The Elderly Fall with a Normal CT: Deciding Who Goes Home
A 82-year-old woman is brought in by her daughter after a mechanical fall at home. She tripped on a rug and hit her head on a doorframe. There was no loss of consciousness witnessed, but she reports a brief 'dizzy spell' before the fall. She takes apixaban for atrial fibrillation, ramipril, and atorvastatin. On arrival: GCS 15, no focal neurology, no scalp haematoma, no neck pain. Vital signs normal. Her CT head is reported as normal by the radiology registrar at 22:00. The daughter says her mother has seemed 'a bit more forgetful' over the last week and has had two other falls in the past month. The patient wants to go home. It is 23:30; the ED is full; the consultant is off-site.
1. Is it safe to discharge this patient now? Justify your answer using the relevant risk factors and the limitations of the investigations performed.
Read the worked answer
No - discharge now is not safe.
Risk factors present:
- Anticoagulation with apixaban. Delayed intracranial haemorrhage can occur up to 24–48 hours after a minor head injury, and a single early CT does not exclude it. Guidelines for anticoagulated patients with head injury generally recommend observation for at least 6–24 hours, with a repeat CT if any deterioration.
- Mechanism and age. Age over 65 plus a head strike is a recognised risk factor for clinically important brain injury.
- Recurrent falls. Three falls in a month is a red flag for an underlying cause - arrhythmia, postural hypotension, medication effect, or a neurodegenerative process. The 'dizzy spell' before the fall may indicate a syncopal or pre-syncopal event rather than a simple mechanical trip.
- Cognitive change. The daughter's report of increasing forgetfulness over a week is a new symptom that may represent a subdural collection, a delirium, or a progressive condition. It is not explained by the normal CT.
Limitations of the workup:
- A single non-contrast CT at 22:00 cannot exclude a delayed bleed.
- The CT was reported by a registrar; a consultant review is advisable, particularly for subtle subdural or contusional change.
- No ECG, lying/standing BP, or medication review has been done to explain the falls.
Plan: Admit for observation, repeat CT if any change in GCS or symptoms, ECG and orthostatic BP, medication review (apixaban timing, ramipril and postural hypotension), and a falls assessment. Discuss with the daughter and document the reasoning.
2. The daughter asks why her mother cannot just be observed at home by family. How do you frame the risk-benefit discussion, and what would you document?
Read the worked answer
Framing the conversation
Use plain language and a shared-decision framework:
- Explain the specific risk: 'Because your mother takes a blood thinner, a bleed inside the head can develop slowly over the next day or two, even though the scan tonight is normal. If that happens at home, it can become serious before anyone notices.'
- Explain the benefit of observation: 'Staying in for a night lets us check her neurology regularly, repeat the scan if anything changes, and also look into why she has been falling - which may be treatable.'
- Acknowledge her preference: 'I understand she wants to be at home. Let's talk about what would make that safer if she chooses it.'
- Offer alternatives if she declines admission: a responsible adult staying with her, written head-injury advice, a clear return threshold, and a follow-up call or review within 24 hours. Document capacity and the discussion.
Documentation should include:
- The risk factors identified (anticoagulation, age, recurrent falls, cognitive change).
- The limitations of the single CT and the registrar report.
- The discussion with the patient and daughter, including their questions and preferences.
- The plan if admitted, and the safety-netting plan if she declines.
- The escalation to the on-call consultant for a second opinion, given the off-site consultant and full department.