What is the best management approach for an elderly patient with a recent history of accident, presenting to the Emergency Room (ER) with confusion, mild headache, left-sided weakness, a Glasgow Coma Scale (GCS) score of 14, and a computed tomography (CT) scan showing a subdural hematoma?

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

This patient requires immediate hospital admission to a monitored setting with serial neurological assessments and urgent neurosurgical consultation—not immediate surgery, not discharge, and ICU admission is appropriate given the combination of elderly age, GCS 14, focal neurological deficit (left-sided weakness), and confirmed subdural hematoma. 1, 2

Why Admission with Observation is the Correct Answer

The British Journal of Anaesthesia and American College of Emergency Physicians guidelines specifically recommend hospital admission with close neurological observation for 24-72 hours for patients with GCS 14 and focal deficits, rather than rushing to immediate neurosurgical intervention. 1, 2 This approach allows time to determine if the patient will stabilize, deteriorate, or require surgical evacuation based on clinical trajectory rather than a single snapshot assessment.

Approximately 1 in 4 patients with mild traumatic brain injury (GCS 13-15) and abnormal neurological findings will require treatment, making admission mandatory rather than discharge. 1

Why Each Wrong Answer is Inappropriate

Discharge (Option A) is Dangerous

The American College of Emergency Physicians explicitly warns against discharging patients based solely on a "mild" GCS of 14, as the combination of elderly age, confusion, focal weakness, and confirmed subdural hematoma creates unacceptably high risk for deterioration. 1, 2 Approximately 1.5% of patients with mild head injury deteriorate, with 57% of deteriorations occurring within 24 hours and 18% between days 2-7. 3

Immediate Neurosurgical Intervention (Option B) is Premature

While neurosurgical consultation should be obtained immediately, actual surgical evacuation is not indicated unless specific criteria are met: clinical deterioration with GCS decline ≥2 points, development of additional focal deficits indicating mass effect, signs of herniation (pupillary changes, posturing), or failure to show neurological improvement within 72 hours. 1 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. 4

ICU with Intubation (Option D) is Excessive

While ICU admission is appropriate for patients with GCS 13-14, focal deficit, and elderly status, intubation is not immediately indicated if the airway is protected. 1 This patient has GCS 14 with confusion and mild headache—not signs of impending respiratory failure or inability to protect the airway. Never administer long-acting sedatives or paralytics before neurosurgical evaluation, as this masks clinical deterioration. 1, 2

Specific Observation Protocol

Perform GCS monitoring every 15 minutes for the first 2 hours, then hourly for 12 hours. 1 Document individual GCS components (Eye, Motor, Verbal) rather than sum scores, as component profiles predict outcomes. 1

At each evaluation, assess:

• Pupillary size and reactivity (critical prognostic indicators) 1
• Focal neurological deficits 1
• Level of confusion/orientation 1, 2

Critical Thresholds Triggering Surgical Intervention

A decrease of 2 or more points in GCS score warrants immediate repeat CT scanning and activation for surgical evacuation. 1 Other triggers include:

• Development of new focal neurological deficits indicating mass effect 1
• Signs of herniation (pupillary changes, posturing) 1
• Failure to show neurological improvement within 72 hours 1

Supportive Care During Observation

Maintain mean arterial pressure ≥80 mmHg to ensure adequate cerebral perfusion. 1 Maintain oxygen saturation >95% to prevent hypoxemic secondary injury. 1 Do not delay correction of secondary insults (hypotension, hypoxia) while waiting to prognosticate. 1

Why This Patient's Focal Deficit Matters

Focal deficits such as left-sided weakness indicate significant mass effect or underlying brain injury. 1 This finding elevates risk substantially and mandates close monitoring, as it may herald impending deterioration requiring surgical decompression.

Timing Considerations

Serial GCS assessments provide substantially more valuable information than single determinations, as declining scores indicate poorer prognosis. 1 Do not make irreversible decisions before 72 hours unless brain death criteria are met or clear clinical deterioration occurs. 1