Whose heads are you scanning?

[TrailRun]

Was wondering if my practice matches others; single coverage community so don't get a lot of feedback

kids = PECARN

severe mechanism, worrisome story or exam = scan

any age anticoagulated = scan (usually even if not headstrike)

65 or over with headstrike = scan


Most curious about whether others scan anti coagulated or >65 falls with NO headstrike?

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[carbonizedeyesockets]

Generally use Canadian Head CT decision rule/aid. Seems a lot of people forget that if no LOC, no amnesia, and no disorientation, then no need to apply the rule - no scan is needed.

65 and older with heatstroke, it's really going to depend on Hx and exam and how reliable they seem. Definitely a lower threshold to scan despite what any decision rule/aid may say.

 

[BoardingDoc]

If they're a reliable historian who can tell me precisely how they fell and how there is zero chance that they hit their head, I document that and don't scan them.

Most of my patients over 65 can't do that though.

 

[RustedFox]

65 or over with headstrike = scan
Most curious about whether others scan anti coagulated or >65 falls with NO headstrike?

65 and older with heatstroke, it's really going to depend on Hx and exam and how reliable they seem. Definitely a lower threshold to scan despite what any decision rule/aid may say.

If they're a reliable historian who can tell me precisely how they fell and how there is zero chance that they hit their head, I document that and don't scan them.

Most of my patients over 65 can't do that though.

** Cries in Florida **

 

[RustedFox]

If they're a reliable historian who can tell me precisely how they fell and how there is zero chance that they hit their head, I document that and don't scan them.

I have an autotext for this. I say: "ZIP: CONTROLLED FALL" intot he mic, and I get:

"The patient states that they were able to fall in a controlled fashion to minimize the potential for head/neck or other serious injury, stating clearly and with certainty that they did not strike their head. To this end; the patient appears to be correct; as there are no visible marks or stigmata of head injury."

 

[thegenius]

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"

 

[Rendar5]

Please don’t. Just stick with Canadian head ct rules. They exist for a reason.
I work in a Florida Ed with average age greater > 65yo. I see nonstop falls. I only ct if there is a head injury or sign of head. We’re the receiving trauma center also so any missed bleeds would show up here and I would be alerted. I have 0 missed bleeds when there is no head trauma in almost 10 years. Patients who can’t tell me their history don’t count

 

[Rendar5]

Generally use Canadian Head CT decision rule/aid. Seems a lot of people forget that if no LOC, no amnesia, and no disorientation, then no need to apply the rule - no scan is needed.

65 and older with heatstroke, it's really going to depend on Hx and exam and how reliable they seem. Definitely a lower threshold to scan despite what any decision rule/aid may say.

I’m not sure what you mean No scan is needed. There are plenty of people with no LOC, no amnesia and no disorientation that the rule applies to that need a scan

 

[gruemd]

In my understanding, the Canadian Head CT rule is actually usually too broadly used for any head trauma. The primary article (summarized well here) as well as MDCalc say this:

"Only apply to patients with Glasgow Coma Scale (GCS) 13-15 and at least one of the following:

• Loss of consciousness.
• Amnesia to the head injury event.
• Witnessed disorientation."

Which really only makes it a pretty narrowly useful tool. But I agree that that doesn't mean that no scan is needed in those cases which don't meet the inclusion criteria.

 

[Groove]

I used to use all the algorithms but nowadays it's pretty much 100% GESTALT. Either that or if they are requesting the CT. I document the obligatory algorithms to cover myself medicolegally.

In general, I scan way fewer people at this point in my career than I did starting out. Most people are pretty reasonable but you've always got that element of people that aren't going to sleep without a negative CTH. I don't fight those anymore and I just order it, especially now that I work in an affluent part of town where the pt population requires a bit more coddling. I work in a ridiculously efficient ED and can get any CT for the most part completed and interpreted in about 20 mins. Sometimes, I'll be in the room getting a history and placing orders on my COW and the CT tech will come in there before I'm even done with my exam to get them for CT.

 

[BoardingDoc]

I’m not sure what you mean No scan is needed. There are plenty of people with no LOC, no amnesia and no disorientation that the rule applies to that need a scan

Agree. That isnt how decision rules work. If you don't meet their inclusion criteria, that doesn't mean that they rule out. It means they don't qualify to use the tool.

A patient on thinners with a head strike, no LOC, not altered and with good recall but who is now vomiting uncontrollably is someone we would obviously all scan, but one which the rule doesn't apply to.

 

[ScepticSkeksis]

At my crappy HCA facility they are now activating a "trauma alert" on any person over 60 with any kind of fall, even if not on blood thinners, and even if no evidence of trauma.

 

[BoardingDoc]

At my crappy HCA facility they are now activating a "trauma alert" on any person over 60 with any kind of fall, even if not on blood thinners, and even if no evidence of trauma.

