All trauma centers are seeing a steady increase in the number of elderly patients, particularly victims of falls. Frequently, these patients strike their head, and some develop various flavors of intracranial hemorrhage. Several are taking drugs that interfere with clotting or platelet function.
Many centers, like my own, have developed practice guidelines to help trauma professionals deal with these issues in a consistent fashion. But are the guidelines suitable for all elderly head-injured patients?
Let’s consider a case.
Scenario 1. An elderly female falls at her senior living facility, striking her head on a side table. She is brought to your center’s emergency department for evaluation. An exam and head CT are performed, which demonstrate an asymptomatic 6mm subdural hematoma with no midline shift. The patient is not taking any drugs that would interfere with clotting. You have a clinical practice guideline that requires neurologic monitoring for 6 hours, followed by a repeat CT scan. If the neurologic exam remains stable and the repeat CT shows no progression of the lesion, the patient may be discharged.
Seems pretty straightforward, right? Now let’s add some interesting tidbits.
Scenario 2. Same as above, but the patient is brought to your center the next morning, 8 hours after the fall.
Scenario 3. Same as scenario 1, but the patient is very demented.
Scenario 4. Same as scenario 1, but the patient has a well-documented “do not actively resuscitate” order in place.
Scenario 5. Same as scenario 1, but the patient is 95 years old.
Think about these carefully. Would the extra findings in scenarios 2-5 cause you to change your practice and diverge from the practice guideline? In what ways? What else do you need to know to make good decisions?
Over my next few posts, I’ll consider each of these cases. I’ll cite some of the pertinent literature that I think we need to know. Then I’ll finish up with my take on each of the scenarios.
As always, feel free to share your thoughts about them. You can email, leave comments at the end of this post, or shout it out on Twitter. I’ll respond to each and every one.
