Whose heads are you scanning?

[gro2001]

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I guess I’m wishing there were a PECARN equivalent for >65 not anticoagulated. I see a significant percentage of elderly who hit their head but deny any headache or any symptoms, no focal deficits, no hemotympanum, etc.. The premise of PECARN as I understand it, it’s not to miss any that would require neurosurgical intervention, intubation, hospitalization for 48 hours. But I guess the key differences in the elderly is their risks anatomically (bridging veins, atrophy) are inherently different and harder to predict.

That and also because of the age related brain atrophy the exam may be normal for longer after an injury.

 

[ShockIndex]

That and also because of the age related brain atrophy the exam may be normal for longer after an injury.

You probably spend a lot more time in the neuroICU then me, so feel free to fact check me on these basic principles:

1) Clinically significant brain injury in the elderly is not limited to surgically significant - especially in elders who are anticoagulated.

2) A normal physical exam does not rule out clinically significant ICH (intracranial hemorrhage) in elderly patients; this is especially true in the elderly and anticoagulated. Plenty of elder patients with clinically significant brain bleeds have normal neuro exams, GCS of 15, and a paucity outward evidence of significant trauma.

3) We do not know of a mechanism threshold for which ICH becomes more likely in the elderly or anticoagulated. This includes whether the mechanism involves a head strike of any certain degree.

Based on these assumptions, I do not try to justify a lack of neuroimaging based on exam or GCS. I’m also reluctant to use a lack of mechanism to justify a minimalist approach, but admit that some patients with isolated extremity injuries will fall outside the scope of this thread. Moreover, I remain unconvinced by the argument that we are over-imaging elderly or anticoagulated patients with minor trauma. A previous post referenced a personal NNT of roughly 30 to find one bleed - more than acceptable in my opinion.

 

[gro2001]

You probably spend a lot more time in the neuroICU then me, so feel free to fact check me on these basic principles:

1) Clinically significant brain injury in the elderly is not limited to surgically significant - especially in elders who are anticoagulated.

2) A normal physical exam does not rule out clinically significant ICH (intracranial hemorrhage) in elderly patients; this is especially true in the elderly and anticoagulated. Plenty of elder patients with clinically significant brain bleeds have normal neuro exams, GCS of 15, and a paucity outward evidence of significant trauma.

3) We do not know of a mechanism threshold for which ICH becomes more likely in the elderly or anticoagulated. This includes whether the mechanism involves a head strike of any certain degree.

Based on these assumptions, I do not try to justify a lack of neuroimaging based on exam or GCS. I’m also reluctant to use a lack of mechanism to justify a minimalist approach, but admit that some patients with isolated extremity injuries will fall outside the scope of this thread. Moreover, I remain unconvinced by the argument that we are over-imaging elderly or anticoagulated patients with minor trauma. A previous post referenced a personal NNT of roughly 30 to find one bleed - more than acceptable in my opinion.

Yes, I agree on all counts.

 

[prolene60]

A couple years ago I had to transfer a 60 yo Male who was on Eliquis who suffered a mechanical fall. Suffered a wrist and hip fracture. Had to be transferred because his orthopedist was there. He was adamant that he didn't hit his head and had absolutely no signs of head trauma. The ED attending at the other hospital actually took the time to call me and asked why I didn't scan his head since he fell and was on blood thinners. She ended up scanning him later (and his neck) which of course were negative. I thought after that phone call that I was somehow practicing well before the standard of care until reading through some of these posts.

 

[skougess]

Interesting timing. Recently was on shift with a colleague who had an elderly woman presenting for a fall with no LOC, no thinners. No sign of head trauma but did say she mildly struck her head, though that was not her main complaint.

Epidural hematoma.

Old people get scanned.

 

[wareagle726]

I have NEVER had a radiologist come tell me "thanks so much for not scanning that patient." I have seen a patient I didn't scan come back sicker and thought "Dang I shoulda scanned that patient."

I think I recently saw something that stated there was a fairly high rate of c-spine injuries with elderly falls without obvious impact/injury. I can't recall the percentage but it was pretty high.

 

[bky3c]

I have NEVER had a radiologist come tell me "thanks so much for not scanning that patient." I have seen a patient I didn't scan come back sicker and thought "Dang I shoulda scanned that patient."

I think I recently saw something that stated there was a fairly high rate of c-spine injuries with elderly falls without obvious impact/injury. I can't recall the percentage but it was pretty high.

I once worked at a place where the radiologists complained that the ED (all of us) "ordered too many negative CTs." 🙄

 

[DocEspana]

very slowly I'm scanning less elderly people, even those on anticoagulation.

I'm extremely confident, perhaps 100% so, that nobody has died over the ensuing days of their discharge from my ER.
I've probably missed 1, perhaps 2, ditzel bleeds on CT.

Need more than "oh I bumped my head" to get a CT.

We are comfortable sending home people with chest pain who have a 30-60 day MACE of 0.5%. We ought to have similar security sending home these patients who we all know are very low risk.

It's gotten to the point that patients now expect a CTH no matter how trivial the head trauma, and they believe the skull serves no purpose other than preventing our brains from oozing out our ears all over the floor.

"You have a skull you know"

I am asking patients if thats what they think their skull is for now.