What is the management for an elderly patient with confusion, left-sided weakness, and a Glasgow Coma Scale (GCS) score of 14, diagnosed with a subdural hematoma after a traumatic accident?

Management of Elderly Patient with Subdural Hematoma, GCS 14, and Focal Neurological Deficit

This patient requires admission with close neurological observation for 24-72 hours with serial clinical assessments and repeat imaging, rather than immediate surgery or discharge (Answer C). 1

Rationale for Admission Over Immediate Surgery or Discharge

Any patient with documented subdural hematoma on CT requires admission regardless of GCS, as delayed deterioration can occur. 1 The combination of confusion, left-sided weakness, and GCS 14 indicates an abnormal neurological examination, and patients with mild traumatic brain injury (GCS 13-15) and abnormal neurological findings should be admitted because approximately 1 in 4 will require treatment. 2

Discharge (Option A) is contraindicated because even patients with normal examinations and subdural hematomas have developed delayed deterioration requiring neurosurgery, leaving patients with permanent deficits. 2 The evidence shows that "observation at home is an illusion" for patients with intracranial hemorrhage. 2

Immediate neurosurgical intervention (Option B) is not indicated at this time because the patient has a GCS of 14 with stable vital signs and no evidence of herniation or rapidly deteriorating neurological status. The extent of primary underlying brain injury is more important than the subdural clot itself in dictating outcome, and the ability to control intracranial pressure is more critical than the absolute timing of subdural blood removal. 3

ICU admission with intubation (Option D) is premature for a patient with GCS 14 who can protect their airway. The motor component of GCS remains robust in determining severity, and this patient does not yet meet criteria for prophylactic intubation. 2

Specific Observation Protocol During Admission

Serial Neurological Monitoring Schedule

• Perform neurological examinations every 15 minutes for the first 2 hours, then hourly for the following 12 hours. 1
• Document individual GCS components (Eye, Motor, Verbal) rather than just sum scores, as component profiles predict outcomes. 1
• Assess pupillary size and reactivity at each evaluation, as these are prognostic indicators. 1

Critical Thresholds Requiring Intervention

• A decrease of 2 or more points in GCS score warrants immediate repeat CT scanning. 1
• Development of focal neurological deficits indicating mass effect necessitates surgical intervention. 1
• Failure to show neurological improvement within 72 hours is a negative prognostic factor requiring reassessment of management strategy. 4, 1

Physiological Targets During Observation Period

• Maintain mean arterial pressure ≥80 mmHg to ensure adequate cerebral perfusion. 4, 1
• Maintain oxygen saturation >95% to prevent hypoxemic secondary injury. 4, 1
• Correct confounding factors including sedating medications, alcohol, or metabolic derangements. 1
• Avoid administering long-acting sedatives or paralytics before neurosurgical evaluation, as this masks clinical deterioration. 1

When Surgery Becomes Indicated

Surgery should be performed if:

• Clinical deterioration occurs with GCS decline of ≥2 points 1
• Progressive focal neurological deficits develop 1
• Signs of herniation appear (pupillary changes, posturing) 2
• Intracranial pressure remains elevated despite medical management 4

Critical Pitfalls to Avoid

• Do not make irreversible decisions before 72 hours unless brain death criteria are met or there is clear clinical deterioration. 4, 1
• Do not delay correction of secondary insults (hypotension, hypoxia) while waiting to prognosticate. 4, 1
• Serial GCS assessments provide substantially more valuable clinical information than a single determination, with declining scores indicating poorer prognosis. 1
• In elderly patients, age per se is not a valid reason to limit treatments, though frailty is a superior predictor of poor outcome. 2

The 72-Hour Decision Point

The first 72 hours constitute the critical interval to determine prognosis. 2 Patients who do not show signs of improvement within 72 hours should be carefully evaluated before undergoing further aggressive treatment. 2, 4 However, among elderly patients, neurological status at 72 hours is a good prognostic factor for in-hospital death but is not a valid tool to predict long-term outcomes for survivors. 2