Ask these questions for traumatic brain injuries

Older patients at high risk

ED nurses are caring for increasing numbers of elders with traumatic brain injuries, mostly due to fall injuries, says a report from the Centers for Disease Control and Prevention (CDC).1 Adults 65 years and older are one of the groups at particularly high risk for traumatic brain injury, says the report, and 61% of these injuries were caused by falls.

"The CDC has been studying traumatic brain injuries among older Americans for a while," says Victor Coronado, MD, MPH, one of the study's authors and medical officer in the CDC's Division of Injury Response. "This is a concern as the U.S. population ages. There are more persons 65 and older who will be at risk for falls."

Signs and symptoms of traumatic brain injury might mimic other more common medical conditions, says Teresa Mancuso, RN, an ED nurse at Baptist Hospital of South Florida in Miami. "Or if the patient has neurologic deficits present at the time of injury, it may be difficult to ascertain additional injury," Mancuso adds.

Baptist's ED nurses use a head injury algorithm at triage to identify patients at high risk for a traumatic brain injury. These include patients older than 60, a Glasgow Coma Scale score of less than 15, individuals on anticoagulation therapy, and patients who have lost consciousness.

"The triage nurse must understand that older patients are at a high risk for traumatic brain injury, due to cerebral atrophy and other brain diseases," says Mancuso.

In addition, older patients often have medical conditions or medications that predispose them to falls. These include decreased vision, unsteady or weak gaits, confusion, or certain medications such as pain medications or sleeping pills, says Mancuso.

Rule out brain bleed

"Any patient falling under the high risk category must have a brain CT to rule out a brain bleed," says Mancuso. "Coagulation values are valuable as well, to detect risk for bleeding."

These practices impacted the outcome of a 93-year-old man who came to the ED with a forehead laceration and a Glasgow Coma Scale score of 15. Although he denied any pain or dizziness, the patient reported falling.

"Due to the fact that he fell under our high risk category, he had labs drawn and was sent to CT," says Mancuso. "He was positive for a subdural hematoma and was admitted to the intensive care unit. This patient had a good outcome because of our emergency room standards."


  1. Faul M, Xy L, Wald MM, et al. Traumatic brain injury in the United States: Emergency department visits, hospitalizations and deaths 2002-2006. Atlanta: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2010.


For more information on elders with traumatic brain injury, contact:

  • Teresa Mancuso, RN, Emergency Department, Baptist Hospital of South Florida, Miami. Phone: (786) 596-1960. E-mail:

Clinical Tip

Don't rule out TBI even with GCS of 15

A patient might present to you neurologically intact, even if she has a traumatic brain injury (TBI), says Teresa Mancuso, RN, an ED nurse at Baptist Hospital of South Florida in Miami. Your patient's Glasgow Coma Scale (GSC) score initially might be a 15.

"The onset of signs and symptoms of a traumatic brain injury may occur days or weeks later," says Mancuso. "In these cases, a fall may not be associated with these signs and symptoms, and a patient may be under-triaged."

Ask these questions if TBI is possible

If you suspect a traumatic brain injury (TBI) is possible in your elder patient, after performing a neurologic exam, these are the most relevant questions to ask, says Teresa Mancuso, RN, an ED nurse at Baptist Hospital of South Florida:

  • Is this patient on anti-coagulant therapy?
  • Did this patient lose consciousness?
  • What is the patient's neurological baseline?
  • Did this patient sustain a laceration or have bruising in the head or facial areas?
  • Does this patient have any pertinent medical history such as coronary artery disease, atrial fibrillation, or pacemaker placement that requires them to be placed on anticoagulant therapy?
  • Did the person fall due to dizziness or lightheadedness? "If so, an EKG is warranted to rule out cardiac involvement," says Mancuso.
  • Does this patient remember the event?