Gotta hit that 20k button when you can baby! /s

Seriously, I have no idea how this crap isn't fraud. If an individual doctor decided to do this, they'd go to prison. Somehow when it's a huge hospital system like HCA though they just get some sort of fine and keep going.

 

[sloh]

Is it really 20k just to activate trauma?

 

[ShockIndex]

Why are people mentioning the Canadian Head CT Rules in the context of anticoagulated patients?

 

[ShockIndex]

There is no validated head injury rule for elderly, anticoagulated head injury patients that doesn’t involve CT. Telling people to use the Canadian Head Injury Rule in this population is wrong because anticoagulated patients were excluded from this study.

There is also no data that risk stratifies these patients based on the degree or even absence of trauma to their head. This is not surprising since the mechanism for SDH, a more common injury pattern in this population, is shear force across bridging veins which requires decelaration but not necessarily impact (although impact should heighten the risk). SDH is an injury pattern associated with trivial and sometimes no recalled mechanism - even in elderly not on anticoagulants. We see this in other shear mechanisms (a prego falls 1 step on her butt and abrupts).

Thus, this is not a patient population where I’m trying to save a buck or mSv. I scan them liberally (along with their c-spine in one foul swoop). Assuming that they are at their neurologic baseline and appropriate for discharge, I tell them that they are still not completely out of the woods, delayed bleeding out to several days occasionally occurs, and they should immediately return for worsening.

 

[TooMuchResearch]

Was wondering if my practice matches others; single coverage community so don't get a lot of feedback

kids = PECARN

severe mechanism, worrisome story or exam = scan

any age anticoagulated = scan (usually even if not headstrike)

65 or over with headstrike = scan


Most curious about whether others scan anti coagulated or >65 falls with NO headstrike?

Over 65 with minor head injury, no anticoagulation, normal mental status doesn't necessarily need a CT if you tell them to come back for signs / symptoms of SDH.

 

[TooMuchResearch]

Gotta hit that 20k button when you can baby! /s

Seriously, I have no idea how this crap isn't fraud. If an individual doctor decided to do this, they'd go to prison. Somehow when it's a huge hospital system like HCA though they just get some sort of fine and keep going.

It is fraud.
But CMS pays and chases fraud later, after HCA makes their money.

 

[thegenius]

I’ve stopped applying the Canadian CT Head rules, at least consciously. Maybe I do it subconsciously though. I don’t know. The rule itself isn’t helpful either…it promotes over scanning and doesn’t diagnose more injuries than physician gestalt. Moreover, physicians (and the Canadian CT rule) don’t miss clinically important TBI.

We should stop using the Canadian CT head rule - First10EM

The best available evidence is that the Canadian CT head rule does not help, and might be harmful, so it shouldn't be used clinically.

first10em.com

Some here scan 90/100 minor blunt head trauma, others scan maybe 60/100. All Of us are not missing clinically important brain injury. This is a heated topic over something that very rarely happens in the low risk population. Kind of reminds me of those who admit almost every low risk chest pain vs those who send home most low risk chest pain. It’s a population I just don’t spend any significant time worrying about.

 

[ScepticSkeksis]

I don't have an issue with scanning all these old people. There's no harm involved really (I'm not worried about brain tumors or nuking the thyroid on an 80-year-old), but the trauma activations are a scam, pure and simple.

When they call a trauma alert, nurses draw blood, and get an EKG. I tell them to not do any of that nonsense.

 

[JacobMcCandles]

At my crappy HCA facility they are now activating a "trauma alert" on any person over 60 with any kind of fall, even if not on blood thinners, and even if no evidence of trauma.

Nothing new.

In alleged health care ‘money grab,’ nation’s largest hospital chain cashes in on trauma centers

HCA charges patients an “activation fee” of up to $50,000 for trauma teams at centers located in half its 179 hospitals — and they often don’t need trauma care, an analysis of insurance claims data shows.

www.tampabay.com

Doctors’ lawsuit: HCA Healthcare and TeamHealth overcharged patients

Recently unsealed case describes alleged widespread use of unnecessary trauma alerts and added tests at HCA Healthcare/ Mission Hospital

www.northcarolinahealthnews.org

I guess the monetary benefit must still be greater than any lawsuit damages.

 

[ShockIndex]

I'll go one step further - not only is the Canadian Head Injury Rule worthless in elderly, anticoagulated, head injury patients but so is clinical gestalt. Correct me if I'm wrong, but no study has looked at this patient population to determine how good we are at predicting EBS (exploding brain syndrome) in these patients using just clinical acumen.

