What is the best course of action for a 60-year-old female with a history of Chronic Obstructive Pulmonary Disease (COPD), osteoarthritis, hyperlipidemia, Gastroesophageal Reflux Disease (GERD), Sjogren's syndrome, rheumatoid arthritis, and chronic depression, who presents with head trauma, dizziness, and orthostatic hypotension after a fall?

Emergency Department Transfer Strongly Indicated Despite Patient Refusal

This 60-year-old patient with head trauma, documented orthostatic hypotension with symptomatic dizziness, and multiple high-risk comorbidities requires immediate emergency department evaluation and should not have been allowed to leave against medical advice without exhaustive attempts at persuasion and documentation of risks. 1, 2

Critical Risk Factors Present

Age and Cardiovascular Risk

• Patients older than 60 years with cardiovascular disease are at high risk of adverse outcomes after syncope and falls. 1
• This patient's age alone increases odds of dying after geriatric trauma by 6.8% for each year beyond 65, and she is approaching this threshold. 1, 3
• The orthostatic vital signs demonstrate a concerning pattern: systolic BP dropped from 136 to 106 mmHg on repeat standing with associated symptomatic dizziness. 4

Head Trauma Considerations

• Head trauma with a "golf ball-sized bump" and periorbital bruising in an elderly patient requires neuroimaging to exclude intracranial hemorrhage, particularly given the mechanism of falling forward and striking the frontal head. 1, 2
• The patient denies loss of consciousness, but this does not exclude significant intracranial injury in elderly patients who may have delayed presentations. 1, 2
• Ground-level falls in elderly patients account for 34.6% of all trauma deaths in patients ≥65 years, with mortality rates of 7% even from seemingly minor mechanisms. 3

Orthostatic Hypotension Assessment

The documented orthostatic vital signs meet criteria for orthostatic hypotension (30 mmHg systolic drop from initial standing to repeat standing), and the patient experienced symptomatic dizziness with positional changes. 4

Key findings:

• Initial lying: 127/73, pulse 72
• First standing: 136/78, pulse 78 (paradoxical rise in systolic BP)
• Repeat standing: 106/68, pulse 78 (30 mmHg drop from first standing)
• Recurrence of symptoms with positional changes is more significant than numeric blood pressure changes alone. 1, 4

Medication-Related Concerns

This patient's polypharmacy for multiple chronic conditions places her at extremely high risk for medication-induced orthostatic hypotension and falls. 1, 4

• Patients taking four or more medications require comprehensive medication review after falls. 2
• Common culprits include antihypertensives, diuretics, vasodilators, and psychotropic medications used for depression. 1, 4, 2
• Antidepressants, particularly older agents, can cause significant orthostatic hypotension in elderly patients. 1, 4
• The American Geriatrics Society notes that multiple origins of syncope and orthostatic hypotension frequently coexist in elderly patients and must be addressed simultaneously. 4

Required Emergency Department Evaluation

Mandatory Diagnostic Testing

The following tests should have been completed before any consideration of discharge: 2

• 12-lead EKG - Despite financial concerns, this is non-negotiable given syncope/presyncope with fall. The EKG has low yield (5%) but can identify life-threatening dysrhythmias or myocardial infarction immediately. 1
• Complete blood count - To assess for anemia from occult bleeding (patient should be screened for melena). 2
• Basic metabolic panel - To evaluate electrolyte abnormalities that could contribute to falls and assess renal function given multiple comorbidities. 2
• Head CT without contrast - Mandatory given significant head trauma with large hematoma and periorbital bruising. 1, 2
• Cervical spine imaging - Ground-level falls in elderly patients commonly cause cervical spine fractures. 3

Physical Examination Gaps

A complete head-to-toe examination must be performed to identify occult injuries, not just the reported head and knee pain. 2

Critical elements that should have been documented:

• Neurologic examination with attention to focal deficits
• Cardiovascular examination for signs of congestive heart failure (high-risk indicator for adverse outcomes) 1
• Musculoskeletal examination of all extremities for occult fractures 2
• Abdominal examination to exclude intra-abdominal injury
• Rib palpation (elderly patients commonly sustain rib fractures from ground-level falls) 3

High-Risk Features Requiring Admission Consideration

Cardiovascular Risk Stratification

This patient has multiple Level B and C risk factors for adverse outcomes: 1

• Age >60 years with likely cardiovascular disease (on treatment for hyperlipidemia)
• Documented orthostatic hypotension with recurrent symptomatic dizziness
• Polypharmacy with medications that likely include antihypertensives and antidepressants
• Physical examination findings should have assessed for congestive heart failure

Frailty Assessment

Frailty should be assessed in all elderly trauma patients as it correlates with increased complications and worse outcomes. 1

This patient demonstrates concerning features:

