What is the best course of action for an elderly patient who fell 7 days ago, hitting her left temporal region, and is now presenting for evaluation?

Management of Elderly Patient with Head Trauma 7 Days Post-Fall

For an elderly patient presenting 7 days after head trauma with temporal impact, obtain a non-contrast head CT scan immediately, as delayed intracranial hemorrhage can occur up to 5% of cases even in neurologically intact patients, and elderly patients on antiplatelet agents (particularly aspirin) have demonstrated delayed ICH requiring neurosurgical intervention in up to 4% of cases. 1

Immediate Assessment

Critical History Elements

• Medication review is essential: Specifically inquire about anticoagulants (warfarin, NOACs) and antiplatelet agents (aspirin, clopidogrel), as these significantly increase risk of delayed intracranial hemorrhage (ICH) even with normal initial presentation 1
• Mechanism details: Document exact fall circumstances, surface type, and whether loss of consciousness or amnesia occurred, as elderly patients frequently have amnesia for loss of consciousness 1
• Interval symptoms: Ask about any vomiting episodes (≥2 episodes increases risk), progressive headache, confusion, or behavioral changes since the fall 1, 2
• Pre-fall symptoms: Assess for syncope, dizziness, or palpitations that may have precipitated the fall, as up to 30% of falls in elderly may be due to syncope 3

Physical Examination Priorities

• Glasgow Coma Scale (GCS) score: Document current score; GCS of 13 has likelihood ratio of 4.9 for severe intracranial injury 2
• Signs of skull fracture: Examine for Battle's sign, raccoon eyes, hemotympanum, or CSF rhinorrhea/otorrhea (LR 16 for severe injury if present) 2
• Neurological examination: Assess pupillary response, focal deficits, gait, and cognitive status using validated tools like Mini Mental State Examination 1
• Orthostatic vital signs: Measure blood pressure supine and after 1-3 minutes standing to evaluate for orthostatic hypotension (drop ≥20 mmHg systolic or ≥10 mmHg diastolic) 3

Imaging Decision

Strong Indications for Immediate CT (Any Present)

The 2023 WSES guidelines recommend a low threshold for CT imaging in geriatric trauma patients, as the diagnostic yield outweighs risks of contrast-induced nephropathy given the potential dramatic effects of under-triage. 1

Apply the Canadian CT Head Rule criteria - CT is indicated if ANY of the following: 1, 2

• Age ≥65 years (this patient qualifies)
• ≥2 vomiting episodes
• Amnesia >30 minutes
• GCS score <15 at 2 hours post-injury
• Suspected skull fracture on examination
• Dangerous mechanism (pedestrian struck, fall >1 meter)

Critical consideration: Even with a 7-day delay, imaging remains essential because delayed ICH has been documented in elderly patients, particularly those on antiplatelet therapy, with one study showing 4% delayed ICH rate in patients >65 years on aspirin, including one death and one requiring neurosurgical decompression 1

Imaging Modality

• Non-contrast head CT is the most appropriate initial examination for acute to subacute head trauma 4, 5
• MRI consideration: If CT is negative but clinical suspicion remains high or patient has persistent symptoms, MRI is more sensitive for parenchymal injury and can be considered for follow-up 5

Risk Stratification Based on Medication History

If Patient on Anticoagulants or Antiplatelets

Patients on anticoagulants or antiplatelet agents with normal initial neurological examination can develop delayed ICH in up to 5% of cases, though most do not require neurosurgical intervention. 1

• Aspirin alone: Elderly patients (≥65 years) on low-dose aspirin have shown 4% delayed ICH rate, with higher risk if there was loss of consciousness, amnesia, or initial GCS <15 1
• Warfarin or NOACs: Delayed ICH requiring neurosurgical intervention occurs in <1% of neurologically intact patients 1
• Management: If CT is negative and patient is neurologically intact, discharge is generally safe with clear return precautions, though observation period may be warranted for high-risk features 1

Additional Diagnostic Testing

Based on 2023 WSES and fall evaluation guidelines: 1, 6

• ECG: To identify arrhythmias or conduction abnormalities that may have caused syncope
• Blood gas analysis: Baseline base-deficit or lactate assessment
• Complete blood count and electrolytes: Especially if admission considered
• Medication levels: If on anticoagulants, check INR (warfarin) or specific drug levels

Disposition Planning

If CT Shows Acute Findings

• Immediate neurosurgical consultation for any surgical lesions 1
• Admission for observation with serial neurological assessments 1

If CT is Negative and Patient Neurologically Intact

Discharge may be appropriate with the following conditions: 1, 6

• Patient has reliable home supervision (critical given relative is present)
• Clear discharge instructions with specific return precautions provided
• Close follow-up arranged within 24-48 hours
• Home safety assessment recommended to prevent future falls

Return precautions must include: 1

• Worsening headache
• Vomiting
• Confusion or behavioral changes
• Seizures
• Focal weakness or numbness
• Loss of consciousness

Special Considerations for Elderly Patients

The 2023 WSES guidelines emphasize that elderly patients (≥55 years) require careful evaluation to avoid under-triage, with lower thresholds for trauma protocol activation. 1

• Fall risk counseling: 53% of elderly with vestibular disorders fall at least once yearly; counsel on home safety modifications 1, 6
• Frailty assessment: Consider using Geriatric Trauma Outcome Score (GTOS) to predict in-hospital mortality 1
• Multidisciplinary follow-up: Arrange physical therapy evaluation for gait/balance, medication review with primary care, and possible cardiology evaluation if syncope suspected 6, 3

Common Pitfalls to Avoid

• Do not rely solely on normal neurological examination: 18.4% of patients with mild head injury and normal exams had intracranial lesions, with 5.5% requiring surgery 7
• Do not dismiss delayed presentation: The 7-day interval does not eliminate risk of delayed complications, particularly in elderly patients on antiplatelet agents 1
• Do not overlook syncope as fall etiology: Amnesia for loss of consciousness is common; always assess cardiovascular causes 1, 3
• Do not discharge without ensuring home safety: Patient needs supervision and fall prevention strategies given high recurrence risk 1, 6