What is the appropriate management and evaluation for an elderly female patient with a large facial bruise resulting from a minor trauma, considering potential underlying conditions and medication use?

Management of Large Facial Bruise in Elderly Female from Minor Trauma

This elderly patient requires immediate assessment for anticoagulant/antiplatelet medication use, comprehensive vital sign evaluation with geriatric-specific thresholds, coagulation studies, and consideration of CT imaging even for this seemingly minor mechanism, as elderly patients are at high risk for occult injury and under-triage from low-energy trauma. 1

Immediate Assessment Priorities

Vital Signs with Geriatric-Specific Thresholds

• Measure heart rate and blood pressure immediately, using lower intervention thresholds: heart rate >90 bpm (not >130 as in younger patients) and systolic blood pressure <110 mmHg (not <90 mmHg) indicate hemodynamic compromise in elderly patients 1
• Perform early blood gas analysis (arterial or venous) for baseline base-deficit or lactate assessment, as these are more reliable than vital signs for predicting occult hypoperfusion in elderly patients 1
• "Normal" vital signs are unreliable in elderly patients who may have chronic occult hypoperfusion and baseline hypertension, making a "normal" blood pressure potentially represent hypotension 1

Critical Medication History

• Immediately screen for anticoagulants (warfarin, dabigatran, rivaroxaban, apixaban) and antiplatelet agents (clopidogrel, aspirin), as these medications put elderly patients at high risk for significant bleeding events even after minor trauma 1
• Document beta-blocker use, which can blunt the physiologic response to injury and mask hemodynamic instability 1
• Assess for chronic steroid use, which increases odds of death after geriatric trauma 1

Laboratory Evaluation

• Perform routine coagulation assays immediately: aPTT, PT/INR, and anti-Xa levels to assess anticoagulant exposure 1
• Obtain baseline lactate and base deficit measurements as markers of tissue perfusion 1
• If patient is on direct oral anticoagulants (DOACs), obtain direct measurements of DOAC levels if quantitative tests are available before deciding on reversal 1

Imaging Considerations

Low Threshold for CT Imaging

• Maintain a low threshold for CT scan even with this minor mechanism (running into door frame), as the diagnostic yield of contrast-enhanced CT outweighs the risk of contrast-induced nephropathy, especially given the dramatic effects of under-triage in elderly patients 1
• Elderly patients commonly experience major trauma from low-velocity mechanisms such as falls from standing height, which are frequently under-triaged 1
• Consider head CT to evaluate for intracranial hemorrhage, particularly if patient is on anticoagulation or has altered mental status 1

Frailty and Comorbidity Assessment

Comprehensive Evaluation

• Assess frailty in this patient using a validated tool such as the Clinical Frailty Score or Trauma-Specific Frailty Index, as frailty is present in 44% of elderly trauma patients and correlates with increased complications and mortality 1
• Document pre-existing conditions including hepatic disease, renal disease, cancer, and cardiovascular disease, as these are independent risk factors for mortality even after adjusting for injury severity 1
• Evaluate the Geriatric Trauma Outcome Score (GTOS) to predict in-hospital mortality risk 1

Anticoagulation Reversal Protocol (If Applicable)

For Vitamin K Antagonists (Warfarin)

• If patient is on warfarin and has uncontrolled bleeding or INR elevation, administer four-factor prothrombin complex concentrates (4F-PCCs) plus 5 mg intravenous vitamin K, with goal INR <1.5 1
• Fresh frozen plasma should only be used if no other treatment is available 1

For Direct Oral Anticoagulants

• Administer reversal agents only in critically ill patients with dosable plasma DOAC levels presenting with hemorrhagic shock not responding to resuscitation 1
• For dabigatran: idarucizumab 5g IV (or activated prothrombin complex concentrates 50 units/kg IV if idarucizumab unavailable) 1
• For rivaroxaban/apixaban: andexanet alfa per protocol 1

Monitoring and Disposition

Serial Assessment

• Perform serial base deficit and lactate measurements to monitor for occult hypoperfusion 1
• Monitor vital parameter trends (heart rate, blood pressure, respiratory rate, urinary output) and mental status closely 1
• Observe for delayed complications, as elderly patients may have delayed clinical deterioration 1

Common Pitfalls to Avoid

• Do not under-triage based on "minor" mechanism—ground-level falls and similar low-energy mechanisms account for 75% of geriatric trauma and carry 7% mortality 1, 2
• Do not rely solely on initial vital signs, which are frequently misleading in elderly patients on beta-blockers or with baseline hypertension 1
• Do not overlook polypharmacy effects, particularly anticoagulants and antiplatelet agents that dramatically increase bleeding risk 1
• Recognize that patients aged ≥55 years should be considered for geriatric trauma protocols, with mortality risk increasing 6.8% for each year beyond age 65 1, 2

Trauma Protocol Activation

• Consider early trauma protocol activation for patients aged ≥55 years to avoid under-triage and ensure appropriate evaluation 1
• Meticulous triage criteria should include physical examination, vital signs, blood gas analysis, and complete medical/drug history 1