgical decompression (when comatose) 5
• When surgical decompression is delayed beyond two hours after onset of coma, mortality from subdural hematoma increases from 47% to 80% 5

Special Considerations in Different Populations

Elderly Patients

• Triage set points should be lower for elderly patients, with systolic blood pressure less than 110 mmHg considered significant 1
• Polypharmacy in elderly patients can mask typical physiologic responses to trauma 1
• Frailty assessment should be included in trauma evaluation of geriatric patients 1

Pediatric Patients

• While rare, children can occasionally sustain major head injuries from short falls due to unusual injury mechanisms or preexisting conditions 6
• Subdural hematomas are the most common intracranial abnormality in abusive head trauma in children 2

Clinical Implications

• All patients with head trauma from falls should be evaluated for risk factors for severe injury, particularly age and anticoagulation status 1
• Patients on anticoagulants with evidence of head injury should be transported to facilities capable of rapid evaluation, imaging, and reversal of anticoagulation 1
• Elderly patients with even minor head trauma should be monitored closely for neurological deterioration, as they may not present with typical signs of serious injury 1
• When evaluating patients with subdural hemorrhage without clear trauma history, other causes such as ruptured intracranial aneurysm should be considered 7