Thus, my approach to these patients has absolutely nothing to do with my ability to predict which patients have (or will eventually have) blood in their head. Instead, I readily admit to the patients and their family members that I cannot clinically predict the likelihood of deterioration from a brain injury. I therefore focus on 2 questions:

1) Does the patient want an aggressive scope of care that might include brain surgery, mechanical ventilation, prolonged hospitalization, nursing home placement, etc. if we were to find a significant injury
2) Would positive CT for ICH change my management in a patient who did not want an aggressive scope of care.

While the answer to #1 is sometime no, the answer to #2 is almost always yes in an anticoagulated patient. That is to say, while the patient may not want brain surgery if we found a bleed, stopping or even reversing their anticoagulation would be a standard practice. In elders who are not anticoagulated, I find that less than a 1/3 are comfortable answering both questions in the negative and taking on the uncertainty associated with forgoing imaging.

Regardless of how you approach these patients, trying to predict who bled is a loser.

 

[TrailRun]

I'll go one step further - not only is the Canadian Head Injury Rule worthless in elderly, anticoagulated, head injury patients but so is clinical gestalt. Correct me if I'm wrong, but no study has looked at this patient population to determine how good we are at predicting EBS (exploding brain syndrome) in these patients using just clinical acumen.

Thus, my approach to these patients has absolutely nothing to do with my ability to predict which patients have (or will eventually have) blood in their head. Instead, I readily admit to the patients and their family members that I cannot clinically predict the likelihood of deterioration from a brain injury. I therefore focus on 2 questions:

1) Does the patient want an aggressive scope of care that might include brain surgery, mechanical ventilation, prolonged hospitalization, nursing home placement, etc. if we were to find a significant injury
2) Would positive CT for ICH change my management in a patient who did not want an aggressive scope of care.

While the answer to #1 is sometime no, the answer to #2 is almost always yes in an anticoagulated patient. That is to say, while the patient may not want brain surgery if we found a bleed, stopping or even reversing their anticoagulation would be a standard practice. In elders who are not anticoagulated, I find that less than a 1/3 are comfortable answering both questions in the negative and taking on the uncertainty associated with forgoing imaging.

Regardless of how you approach these patients, trying to predict who bled is a loser.

I think everything you said is correct, but I can’t remember the last time I saw a significant ICH (that required surgical intervention (aside from their recommendation of a repeat CT in 6 hours) in a patient with a reassuring exam, history, GCS

 

[ShockIndex]

I think everything you said is correct, but I can’t remember the last time I saw a significant ICH (that required surgical intervention (aside from their recommendation of a repeat CT in 6 hours) in a patient with a reassuring exam, history, GCS

Does elderly (age > 65) and anticoagulated fit your definition of a reassuring history?

There is really no circumstance where I’m reassured by anticoagulation. I’ve literally never said, “Oh, thank God you’re on blood thinners.”

 

[gro2001]

I think everything you said is correct, but I can’t remember the last time I saw a significant ICH (that required surgical intervention (aside from their recommendation of a repeat CT in 6 hours) in a patient with a reassuring exam, history, GCS

I am both an emergency physician and a neurointensivist, and this is one way that my fellowship has changed my EM practice. I scan a lot more now.

I fairly often see patients with chronic subdurals that were almost certainly due that fall a couple of months ago that was missed. Sometimes the delay is an issue and they need a bigger surgery than they otherwise would have. Sometimes it's an issue because they were continued on anticoagulation and subsequently re-bled.

I think people are falsely reassured by not having seen bounce backs. Even if you are the only hospital with a neurosurgeon in house, patients can still present to another hospital and be transferred to your ICU without passing through the ER. Unless you are involved in reviewing all transfers for your institution, you would not know about these. And also, people cross county lines (and even state lines I hear) and are perhaps more likely to do so if they have a suspicion something was missed the first time.

I have a fairly low threshold to get a CTH in anyone over 65 or so. Would get for most but the mildest of head trauma in that age group. Would scan anyone on anticoagulation almost regardless of mechanism or actual head strike. Anyone who has a headache/nausea/confusion after injury even if they did not hit their head.

Also surgery for subdural is not necessarily a big crazy thing. A lot of times it's some combination of a single burr hole and/or middle meningeal artery embolization. Both are very well tolerated, including in the elderly. For chronic subdurals there are even bedside techniques like SEPS. For Even craniotomies (taking off a section of the skull and then putting it back) is pretty well tolerated. I think most people are imaging craniectomies (when a section of the skull comes off and stays off) but that's mostly done for more severe head injuries, ones in which you are not on the fence about getting a CT scan of the head in the first place.

 

[gro2001]

Does elderly (age > 65) and anticoagulated fit your definition of a reassuring history?

There is really no circumstance where I’m reassured by anticoagulation. I’ve literally never said, “Oh, thank God you’re on blood thinners.”

I very often look at a patient in atrial fibrillation and think thank God for blood thinners. They prevent so many strokes!

 

[Rendar5]

I very often look at a patient in atrial fibrillation and think thank God for blood thinners. They prevent so many strokes!

