By Thomas A. Sharon, R.N., M.P.H. and Joel Passick, M.D., J.D. (guest co-author)
Head trauma is a frequent adverse occurrence in hospitals and nursing homes.
When it results in subdural hematoma it is a time factor injury. In other
words, there is a narrow window of time during which there is a single
opportunity to save the patients life or prevent catastrophic brain damage.
Therefore, any evidence of head trauma after a fall must be followed by
a CAT scan of the head immediately upon discovery. Any delay is inexcusable
and is tantamount to depriving the patient of his/her right to competent
emergency care. It is well known that bleeding inside the head with the
formation of a subdural hematoma can be insidious in that clinical symptoms
may not manifest until it is too late.
The issue is one of susceptibility as pointed out in numerous independent
studies conducted around the world all reaching the same conclusion. L.
Wolf in the Journal of Emergency Nursing
1. Munro, et al
2. found that age over 65 was an independent factor in determining morbidity
and mortality in head injury. The incidence of subdural and extradural
hematoma was significantly higher in the older age groups. Mosenthal, et al
3. demonstrated that elderly patients (aged 60 years and older) have an increased
mortality after isolated traumatic brain injury.
Ono, et al published a study in Japan that indicated that age over 60 was
a significant reason to order a CT scan of the head even in mild head injury
4. Sabbori, et al
5. found age over 60 to be a significant factor in finding positive results
on CT scan after minor head injury. Ibañez J. et al
6. identified age over 65 as an independent risk factor of minor head injury
resulting in a subdural hematoma.
Therefore, we can conclude that the standard of care from both the medical
and nursing purview is to conduct a CT scan of the head without delay
with any overt evidence of head trauma regardless of severity in patients
who are 60 years of age or older. The failure to do so would result in
undiagnosed subdural hematoma in approximately one third of the patients
with head injury at any level of severity and would constitute depriving
the patient of his or her right to competent emergency medical care.
Case in point: A 72 year old male fell in his nursing home room and hit the back of his
head on the floor. There was no loss of consciousness and no laceration.
There was a small lump at the back of the head just above the base of
the skull. The nurses took his vital signs put him in bed and called the
doctor. The doctor ordered bed rest and neurological checks every four
hours. Three days later the patient lapsed into a coma at some unknown
point in time and the CT scan taken at the hospital showed brain stem
herniation from a subdural hematoma (SH). The patient expired and a wrongful
death action ensued with a demand for punitive damages, given the high
probability of undiagnosed SH in the elderly after minor head trauma without
a CT scan.
1. Wolf, L.; "Triage and Early Recognition of Significant Head Injury
in the Geriatric Trauma Patient." Journal of Emergency Nursing,Volume
32,Issue 4,Pages 357-359
2. Munro, Philip T., et al; "Effect of patients’ age on management
of acute intracranial hematoma: prospective national study." BMJ.
2002 November 2; 325(7371):1001.
3. Mosenthal, Anne C. MD, et al; "The Effect of Age on Functional
Outcome in Mild Traumatic Brain Injury: 6-Month Report of a Prospective
Multi Center Trial." Journal of Trauma-Injury Infection & Critical
Care. 56(5):1042-1048, May 2004.
4. Ono K,, et al "Indications for computed tomography in patients
with mild head injury." Neurol Med Chir (Tokyo). 2007 Jul;47(7):291-7;
5. Saboori M., et al. "Indications for brain CT scan in patients with
minor head injury." Clinical Neurology Neurosurgery. 2007 Jun;109(5):399-405.
Epub 2007 Mar 9.
6. Ibañez J. et al; "Reliability of clinical guidelines in
the detection of patients at risk following mild head injury: results
of a prospective study." Journal of Neurosurgery. 2004 May;100(5):825-34
Thomas A. Sharon, R.N., M.P.H.
The guest co-author, Joel Passick, M.D., J.D. is board certified in internal
medicine, currently practicing in South Florida