What are the guidelines for hospital admission for an elderly person with a head laceration and probable Loss of Consciousness (LOC) after an unwitnessed fall?

Hospital Admission Guidelines for Elderly Patients with Unwitnessed Fall, Probable LOC, and Head Laceration

An elderly patient with an unwitnessed fall, probable loss of consciousness, and head laceration should be admitted to the hospital for observation and comprehensive evaluation, as this presentation carries significant risk for intracranial injury and delayed deterioration. 1

Key Risk Factors Mandating Admission

Loss of Consciousness

• Loss of consciousness (LOC) is a critical predictor of intracranial injury in elderly fall patients, with an odds ratio of 2.02 for traumatic intracranial injury. 2
• LOC in elderly patients after falls is associated with a 4.6-fold increased risk of abnormal CT findings (OR 4.6,95% CI 1.2-18.4). 3
• Elderly patients often present atypically—they may have amnesia for LOC, lack prodromal symptoms, and events are frequently unwitnessed, making the history of "probable LOC" particularly concerning. 4

Head Laceration (Signs of Head Trauma)

• Physical signs of head trauma carry an odds ratio of 2.6 for intracranial injury in geriatric fall patients. 2
• The combination of LOC and signs of head trauma has a sensitivity of 86.5% for detecting intracranial injury, though 7 injuries could be missed if used as an exclusion criterion. 2
• High-risk injuries such as blunt head trauma in elderly patients warrant extensive workups, as injuries may be "occult" and present without classic signs. 1

Age-Related Vulnerability

• Ground-level falls in patients ≥65 years account for 34.6% of all trauma deaths in this age group. 1
• Adults ≥70 years have significantly higher rates of intracranial injury and in-hospital mortality from ground-level falls compared to younger patients. 1
• Elderly patients have altered physiologic responses—systolic blood pressure <110 mmHg may represent shock after age 65, and occult hypotension is present in 42% of elderly trauma patients with "normal" vital signs. 1

Mandatory Initial Assessment Components

Critical History Elements

The following must be documented for all elderly fall patients: 1

• Exact circumstances of fall (location, witnessed vs. unwitnessed status)
• Time spent on floor/ground (prolonged immobility increases complications)
• Loss of consciousness or altered mental status (even if uncertain or "probable")
• Near-syncope or orthostatic symptoms
• Previous falls in recent months
• Medication review, particularly:
  • Anticoagulants (warfarin, NOACs)
  • Antiplatelet agents (aspirin, clopidogrel)
  • Vasodilators, diuretics
  • Antipsychotics, sedative/hypnotics 1
• Comorbidities: dementia, Parkinson's disease, stroke, diabetes, depression 1

Physical Examination Requirements

• Complete head-to-toe examination for all patients, even with seemingly isolated injuries, as occult injuries are common. 1
• Orthostatic blood pressure assessment (critical in elderly patients). 1
• Neurologic assessment focusing on:
  • Mental status and Glasgow Coma Scale
  • Presence/absence of neuropathies
  • Proximal motor strength
  • Pupillary response 1
• Gait assessment using "Get Up and Go Test" before any discharge consideration. 1

Diagnostic Testing

While no standardized test panel exists, maintain low threshold for: 1

• CT head imaging (mandatory given LOC and head laceration)
• ECG (to evaluate for cardiac syncope)
• Complete blood count
• Electrolyte panel
• Medication levels if applicable

Anticoagulation Considerations

Critical Risk Factor for Deterioration

• Anticoagulated patients with head injury are at high risk for rapid deterioration and should be transported to facilities capable of rapid imaging and anticoagulation reversal. 1
• Among elderly patients on warfarin or clopidogrel with minor head injuries and GCS 15,29% had intracranial hemorrhage. 1
• Ground-level fall deaths in elderly patients showed 30% were anticoagulated with aspirin, warfarin, clopidogrel, or heparin. 1
• Clopidogrel use is associated with dramatically higher mortality (OR 14.7,95% CI 2.3-93.6) and discharge to long-term facilities (OR 3.25). 1

Management Implications

• If the patient is on anticoagulation or antiplatelet therapy, admission is strongly indicated even with normal initial CT, as delayed intracranial hemorrhage can occur. 1
• Patients on antiplatelet agents (especially elderly) with high-risk features (LOC, amnesia, or GCS <15) require observation even if repeat CT is not performed. 1
• The 2023 ACEP guidelines note that while delayed ICH is rare in neurologically intact anticoagulated patients with normal initial CT, elderly patients on aspirin may require longer observation. 1

Admission Criteria

Admission should be considered if patient safety cannot be ensured. 1 This includes:

• Probable or confirmed loss of consciousness (your patient meets this criterion) 1, 3, 2
• Head laceration or signs of head trauma (your patient meets this criterion) 1, 2
• Anticoagulation or antiplatelet use (assess medication list) 1
• Inability to perform "Get Up and Go Test"—patients unable to rise from bed, turn, and steadily ambulate should be reassessed and likely admitted 1
• Abnormal neurologic examination 1
• Unsafe home environment or inadequate social support 1
• Multiple fall risk factors requiring multidisciplinary intervention 1

Inpatient Management Requirements

Mandatory Consultations

• Physical therapy and occupational therapy evaluation for all patients admitted after a fall. 1
• Consider early palliative care team involvement for frail elderly patients to align care with goals and improve outcomes. 1

Observation Protocol

• Serial neurologic assessments to detect delayed deterioration, particularly in anticoagulated patients 1
• Repeat imaging considerations based on clinical course and anticoagulation status 1
• Comprehensive fall risk assessment addressing multifactorial causes 1

Discharge Planning

• Expedited outpatient follow-up including home safety assessments 1
• Clear discharge instructions with return precautions, especially for anticoagulated patients 1
• Ensure someone can assist with discharge care instructions and provide safe environment during recovery 1

Common Pitfalls to Avoid

• Undertriage of elderly patients: The elderly are frequently undertriaged because standard physiologic parameters don't apply—low-energy mechanisms can cause severe injury. 1
• Dismissing "unwitnessed" falls: Unwitnessed falls in elderly patients often involve LOC that the patient cannot recall due to amnesia, making them higher risk. 4
• Assuming normal vital signs mean stability: Occult hypotension is present in 42% of elderly trauma patients with "normal" vital signs. 1
• Discharging anticoagulated patients too quickly: Even with normal initial CT, these patients can deteriorate rapidly and require facilities capable of urgent intervention. 1
• Failing to assess gait before discharge: Patients who cannot perform the "Get Up and Go Test" are not safe for discharge. 1
• Missing the "geriatric syndrome": Falls in elderly patients are typically multifactorial, requiring comprehensive assessment beyond the immediate injury. 1

Special Consideration: Goals of Care

While admission is medically indicated, if the patient is enrolled in hospice or has clear advance directives limiting aggressive care, involve palliative care teams early to align management with patient wishes. 1, 5 However, for a typical elderly patient without such directives, admission for observation and comprehensive evaluation is the standard of care given the high-risk presentation. 1