I’m pretty sure he meant in reference to someone who fell and hit their head…

 

[Rendar5]

Over 65 with minor head injury, no anticoagulation, normal mental status doesn't necessarily need a CT if you tell them to come back for signs / symptoms of SDH.

As long as you’re comfortable realizing that this is not standard of care, and you will not have a physician supporting your care medicolegally if there’s a bad outcome.

And I say that objectively, not sarcastically. I prefer to use a safety net on the tightrope. You feel comfortable enough not using one.

You can do whatever you feel is appropriate and you’re going to be fine most of the time. You’ll just need to settle any cases if someone returns for symptoms of a SDH AND their family was unhappy with your recommendations.

Here is one clinical policy that would recommended automatic head ct on all folks over 65 with a head injury:

https://www.acep.org/siteassets/new-pdfs/clinical-policies/clinical-policy-resources/tbi-clinicians_factsheet-508.pdf

 

[Rendar5]

I think everything you said is correct, but I can’t remember the last time I saw a significant ICH (that required surgical intervention (aside from their recommendation of a repeat CT in 6 hours) in a patient with a reassuring exam, history, GCS

I’d say I see one of these every couple months. I see on average 1-2 unremarkable elderly head injuries every shift not counting trauma alerts that come in.

 

[thegenius]

As long as you’re comfortable realizing that this is not standard of care, and you will not have a physician supporting your care medicolegally if there’s a bad outcome.

And I say that objectively, not sarcastically. I prefer to use a safety net on the tightrope. You feel comfortable enough not using one.

You can do whatever you feel is appropriate and you’re going to be fine most of the time. You’ll just need to settle any cases if someone returns for symptoms of a SDH AND their family was unhappy with your recommendations.

Here is one clinical policy that would recommended automatic head ct on all folks over 65 with a head injury:

https://www.acep.org/siteassets/new-pdfs/clinical-policies/clinical-policy-resources/tbi-clinicians_factsheet-508.pdf

That link isn't very helpful, just read it.

Not sure if the bold is true either. It's not standard of care to image 100% of these patients. Even the studies show that imaging occurs 65-80% of cases.

 

[thegenius]

I am both an emergency physician and a neurointensivist, and this is one way that my fellowship has changed my EM practice. I scan a lot more now.

I fairly often see patients with chronic subdurals that were almost certainly due that fall a couple of months ago that was missed. Sometimes the delay is an issue and they need a bigger surgery than they otherwise would have. Sometimes it's an issue because they were continued on anticoagulation and subsequently re-bled.

I think people are falsely reassured by not having seen bounce backs. Even if you are the only hospital with a neurosurgeon in house, patients can still present to another hospital and be transferred to your ICU without passing through the ER. Unless you are involved in reviewing all transfers for your institution, you would not know about these. And also, people cross county lines (and even state lines I hear) and are perhaps more likely to do so if they have a suspicion something was missed the first time.

I have a fairly low threshold to get a CTH in anyone over 65 or so. Would get for most but the mildest of head trauma in that age group. Would scan anyone on anticoagulation almost regardless of mechanism or actual head strike. Anyone who has a headache/nausea/confusion after injury even if they did not hit their head.

Also surgery for subdural is not necessarily a big crazy thing. A lot of times it's some combination of a single burr hole and/or middle meningeal artery embolization. Both are very well tolerated, including in the elderly. For chronic subdurals there are even bedside techniques like SEPS. For Even craniotomies (taking off a section of the skull and then putting it back) is pretty well tolerated. I think most people are imaging craniectomies (when a section of the skull comes off and stays off) but that's mostly done for more severe head injuries, ones in which you are not on the fence about getting a CT scan of the head in the first place.

How would you interpret the following scenario. Patient comes to ED with blunt head trauma (from a very mild mechanism) on forehead with no symptoms beside mild HA right at the site of the impact (note not 2 inches around it either), no lac, normal neuro exam, no other concerning symptoms and signs. On DOAC. 1) ED doc images, there is a very small 2 mm subdural. Reversal to DOAC given. Admitted. Repeat CTH 6-12 hours from now unchanged. NSG consults and says d/c. 2) ED doc does not image. Pt sent home. Fast forward 4 months from now...in both cases pt gets repeat CTH from some doctor which now shows a much larger SDH/hygroma with acute on chronic blood products, mild shift, and pt has mostly HA with some mild contralateral weakness. NSG consulted again, says stops DOAC, and pt receives surgery 48 hours later with uneventful course. What would have Dr. Wyer said? Image or no image?

Would it have mattered if a tennis ball hit the pt in the head? What if said tennis ball was tossed and not hit with a racket? What if a piece of luggage slipped coming out from the overhead airplane bin and hit the pt on the head? I can think of innumerable number of other mechanisms.

