DogLovingPA Posted June 15, 2016 Share Posted June 15, 2016 Curious how low of a threshold everyone has for getting a head CT in trauma in the elderly. I am specifically interested in when/if you are scanning patients who meet the following criteria: - mechanical fall from standing - they can tell you exactly how and why they fell - no LOC - no use of anticoagulants - no subjective neuro complaints, no pain to head or neck - normal neuro exam - either no external signs of trauma or only minor physical signs (small "goose egg", small scalp or facial lac) Link to comment Share on other sites More sharing options...
Boatswain2PA Posted June 15, 2016 Share Posted June 15, 2016 Elderly Guy yesterday, on coumadin, tripped and fell from standing, landed on elbow. Small elbow lac that bled terribly. A&O, able to completely explain to me his fall and how he did NOT hit his head, no indication of head injury....I didn't scan his head. Link to comment Share on other sites More sharing options...
DogLovingPA Posted June 15, 2016 Author Share Posted June 15, 2016 I guess I should have specified.... pt says they did hit their head but with the criteria I listed.... We see a lot of elderly folks in Urgent Care who come in for falls whose primary complaint is elbow, ankle, etc. IF during this fall they say they also hit their head, but have no complaints with no evidence or minor evidence of trauma to their head do you scan? Recent example: elderly gentleman trips stepping up a curb and falls forward. Minor abrasions to palms, 1.5 centimeter lac above left eye. No loss of consciousness, witnessed fall, not anti coagulated, no neuro complaints with a completely normal neuro exam comes in mainly because his left shoulder hurts. Link to comment Share on other sites More sharing options...
Boatswain2PA Posted June 15, 2016 Share Posted June 15, 2016 I guess I should have specified.... pt says they did hit their head but with the criteria I listed.... We see a lot of elderly folks in Urgent Care who come in for falls whose primary complaint is elbow, ankle, etc. IF during this fall they say they also hit their head, but have no complaints with no evidence or minor evidence of trauma to their head do you scan? Recent example: elderly gentleman trips stepping up a curb and falls forward. Minor abrasions to palms, 1.5 centimeter lac above left eye. No loss of consciousness, witnessed fall, not anti coagulated, no neuro complaints with a completely normal neuro exam comes in mainly because his left shoulder hurts. Sorry, should've read that into your OP. I just go with gestalt. Frail little old guy, more likely to scan. Nothing wrong with keeping them in the ED for a few hours while you watch them, but I'm not worried about causing brain cancer in them in 10 years either. Don't have a good answer for you, but we have the CT machine, we have the techs, we have the radiologists, and I'm not worried about the effects of radiation = I scan a lot of them. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted June 15, 2016 Share Posted June 15, 2016 One perspective, Ottawa knee rules. 55> y/o, knee pain -> X-Ray automatically. Doesn't matter about any other lack of findings. Head CT in an anticoagulated pt. with blow to head? Seems to me to be a better reason to irradiate compared to the "automatic" knee. Another perspective to consider based on degree of risk aversion, easier to defend scan that's negative versus positive scan that you have to defend deferral on. No right answer. Link to comment Share on other sites More sharing options...
jmj11 Posted June 15, 2016 Share Posted June 15, 2016 I may have missed it but c/o headache? If so, then 100% CT. If not, I go with gastaut, for example if he is a injury lawyer then CT daily for a week. Link to comment Share on other sites More sharing options...
PACdan Posted June 15, 2016 Share Posted June 15, 2016 Student here, Negating cost/incidental findings/"waste", isn't one big reason for not getting CT to avoid unnecessary radiation exposure? The likelihood of inducing a cancer in persons >65 is negligible with modern scanners due to the exposure vs. life expectancy. In other words, advanced age lowers the threshold for scanning in my mind. Link to comment Share on other sites More sharing options...
DogLovingPA Posted June 15, 2016 Author Share Posted June 15, 2016 Anyone who can't tell me why they fell, had a LOC, are anticoagulated or have any complaints (HA, blurred vision, neck pain, etc) or any neuro exam findings go to the ER for a spin. I was just curious to see where the line was for folks for scanning patients who may have have hit their head but have no obvious reason to scan them except for their age. UC is a funny place.... people get mad when you tell them you think they need to be seen at the ER. Lol. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted June 16, 2016 Share Posted June 16, 2016 In elderly with fall/syncope, don't forget vertebral art., i.e.-listen for occipital bruit. Link to comment Share on other sites More sharing options...
treejay Posted June 16, 2016 Share Posted June 16, 2016 My decision would be based on how reliable the patient and or family is on monitoring for mental status deterioration if I decide to discharge without scanning. If very reliable, would discharge. If less likely to be reliable to f/u, more likely to scan Link to comment Share on other sites More sharing options...
sk732 Posted June 17, 2016 Share Posted June 17, 2016 This is my issue with the Canadian Head CT Rules, since if you answer no to everything other than age >/= 65, it still comes out as high risk, CT required. Common sense has to be used of course as well - if the noodle isn't hurt(ing) and you are certain as to why they fell, I say they fall into the NNTN category...NNTN meaning No Need To Nuke. Of course if I'm working with my SP that we've nicknamed "Capt CAT Scan", well you know where that will end up. SK Link to comment Share on other sites More sharing options...
