Indications for Head CT in Elderly Patients After Falls

Assessment of Need for Head CT After Fall

• The American College of Radiology recommends a head CT scan for patients with focal neurologic deficits, as neurologic symptoms or signs suggest intracranial injury 1
• The American College of Radiology suggests that patients on anticoagulation therapy have a higher risk of intracranial bleeding, warranting a head CT scan 1
• Altered mental status or decreased level of consciousness suggests possible brain injury, according to the American College of Radiology 2, 1
• Signs of elevated intracranial pressure, including severe headache, vomiting, or visual disturbances, indicate the need for a head CT scan, as per the American College of Radiology 1
• Significant deterioration of consciousness, or any decline in alertness or responsiveness, requires a head CT scan, according to the American College of Radiology 1

Evidence-Based Approach

• The American College of Radiology states that a fall without loss of consciousness, no impact to the head, and a normal neurological examination do not necessitate a head CT scan 3
• The absence of anticoagulant therapy and no headache or vomiting also do not require a head CT scan, as per the American College of Radiology and Annals of Emergency Medicine 1, 4
• The American College of Emergency Physicians guidelines recommend considering head CT in patients with head trauma if there is age >60 years PLUS one or more of: headache, vomiting, drug/alcohol intoxication, short-term memory deficits, physical trauma above clavicle, seizure, GCS <15, focal deficit, or coagulopathy 3

Clinical Decision Rules

• The Canadian CT Head Rule, validated and recommended by the Journal of the American College of Radiology, can reduce unnecessary CT scans by 37% while maintaining high sensitivity for clinically important brain injuries 3
• The New Orleans Criteria, more sensitive but less specific than the Canadian CT Head Rule, would recommend CT for any elderly patient with headache, vomiting, age >60 years, intoxication, memory deficits, trauma above clavicle, or seizure, as per Annals of Emergency Medicine 4

Guidelines for CT Scan After Falls

Indications for Head CT After Falls

• The American College of Emergency Physicians recommends CT for patients with altered mental status or decreased level of consciousness, as indicated by a Glasgow Coma Scale (GCS) score of less than 15, with a study suggesting this criterion is effective in identifying patients who require CT scans 5
• The American College of Radiology suggests that signs of basilar skull fracture are an indication for CT, with a study highlighting the importance of considering this factor in patients with head trauma 6
• The Canadian CT Head Rule, as recommended by the Canadian medical community, is more specific than the New Orleans Criteria and can reduce CT scans by 37% while maintaining high sensitivity, with criteria including GCS <15 at 2 hours post-injury, suspected open or depressed skull fracture, signs of basilar skull fracture, vomiting ≥2 episodes, age ≥65 years, amnesia >30 minutes before impact, and dangerous mechanism of injury 5
• The Canadian CT Head Rule also recommends CT for patients with amnesia >30 minutes before impact, as this is a significant predictor of traumatic brain injury, according to a study published in the Annals of Emergency Medicine 5
• The Florida Geriatric Head Trauma CT Clinical Decision Rule, specifically validated for patients ≥65 years old, recommends CT for patients with a point score ≥25, with points assigned for factors such as arrival via EMS, GCS <15, antiplatelet medications, loss of consciousness, signs of basilar skull fracture, and headache, with a study highlighting the importance of considering antiplatelet medications and signs of basilar skull fracture in this patient population 6

Clinical Decision Rules

• The New Orleans Criteria, as recommended by the American College of Emergency Physicians, are more sensitive but less specific than the Canadian CT Head Rule, with criteria including headache, vomiting, age >60 years, drug or alcohol intoxication, persistent anterograde amnesia, visible trauma above clavicle, and seizure, although the strength of evidence for these criteria is not explicitly stated 5