Is there even a point in asking someone questions about what happened during the trauma? Based on some of the comments listed above, I suspect that many would say no and there is no reason to even ask about mechanism. Pt should go right to CT.

What is magical about age 65 and DOAC? Would medical decision making change if pt was 64.5 years old and on a DOAC? What about 62? What about even younger? Do skulls stop providing any protection once we hit 65?

With the above example, this pt had a non clinically important TBI and unfortunately it got worse over the next 4 months. That's low risk.

The only thing I can think of, in an ideal world, is that in the above example the NSG doctor will have made an appointment to see that patient in 3-4 weeks and gotten a repeat CTH regardless of symptomology. I'm not a NSG so I don't know if that is good medicine. I don't know if it's important to get a repeat CTH in the above example if the pt remains asymptomatic in perpetuity. I suspect not, but I don't know. Even if the repeat CTH in 4 weeks the SDH grew from 2mm to 5mm and otherwise normal, I don't know if that's an indication for surgery.

I just wonder with all the comments above why people even talk to and examine patients with mild blunt head trauma on DOAC. Probably just for show. The paper I quoted above says that physical gestalt doesn't miss clinically relevant TBI, at least in that study over 6 community sites and 6 academic sites, imaging about 4000 patients over a year.

Is there harm in imaging every single person with suspected mild TBI?

The thing is I'm confident that none of us here image 100%, so we do use gestalt. We just don't want to admit it.

 

[Rendar5]

How would you interpret the following scenario. Patient comes to ED with blunt head trauma (from a very mild mechanism) on forehead with no symptoms beside mild HA right at the site of the impact (note not 2 inches around it either), no lac, normal neuro exam, no other concerning symptoms and signs. On DOAC. 1) ED doc images, there is a very small 2 mm subdural. Reversal to DOAC given. Admitted. Repeat CTH 6-12 hours from now unchanged. NSG consults and says d/c. 2) ED doc does not image. Pt sent home. Fast forward 4 months from now...in both cases pt gets repeat CTH from some doctor which now shows a much larger SDH/hygroma with acute on chronic blood products, mild shift, and pt has mostly HA with some mild contralateral weakness. NSG consulted again, says stops DOAC, and pt receives surgery 48 hours later with uneventful course. What would have Dr. Wyer said? Image or no image?

Would it have mattered if a tennis ball hit the pt in the head? What if said tennis ball was tossed and not hit with a racket? What if a piece of luggage slipped coming out from the overhead airplane bin and hit the pt on the head? I can think of innumerable number of other mechanisms.

Is there even a point in asking someone questions about what happened during the trauma? Based on some of the comments listed above, I suspect that many would say no and there is no reason to even ask about mechanism. Pt should go right to CT.

What is magical about age 65 and DOAC? Would medical decision making change if pt was 64.5 years old and on a DOAC? What about 62? What about even younger? Do skulls stop providing any protection once we hit 65?

With the above example, this pt had a non clinically important TBI and unfortunately it got worse over the next 4 months. That's low risk.

The only thing I can think of, in an ideal world, is that in the above example the NSG doctor will have made an appointment to see that patient in 3-4 weeks and gotten a repeat CTH regardless of symptomology. I'm not a NSG so I don't know if that is good medicine. I don't know if it's important to get a repeat CTH in the above example if the pt remains asymptomatic in perpetuity. I suspect not, but I don't know. Even if the repeat CTH in 4 weeks the SDH grew from 2mm to 5mm and otherwise normal, I don't know if that's an indication for surgery.

I just wonder with all the comments above why people even talk to and examine patients with mild blunt head trauma on DOAC. Probably just for show. The paper I quoted above says that physical gestalt doesn't miss clinically relevant TBI, at least in that study over 6 community sites and 6 academic sites, imaging about 4000 patients over a year.

Is there harm in imaging every single person with suspected mild TBI?

The thing is I'm confident that none of us here image 100%, so we do use gestalt. We just don't want to admit it.

I image 100% of closed head injuries over 65 who allow me to. That is in line with published standards from CDC and ACEP. That is standard of care in the US.

The difference in your scenarios is medicolegal, not clinical.

In scenario 1, you proved absence of clinically important TBI.

In scenario 2 you have zero evidence that there was no clinically important SDH on initial visit. You don’t have scans showing lack of progression. Plaintiff attorney has a very easy argument: you missed the SDH and kept the patient on blood thinners until it eventually lead to a disastrous outcome. If only you had stopped the DOAC they would not have needed surgery.

 

[thegenius]

I image 100% of closed head injuries over 65 who allow me to. That is in line with published standards from CDC and ACEP. That is standard of care in the US.

The difference in your scenarios is medicolegal, not clinical.

In scenario 1, there is fantastic defense against a suit and it would be difficult and expensive for a plaintiff to press a suit very far. You have clearcut guidelines from physician society’s supporting care. And can even make an argument that the SDH 4 months later was from a separate injury unrelated to their presentation.

