Low Impact Head Injury in the Elderly: What is the Appropriate Action?
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; discussion 297-8.
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