Geriatric Case 5: Trauma with Head Injury

This case is the fifth in a six-part mini-series focusing on the management of geriatric patients in the ED. This series of cases was written by Drs. Rebecca Shaw, Nemat Alsaba, and Victoria Brazil.

Dr. Rebecca Shaw is an emergency physician currently working as a medical education fellow within the Emergency Department of the Gold Coast Hospital and Health Service in Queensland, Australia. Dr. Nemat Alsaba (@talk2nemat) is an emergency physician with a special interest in geriatric emergency medicine, medical education and simulation. She is trying her best to combine these interests to improve geriatric patient care across all health sectors. She is also an assistant professor in medical education and simulation at Bond university. Dr. Victoria Brazil is an emergency physician and medical educator. She is Professor of Emergency Medicine and Director of Simulation at the Gold Coast Health Service, and at Bond University medical program. Victoria’s main interests are in connecting education with patient care – through healthcare simulation, technology enabled learning, faculty development activities, and talking at conferences. Victoria is an enthusiast in the social media and #FOAMed world (@SocraticEM), and she is co-producer of Simulcast (Simulationpodcast.com).

Why It Matters

Elderly patients who have sustained trauma are frequently encountered in the ED. These patients have unique physiology and are often complex due to frailty and polypharmacy concerns. Care of the elderly trauma patient requires attention to these complexities, to goals of care, and to communication with family members. This case gives the opportunity to learn and enhance these skills.

Clinical Vignette

The bedside nurse informs you that “EMS just off-loaded an elderly male to the resuscitation bay. He had a fall down the stairs and sustained a head injury. He was GCS 15 and hemodynamically stable when they picked him up, so they didn’t activate the trauma team, but he has deteriorated during transport. He has an obvious large, boggy scalp hematoma over the left parietal region. I am worried because he’s getting restless and won’t follow commands.”

Case Summary

An 81-year old man falls down the stairs at home. He is initially asymptomatic but his level of consciousness declines and he starts to show signs of raised ICP. Providers must recognize and treat this, as well as reverse his anticoagulation, provide neuroprotective RSI and safely transport to the CT scanner. Providers must then talk with the patient’s wife, to provide information on his condition and prognosis and discuss the patient’s goals of care.