In scenario 2 you have zero evidence that there was no SDH that warranted treatment. Medmal

That's not ACEP standard, at least the link you posted. The language says "indicated" in some cases and "should be considered" in other cases.

 

[thegenius]

BTW, it's fine to image 100% of people for medmal purposes, just say that though and don't hide behind a phantom clinical reasoning that doesn't exist. We all, 100% of all doctors, me, you and everyone else, order tests and do interventions to prevent getting sued that may not have any real basis for clinical care.

 

[TrailRun]

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.

 

[ShockIndex]

I’m pretty sure he meant in reference to someone who fell and hit their head…

Some people drink deep from the glass of wisdom and wit; others swish and spit.

 

[skougess]

There are so many things that are worth mental consideration in EM. A non contrast head CT on an elderly fall is not one of them. They get done fast. They get read fast. Patients love it. Lawyers love it. Sometimes you catch things.

I light them up without hesitation. If they are on no AC and didn’t even hit their head that’s one thing. But any whiff of head injury or any AC (regardless of reported head trauma) gets scanned.

 

[ShockIndex]

2 recurring themes:
1) I don’t recall having seen it, so it must not be a problem.

2) I never heard there was a problem with my approach, so what I’m doing is fine.

 

[Zebra Hunter]

2 recurring themes:
1) I don’t recall having seen it, so it must not be a problem.

2) I never heard there was a problem with my approach, so what I’m doing is fine.

Meh, I scan essentially everyone on AC with head trauma, and elderly possible or known head trauma, and I think it’s perfectly reasonable practice to not scan carefully selected individuals who are reliable historians stating they didn’t hit their head when they fell, or head strike was minimal.

I scan something like 30-40 elderly/AC patients to find a single bleed. And probably more like 100 to find one that requires surgical intervention (community lvl 3 trauma hospital). This isn’t like sending home a vasculopath with chest pain with new t-wave inversions and only a single negative trop. This is like sending home a patient with a heart score of 4 for age and diabetes/htn/hld with two negative hs trops who had reproducible chest pain in terms of risk to the patient. I don’t typically forgo CT because it’s so easy to get, but these really are pretty low risk scenarios when there is no evidence of injury and no concerning symptoms. Yeah, everyone has a story of one of those, but they are not that common.

Why are we comfortable with 1.7% risk of MACE or VTE with regard to HEART/PERC but not with head trauma? I would gladly defend someone who wrote something like what rustedfox puts in his chart if there was a bad outcome.

The above conversations are exactly why we have such a terrible medmal culture in the US. There is this bizarre expectation that you should never miss anything.

 

[throway134]

Meh, I scan essentially everyone on AC with head trauma, and elderly possible or known head trauma, and I think it’s perfectly reasonable practice to not scan carefully selected individuals who are reliable historians stating they didn’t hit their head when they fell, or head strike was minimal.

I scan something like 30-40 elderly/AC patients to find a single bleed. And probably more like 100 to find one that requires surgical intervention (community lvl 3 trauma hospital). This isn’t like sending home a vasculopath with chest pain with new t-wave inversions and only a single negative trop. This is like sending home a patient with a heart score of 4 for age and diabetes/htn/hld with two negative hs trops who had reproducible chest pain in terms of risk to the patient. I don’t typically forgo CT because it’s so easy to get, but these really are pretty low risk scenarios when there is no evidence of injury and no concerning symptoms. Yeah, everyone has a story of one of those, but they are not that common.

Why are we comfortable with 1.7% risk of MACE or VTE with regard to HEART/PERC but not with head trauma? I would gladly defend someone who wrote something like what rustedfox puts in his chart if there was a bad outcome.

The above conversations are exactly why we have such a terrible medmal culture in the US. There is this bizarre expectation that you should never miss anything.

If there were a test with a turnaround time of <60 minutes (in many community eds, acknowledge academics it’s different) that provided the gold standard evaluation without any realistic risk and cost a few hundred dollars do you think we would accept 1.7% mace?

 

[Zebra Hunter]

If there were a test with a turnaround time of <60 minutes (in many community eds, acknowledge academics it’s different) that provided the gold standard evaluation without any realistic risk and cost a few hundred dollars do you think we would accept 1.7% mace?

It’s about 2 hours vs 3 hours for CT head discharge vs chest pain discharge in my ED. Hardly a difference that would go into my calculation.

We do 2 hour trops

 

[Apollyon]

2 recurring themes:
1) I don’t recall having seen it, so it must not be a problem.

2) I never heard there was a problem with my approach, so what I’m doing is fine.

Those are both the "fallacy of anecdote: I've never seen it, therefore, it doesn't exist".

 

[ShockIndex]

Those are both the "fallacy of anecdote: I've never seen it, therefore, it doesn't exist".

