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!

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.