I described several variations on the theme of elderly patients and subdural hematoma in my last post. All were situations in which an operation was not immediately indicated. Practice guidelines were in place to smooth the evaluation process for such patients. But do those guidelines really apply in some or all of these cases?

The real question that needs to be answered is “what is the real purpose of the guideline?”

Is it designed to standardize and streamline care? Certainly. But what is it’s real purpose? It is supposed to separate those who need additional treatment from those who do not. So in this case, it seeks to identify patients who are likely to need surgical intervention for their lesion.

In scenario 2, where the patient presents 8 hours after the fall, the “evaluation timer” started at the time of the event. If your practice guideline dictates that you obtain a repeat head CT 6 hours after arrival in the ED, isn’t your first scan at 8 hours really the same as the repeat scan? Shouldn’t you just need the one image, then send them home if they have a normal neurologic exam?

And isn’t there a point at which surgical intervention is no longer an option? That’s what makes scenarios 3-5 more difficult. Can we identify a subset of patients for whom surgery is not an option? For those who have a written “do not resuscitate” status (scenario 4) and don’t change their mind, is any followup evaluation needed at all?

For the other scenarios, we really need to know if there are subsets of patients for whom surgical intervention is inadvisable or contraindicated. Those patients should not need followup studies or even additional monitoring. One could even argue that they don’t need to be seen in an ED at all!

Lots of questions! In my next post, I’ll review some of the data on outcomes after brain surgery for traumatic injuries in elderly patients. Hopefully, we can come to some conclusions and/or recommendations for my scenarios based on this data!