Yep, but I avoided the word fallacy to keep it civil. There sure are a lot of people determining what is reasonable based on numbers from their experience.

I suspect another aspect is people living vicariously through the anonymity of the internet the doctor that they want to be. Nobody is actually trying to find these unicorns who can be discharged without a CT, but it’s fun to come onto the internet and opine about circumstances that never exist and how what we want to do is reasonable.

 

[Mount Asclepius]

This whole back and forth on the power, control and use of the CT scanner makes me think of the big picture.

In historical times physicians just examined patients without the ability to perform diagnostic testing.

Currently we imperfectly and non-uniformly combine history/exam with imaging. Lots of practice variability for better or worse.

The future could very well just become pan-scan and pan-lab testing for a lot of patients.

The question being if the art of medicine will remain, or will the skill of a physician and the profession of medicine be replaced by AI and readily available technology.

Limited resources and resource utilization protect our careers to some degree even if frustrating bureaucracy.

 

[Zebra Hunter]

Yep, but I avoided the word fallacy to keep it civil. There sure are a lot of people determining what is reasonable based on numbers from their experience.

I suspect another aspect is people living vicariously through the anonymity of the internet the doctor that they want to be. Nobody is actually trying to find these unicorns who can be discharged without a CT, but it’s fun to come onto the internet and opine about circumstances that never exist and how what we want to do is reasonable.

You’re saying you’ve never in your career had a reliable elderly patient who fell who told you they didn’t hit their head that you didn’t scan? Kinda crazy to call these “unicorns”. I see one of these a shift.

I think yourself, as well as many responding are confusing definitive head trauma + AC or elderly (which is not what the OP is asking) with elderly or AC falls without report of head trauma.

Now there are a few that I think might be stating they don’t always scan definitive head trauma in elderly/AC, which is a more questionable practice although potentially reasonable in the right scenario, but if a patient is telling you they definitively did not hit their head during their fall, I have a hard time believing most of you are actually scanning those patients, and if so I have to ask, why? Just document, “patient and/or witnesses report no head trauma” if the patient is reliable. There is essentially zero medicolegal risk in this scenario.

 

[ShockIndex]

You’re saying you’ve never in your career had a reliable elderly patient who fell who told you they didn’t hit their head that you didn’t scan? Kinda crazy to call these “unicorns”. I see one of these a shift.

I think yourself, as well as many responding are confusing definitive head trauma + AC or elderly (which is not what the OP is asking) with elderly or AC falls without report of head trauma.

Now there are a few that I think might be stating they don’t always scan definitive head trauma in elderly/AC, which is a more questionable practice although potentially reasonable in the right scenario, but if a patient is telling you they definitively did not hit their head during their fall, I have a hard time believing most of you are actually scanning those patients, and if so I have to ask, why? Just document, “patient and/or witnesses report no head trauma” if the patient is reliable. There is essentially zero medicolegal risk in this scenario.

The unicorn that I’m referring to is the elderly, anticoagulated patient who presented to the ED but is also absolutely sure that they didn’t hit their head or the head strike was “minimal” as you call it. Yeah, I worked in a variety of EDs of volumes ranging from 30-100K, and can’t say that such patients were a clogging up the pipes. Now, I saw plenty of “I might have hit my head” and “Maybe I hit my head” and “WTF happened to my head?” I even saw some, “We found demented Ms. Jones next to her bed this morning…don’t know how she got there or how long that she has been there for and we are unsure if she hit her head.” But the number of these anticoagulated patients that I saw who fell and are absolutely sure that they didn’t hit their head (or “minimally” hit their head) but still came to ED worried about their head is so infantesomly small that it’s nowhere close to being on my radar. I never saw anything close to 1 per shift like you claim. That would extrapolate to roughly 5% of the ED population unless you work at a warfarin factory. However, the real reason why I don’t care about this unicorn presentation of “I’m in your ED after falling but didn’t hit my head” is because SDH in these trivial mechanism falls is absolutely a real thing. Hell, SDHs with NO mechanism is well described - they just bent over, got shaken, or sneezed too hard. They are anticoagulated - they bleed with trivial or no injury, that’s is just what they do. That is because the mechanism is often one of shear forces and it doesn’t take a head strike to decelerate a brain enough to cause a SDH when it’s a shriveled up noodle from a life well lived. Making matters worse, delayed presentation is often the norm because signs and symptoms only become apparent days later when enough blood has accumulated. So much for the reassuring history and exam.

However, if you read my posts very carefully, you’ll notice I’m really here to push back on this notion that these elderly, anticoagulated patients who might have or definitely hit their head can somehow be risk stratified without imaging. There are EM attendings suggesting that the Canadian Head Injury Rules should be applied which is embarrassing. There is no decision rule for these patients. If you think that they sustained a head injury of any severity, order the CT.