• Multiple chronic conditions (COPD, osteoarthritis, rheumatoid arthritis, Sjogren's syndrome)
• Recurrent dizziness suggesting impaired physiologic reserve
• Fall from standing height with inability to prevent injury

Physiologic Considerations in Elderly Trauma

"Normal" vital signs in elderly patients are unreliable indicators of hemodynamic stability. 1

• Systolic BP <110 mmHg represents shock in elderly patients (this patient reached 106 mmHg). 3
• Heart rate >90 beats/min indicates hemodynamic compromise in elderly (this patient's HR was 78, but beta-blockers or other medications may blunt tachycardic response). 1, 3
• Elderly patients may have chronic occult hypoperfusion making "normal" vital signs misleading. 1

Critical Management Errors

Deferring EKG Due to Financial Constraints

This represents a significant deviation from standard of care. 1, 2

• The EKG is inexpensive, non-invasive, and provides immediate results
• Financial concerns should never delay essential diagnostic testing in acute presentations with syncope and head trauma
• The statement that it "would be completed in the emergency room if needed" acknowledges the necessity but inappropriately delays it

Allowing AMA Departure Without Adequate Risk Communication

The documentation should reflect extensive counseling about specific risks: 1, 2, 3

• Risk of delayed intracranial hemorrhage with potential for death
• Risk of undiagnosed cardiac arrhythmia causing sudden death
• Risk of recurrent falls with serious injury
• Risk of cervical spine injury with neurologic deterioration
• Increased mortality risk in elderly patients with head trauma (7% for ground-level falls) 3

Failure to Perform "Get Up and Go Test"

Before any discharge consideration, a functional assessment must be performed to ensure patient safety. 2

• The "Get Up and Go Test" assesses whether the patient can safely ambulate
• A time >12 seconds indicates increased fall risk 1
• Discharging patients who cannot pass this test without reassessment increases immediate fall risk. 2

Proper Documentation for AMA Departure

When a high-risk patient insists on leaving AMA, documentation must include: 1, 2, 3

• Detailed explanation of all risks discussed with patient and family member present
• Specific mention of risk of death from intracranial hemorrhage, cardiac arrhythmia, or recurrent falls
• Documentation that patient demonstrated capacity to make medical decisions
• Clear statement that medical team strongly recommended emergency transport
• Instructions given for immediate return if symptoms worsen (headache, vision changes, recurrent dizziness, loss of consciousness)
• Follow-up plan with primary care physician within 24-48 hours

Recommended Actions Moving Forward

Immediate Follow-Up Protocol

Given that the patient left AMA, urgent outreach is warranted: 2

• Contact patient within 24 hours to reassess symptoms
• Strongly encourage emergency department evaluation if any concerning symptoms persist
• Arrange urgent primary care follow-up if patient refuses ED
• Document all attempts at contact and patient responses

Medication Review

A comprehensive medication review must occur at next contact to address polypharmacy and fall risk. 1, 2

Priority medications to review:

• Antihypertensives (may need dose reduction or discontinuation if causing orthostatic hypotension) 1, 4
• Antidepressants (particularly if older tricyclics or trazodone, which have high orthostatic hypotension risk) 1, 4
• Any anticholinergic medications (antihistamines, muscle relaxants, overactive bladder agents) 1
• GERD medications if they include H2 blockers with anticholinergic properties 1

Fall Prevention Interventions

Multifactorial fall prevention must be implemented: 2

• Physical therapy referral for balance and strength training (tai chi, walking, resistance exercises) 1, 2
• Home safety evaluation and modification 2
• Vision assessment 2
• Evaluation for appropriate assistive devices 2
• Address P-SCHEME factors: Pain, Shoes, Cognitive impairment, Hypotension, Eyesight, Medications, Environmental factors 1

Common Pitfalls Illustrated by This Case

This case demonstrates multiple critical errors in geriatric trauma management: 1, 2, 3

1. Under-triage of ground-level falls - Low-velocity mechanisms in elderly patients are frequently under-triaged despite high mortality risk 3
2. Accepting financial constraints as reason to defer essential testing - EKG is mandatory in syncope evaluation 1
3. Failing to perform complete head-to-toe examination - Occult injuries are common and easily missed 2
4. Inadequate risk communication before AMA departure - Specific risks of death and disability must be explicitly stated 1, 2
5. Not performing functional assessment before discharge consideration - "Get Up and Go Test" is essential 2
6. Overlooking medication review - Polypharmacy is a leading cause of falls in elderly patients 1, 2

The combination of head trauma, orthostatic hypotension, recurrent dizziness, and multiple comorbidities in a 60-year-old patient represents a medical emergency requiring immediate comprehensive evaluation in an emergency department setting, regardless of patient preference or financial concerns. 1, 2, 3