“An 85 y/o patient trips over a step and hits her occiput against the wall resulting in a non-depressible scalp laceration which is sutured. The patient is not anticoagulated, did not lose consciousness, vomit, or develop any neurological deficit. Overall, the patient does not meet any of the NICE [the UK’s National Institute for Clinical Excellence] guidelines for CT brain, and is discharged with safety advice,” shared an emergency medicine physician.
“Ten days later, she presents to the ER complaining of dizziness and is found to have a subdural hematoma. Despite best neurosurgical care, she passes away 10 days afterwards.”
The physician asks, “Would you have CT scanned this patient in your institution? Do you think the decision not to scan on first attendance (as per local guidelines) constitutes any degree of negligence?”
The community expressed why performing a CT scan would have been appropriate in this case.
“Her age automatically puts her in a different category of care. As we age, our brain shrinks, a fall that does not even result in a blow to the head can cause this as the brain will hit the inside of the skull, and vessels will tear. Those vessels become stretched as the brain shrinks, rip easily. She should have been hospitalized for a few days and watched closely, with follow up CT scans.”Cardiologist
“Agree with the choice to scan given patients age but would have d/c home if negative CT head on initial encounter with PCP follow up for any new or worsening symptoms.”Medical Student
“Can’t agree more, her age & head injury all lead to one thing –> CT scan & admit her 24-48 hours under observation.”Neurosurgeon
Another emergency medicine physician offered some practical logistics for consideration in deciding the next best course of action.
“Very sensible approach. However, imagine the number of hospital beds and amount of resources that would be required if every elderly patient with such head injury/history were to be hospitalized for a few days and follow up scans.”Emergency Medicine Physician
“In our institution, we don’t follow these guidelines. We scan every trauma patient we see, no matter how little and unremarkable the injury as long as there’s reason to believe there was head trauma, even with a normal GCS and no visible lacerations. We usually catch a lot of intracranial hemorrhages from the most unassuming trauma cases this way.”Radiologist
The emergency medicine physician who posted the case explains the influence regional standards have on deciding patient care.
“I am a big fan of this approach, however, it cannot conceivably be implemented in the UK due to their strict adherence to NICE recommendations.”Emergency Medicine Physician
What would you have done? What do your institution’s guidelines suggest? Join the discussion with other healthcare professionals on Figure 1.
Published September 21, 2021
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