 

[thegenius]

Hell, SDHs with NO mechanism is well described - they just bent over, got shaken, or sneezed too hard.

By that notion, I would expect you to CTH elderly anticoagulated patients who have a cold and are blowing their nose, because of course they can sustain an asymptomatic SDH. And I know (without being able to prove it) that you don't scan 100% of them.

I'm going to try not to wade into this topic any further if possible. We don't need clinical decision rules for every single aspect of all medical decision making, lest we unabatedly test with impunity until someone does a study to make sure that we are practicing medicine appropriately. This conversation reminds me of a similar one we had awhile aback about implementing the BIG criteria and whether it's OK to miss little, tiny bleeds. There are some who think it's unconscionable and will scan every single patient with suspected head injury regardless of mechanism, and there are others who don't. We are just rehashing that same conversation again. And the same kind of pseudo ad hominin attacks resurface along with reading the same passive, subtle putdowns of fellow doctor's competence.

 

[Zebra Hunter]

The unicorn that I’m referring to is the elderly, anticoagulated patient who presented to the ED but is also absolutely sure that they didn’t hit their head or the head strike was “minimal” as you call it. Yeah, I worked in a variety of EDs of volumes ranging from 30-100K, and can’t say that such patients were a clogging up the pipes. Now, I saw plenty of “I might have hit my head” and “Maybe I hit my head” and “WTF happened to my head?” I even saw some, “We found demented Ms. Jones next to her bed this morning…don’t know how she got there or how long that she has been there for and we are unsure if she hit her head.” But the number of these anticoagulated patients that I saw who fell and are absolutely sure that they didn’t hit their head (or “minimally” hit their head) but still came to ED worried about their head is so infantesomly small that it’s nowhere close to being on my radar. I never saw anything close to 1 per shift like you claim. That would extrapolate to roughly 5% of the ED population unless you work at a warfarin factory. However, the real reason why I don’t care about this unicorn presentation of “I’m in your ED after falling but didn’t hit my head” is because SDH in these trivial mechanism falls is absolutely a real thing. Hell, SDHs with NO mechanism is well described - they just bent over, got shaken, or sneezed too hard. They are anticoagulated - they bleed with trivial or no injury, that’s is just what they do. That is because the mechanism is often one of shear forces and it doesn’t take a head strike to decelerate a brain enough to cause a SDH when it’s a shriveled up noodle from a life well lived. Making matters worse, delayed presentation is often the norm because signs and symptoms only become apparent days later when enough blood has accumulated. So much for the reassuring history and exam.

However, if you read my posts very carefully, you’ll notice I’m really here to push back on this notion that these elderly, anticoagulated patients who might have or definitely hit their head can somehow be risk stratified without imaging. There are EM attendings suggesting that the Canadian Head Injury Rules should be applied which is embarrassing. There is no decision rule for these patients. If you think that they sustained a head injury of any severity, order the CT.

My last post on this, but again, you are not appropriately comprehending the scenario that was proposed. It was not “elderly and on AC” it was “elderly or AC”. And yes, I as well as every practicing EM physician on this site sees elderly falls without head trauma numerous times a month. They don’t come in for head trauma, they come in for “wrist pain” or “back pain” or “knee pain”. I highly doubt you are scanning all of them, and if you are, that definitely is not standard of care, but again, I highly doubt you are.

 

[Rendar5]

That's not ACEP standard, at least the link you posted. The language says "indicated" in some cases and "should be considered" in other cases.

​

That's not ACEP standard, at least the link you posted. The language says "indicated" in some cases and "should be considered" in ot

My last post on this, but again, you are not appropriately comprehending the scenario that was proposed. It was not “elderly and on AC” it was “elderly or AC”. And yes, I as well as every practicing EM physician on this site sees elderly falls without head trauma numerous times a month. They don’t come in for head trauma, they come in for “wrist pain” or “back pain” or “knee pain”. I highly doubt you are scanning all of them, and if you are, that definitely is not standard of care, but again, I highly doubt you are.

I am scanning none of these patients outside maybe MVCs of concerning mechanism. I think it is a tad ridiculous as you said, to scan if we are told no head injury and there is no mark on their head.

But I think a lot of people on this thread are also talking about not scanning people who are either elderly or anticoagulants WITH head injuries (which is not a currently supported action)

 

[ShockIndex]

​

I am scanning none of these patients outside maybe MVCs of concerning mechanism. I think it is a tad ridiculous as you said, to scan if we are told no head injury and there is no mark on their head.

But I think a lot of people on this thread are also talking about not scanning people who are either elderly or anticoagulants WITH head injuries (which is not a currently supported action)

I got a kick out of the term “minimally” in relation to head strikes. Would that be less than 3 on a visual analog scale? In other words, no harder than Will Smith…right?