Kudu Emre, Altun Mustafa, Danış Faruk, Karacabey Sinan, Sanri Erkman, Denizbasi Arzu
Department of Emergency Medicine, Marmara University School of Medicine, Fevzi Çakmak Mahallesi, Muhsin Yazıcıoğlu Caddesi, Pendik, Istanbul, Turkey.
Department of Emergency Medicine, Bolu Abant İzzet Baysal University Medical School, Bolu, Turkey.
CJEM. 2025 May 13. doi: 10.1007/s43678-025-00937-y.
Falls are a leading cause of traumatic brain injury in older adults, with ground-level falls being the most common mechanism. Despite the increasing use of head computed tomography (CT) in older adults with ground-level falls, there is an ongoing debate regarding the necessity of routine neuroimaging in all cases. The falls decision rule was developed to safely exclude clinically important intracranial bleeding without head CT in older adults. This study aims to validate the falls decision rule externally and assess its accuracy in identifying low-risk patients while reducing unnecessary imaging.
This prospective cohort study at a Level-1 trauma center enrolled consecutive patients aged ≥ 65 years presenting within 48 h of a ground-level fall. Patient management, including the decision to perform head CT, was determined independently by the treating emergency physician. Patients were followed up for 42 days to identify clinically important intracranial bleeding cases. The rule's diagnostic performance was evaluated using sensitivity, specificity, and predictive values using 95% confidence intervals (CI).
A total of 800 patients were included, with a median age of 78 years (IQR 72-85), and 59.9% were female. Clinically important intracranial bleeding was identified in 6.1% (n = 49) of patients. Head CT was performed in 67.6% of cases, identifying 43 initial hemorrhages, with six additional cases detected during follow-ups. The falls decision rule demonstrated 97.9% sensitivity (95% CI 89.1-99.9), 31.9% specificity (95% CI 28.6-35.4), and 99.5% negative predictive value (95% CI 97.1-99.9), potentially reducing CTs by one-third.
This validation confirms the falls decision rule's high sensitivity and negative predictive value for identifying low-risk older adults after ground-level falls, potentially reducing unnecessary CT scans by approximately one-third. This approach could alleviate ED overcrowding and resource strain while ensuring diagnostic safety.
跌倒为老年人创伤性脑损伤的主要原因，其中平地跌倒最为常见。尽管在平地跌倒的老年人中，头部计算机断层扫描（CT）的使用日益增加，但对于所有病例常规神经影像学检查的必要性仍存在争议。跌倒决策规则旨在安全地排除老年人中无头部CT检查时临床上重要的颅内出血。本研究旨在对外验证跌倒决策规则，并评估其在识别低风险患者同时减少不必要成像方面的准确性。
本前瞻性队列研究在一家一级创伤中心纳入了年龄≥65岁、在平地跌倒后48小时内就诊的连续患者。患者管理，包括进行头部CT的决策，由主治急诊医生独立决定。对患者进行42天的随访，以确定临床上重要的颅内出血病例。使用95%置信区间（CI）的敏感性、特异性和预测值评估该规则的诊断性能。
共纳入800例患者，中位年龄为78岁（四分位间距72 - 85岁），59.9%为女性。6.1%（n = 49）的患者被发现有临床上重要的颅内出血。67.6%的病例进行了头部CT检查，发现43例初始出血，随访期间又发现6例。跌倒决策规则显示敏感性为97.9%（95% CI 89.1 - 99.9），特异性为31.9%（95% CI 28.6 - 35.4），阴性预测值为99.5%（95% CI 97.1 - 99.9），有可能将CT检查减少三分之一。
本验证证实了跌倒决策规则在识别平地跌倒后低风险老年人方面具有高敏感性和阴性预测值，有可能将不必要的CT扫描减少约三分之一。这种方法可以缓解急诊科的拥挤和资源紧张，同时确保诊断安全。