Moderator ventana Posted June 17, 2016 Moderator Share Posted June 17, 2016 Really no negative to the scan besides time and money in the elderly (minimal risk of CA) BUT huge risk of missing something Anyone on anticoag that hits their head, or has signs of head trauma gets offered scan Anyone old, or demented gets offered that hits head, has sign of trauma, gets offered ASA counts in my mind as anticoag... Peds, not the same...... Really need to think about it an beyond this post.. And sedation less then 3 years of age has shown to have some long term negative mentation effects.... Link to comment Share on other sites More sharing options...
Guest ERCat Posted June 17, 2016 Share Posted June 17, 2016 Take this with a grain of salt because I am an ER new grad but in my book... Anyone 65+ with any head injury gets a CT. In my six months I've only seen ONE bleed so maybe I am being overly cautious but a head CT is minimal radiation... It is equivalent to only 100 chest x-Rays (as opposed to abdomen and pelvis which is more like 600). And these old people are unlikely to die of cancer from the CTs. I feel like it's better to be cautious. My guy with a subdural was a healthy sixty something year old dude who hit his head on the car door frame while getting into the car (!!!!!!) and wasn't on blood thinners - and ended up with a subdural bleed. Link to comment Share on other sites More sharing options...
DogLovingPA Posted June 17, 2016 Author Share Posted June 17, 2016 sky732 - your response is exactly where I was going with this question - I realize most of medicine has a large gray area but in following the Canadian head CT rules - age alone makes using the guidelines invalid. So far, I've been treating similar to you and treejay. Based on answers so far, I don't think I'll make any drastic clinical changes in who I send for a scan but will likely change some of the conversation I have with family and patient in terms of talking about risks, offering a scan, etc. M-F during day time hours we do have access to outpatient scanners so would not necessarily require an ER trip. Thanks for the input so far from everyone! Link to comment Share on other sites More sharing options...
Reality Check 2 Posted June 17, 2016 Share Posted June 17, 2016 Don't forget the C2 Hangman's fracture. I have had 2 with blows to the head in recent past - both over 90. Both unwitnessed falls without known LOC. Both with minimal if any complaints. One nonverbal dementia. BOTH had C2 fractures but nothing in the noggin busted. I am in a private FP and they somehow never went to ER or called 911 during fall but come in 2-3 days later bruised and sore and I am working against time and baseline symptoms. And usually on a Friday afternoon.................... Link to comment Share on other sites More sharing options...
Eastcoast PA-C Posted June 17, 2016 Share Posted June 17, 2016 I think it's a good place for shared decision making. Low overall suspicion, pt has someone at home to keep an eye on them, PCP follow up available, pristine neuro exam and the pt is reliable and agrees with foregoing the scan--just document like crazy. Anyone over 65 at least gets offered a scan and usually accepts. As an aside I'd also like to throw this out there: So far I've never seen a patient with an abnormal head ct that surprised me. There has always been a significant mechanism, mental status change or focal neurological finding. Just wondering if anyone has had a patient that was CT+ that they wouldn't have expected. Sent from my iPhone using Tapatalk Link to comment Share on other sites More sharing options...
DogLovingPA Posted June 17, 2016 Author Share Posted June 17, 2016 All good things to keep in mind. Will definitely be ensuring I have copious documentation and thorough conversations with the patient and family. Reality Check 2 - I've had one C2 fracture....she came in 16 hours post fall c/o of neck pain "even after I took a Percocet". I didn't even lay a finger on her - straight to the ER. (she was also on xarelto so she was going regardless of pain) Link to comment Share on other sites More sharing options...
Moderator ventana Posted June 18, 2016 Moderator Share Posted June 18, 2016 oh yeah and one other point Down's syndrome has C1-2 instability due to their condition.... if MVA or head/neck trauma ---scan them - have had a few C-1-2 fx back that gave me a big pucker factor....... Link to comment Share on other sites More sharing options...
ajnelson Posted June 18, 2016 Share Posted June 18, 2016 I have a VERY low threshold in ordering a CT head/neck on elderly fall/trauma, even in an asymptomatic patient. Being in the ED it's hard to defend why you didn't do it. In urgent care, you don't have access to CT, so I think you have a little more leniency. Two examples of why I CT heads...70yo fall, hit head. Neuro intact. Could tell us everything about the fall. Ended up with subdural, multiple surgeries and complications. #2...the elderly population has a really high and incidence of alcohol use and abuse. (Most of the time they won't admit it either). That's another huge risk factor for traumatic head injuries. Link to comment Share on other sites More sharing options...
DogLovingPA Posted June 19, 2016 Author Share Posted June 19, 2016 Ventana - thanks for the heads up on folks with Downs. AJ - I think you bring up a good point about location and if I was in the ER my threshold would likely be lower, because as you say (and others noted above) - you have the scanner, the people, etc. Except for those out of town folks (which we do see a LOT of) or Fridays on holiday weekends, I can usually arrange an outpatient scan within 24-48 hours which sounds like it might be a reasonable option for those without obvious need for an immediate scan. I'll definitely be tweaking my practice a little based on the above responses and a having more in depth discussion with my patients and family and likely getting a few more scans. Thanks guys! And as usual, reading this forum has sufficiently reminded me why I should always be scared out of my mind and keep a high index of suspicion for EVERYTHING :-) Link to comment Share on other sites More sharing options...
MedicinePower Posted June 20, 2016 Share Posted June 20, 2016 Relatively speaking a head CT absorbs the least amount of ionizing radiation then any other (abdominal the most).. The threshold for a head CT can be low without fear of causing brain cancer in the elderly. Link to comment Share on other sites More sharing options...
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