Background: BRASH syndrome (bradycardia, renal failure, atrioventricular nodal blockade, shock, and hyperkalemia) is a rare clinical condition with potentially severe outcomes. Patients with BRASH syndrome can present with diverse signs and symptoms and are usually in critical condition, but if recognized early, the syndrome is treatable and may have a favorable prognosis. Case presentation: This case study presents a 74-year-old patient with a history of multiple chronic conditions who was brought to the emergency department with a suspected cerebrovascular accident, altered mental status, and bradycardia. A head computed tomography scan was unremarkable but laboratory results showed hyperkalemia, acidosis, and renal failure with concomitant progressive hypoglycemia. The patient was diagnosed with a BRASH syndrome characterized by a vicious cycle of atrioventricular nodal blockade induced by the potentiated effect of beta-blockers or calcium channel blockers, in combination with progressive hypoglycemia due to the suspected accumulation of anti-diabetic medications, which influenced the presentation and initial triage in the emergency department. She was admitted to the intensive care unit for further management, where she continued to improve and was ultimately discharged in a relatively stable condition. Conclusion: This case study highlights the importance of considering rare and atypical presentations of medical conditions, particularly in elderly patients who may have multiple comorbidities. Early recognition and prompt management of such cases are crucial for improving patient outcomes.

Background: Traumatic brain injury (TBI) is one of the most common trauma-related diagnoses among the elderly population treated in emergency departments (ED). Identification of patients with increased or decreased risk of intracranial bleeding is of clinical importance. The objective of this study was to evaluate the implication of cutaneous impact location (CIL) on the prevalence of intracranial injury after suspected or confirmed TBI irrespective of its severity. Methods: This was a retrospective, single-center, descriptive observational study of geriatric patients aged 65 years and older treated for suspected or confirmed TBI in a trauma surgery ED. The primary outcome of the study was the assessment of a CIL of the injury and its association with the prevalence of intracranial lesions found on a head computed tomography scan. Results: Among 381 patients included in the analysis, the CIL of interest (temporo-parietal and occipital impacts) was present among 178 (46.7%) cases. Thirty-six (9.5%) patients were diagnosed with intracranial bleeding. The prevalence of intracranial bleeding was higher in the CIL of interest group compared with other locations outside (12.9% vs 6.4%; p = 0.030). CIL of interest was a predictor of intracranial bleeding (p = 0.033; OR: 2.17; 95% CI: 1.06 to 4.42). Conclusion: The CIL of head injury is a predictor of intracranial lesions among geriatric patients with traumatic brain injury. Physicians should be aware of this association when assessing elderly patients with head injuries. More studies are needed to develop a clinical management tool incorporating CIL to guide the diagnosis of TBI in this population.

Mild traumatic brain injury (mTBI) is one of the most common trauma-related diagnoses treated in emergency departments, especially among the geriatric population. Higher age alone is often an indication for a computed tomography (CT) scan, even when, approximately 90% of these scans do not reveal intracranial injuries. Incorporation of new diagnostic parameters into indication schemes for CT scans could improve the efficiency and reduce unnecessary imaging. The primary outcome of this study was to evaluate the association of acute behavioral changes among elderly patients treated for mTBI with the prevalence of intracranial injuries diagnosed by CT scans. A retrospective cross-sectional study was conducted at Louis Pasteur University Hospital in Košice. All patients aged 65 and older who presented during the period of 12 months with suspected mTBI and underwent CT imaging were included in the study. Electronic health records were used as a data source. A total of 586 patients were included in the study. Acute behavioral changes were observed among 60 (10.2%) patients. Intracranial injury was diagnosed in 35 patients (6.0%). There was a statistically significant association between acute behavioral changes and the presence of intracranial injuries (p < 0.05), with those exhibiting behavioral changes having higher odds of injury (OR: 6.51; 3.01–13.7; p < 0.001). Elderly patients with mTBI who present with acute behavioral changes are more likely to have intracranial injuries detected by CT scans. Incorporating these symptoms into indication schemes for head CT scans may improve strategies aimed at more effective and judicious use of imaging. Clinical trial number: Not applicable, retrospectively registered.

Background: Falls among older adults are now the leading cause of traumatic brain injury worldwide. We aimed to identify historical and clinical characteristics including the visible head impact location indicative of significant acute traumatic intracranial hemorrhage in older patients presenting to emergency department with mild traumatic brain injury subsequent to a ground-level fall. Methods and findings: We conducted a multicentre prospective cohort study across five university-affiliated emergency departments over a 2-year period (1 July 2023 to 30 June 2025) in Europe. We included patients aged 65 years or older who presented with mild traumatic brain injury (defined as head trauma with a Glasgow Coma Scale score of 13–15 upon emergency department presentation) following a ground-level fall and who underwent a computed tomography scan. The primary outcome was significant acute traumatic intracranial hemorrhage, defined as a neuroimaging radiological interpretation system (NIRIS) score > 1. Predictors were identified using logistic regression and recursive partitioning. A predictor was included in the decision rule if its association with the primary outcome and its interobserver reliability were strong. Using logistic regression, associations between independent variables and the outcome were adjusted for age, antithrombotic medication, and precipitating factors for the fall. Internal validation was performed using bootstrapping. The study included 1,620 patients (mean age, 84.6 ± 8.5 years). A significant acute traumatic intracranial hemorrhage was identified in 72 patients (4.4%, 95% CI [3,6]) of which five (0.3%, 95 CI% [0,1]) required urgent neurosurgical intervention. Eight criteria were identified as strong and reliable predictors: visible forehead-scalp impact, Glasgow Coma Scale score below baseline, focal neurological deficit, sign of basal skull fracture, acute confusion, vomiting, loss of consciousness, and headache. We then derived two clinical decision rules (PIWI 1 and PIWI 2), which both showed 100% sensitivity (95% CI [95,100]) with specificities ranging from 25.3% (95% CI [23,28]) to 43.6% (95% CI [41,46]). Application of either clinical decision rule would have allowed reductions (41.7% or 24.2%) of the numbers of patients sent to the CT scan unit. Internal validation confirmed the strong performance of both rules, based on C-statistics of 0.84 (95% CI [0.8,0.9]) and 0.79 (95% CI [0.7,0.9]). Because we only included patients who underwent a head CT scan during their emergency department stay, the potential for selection bias must be considered. Additionally, a risk of misclassification bias exists because we did not perform a centralized independent review of the CT scans. Conclusion: Our findings revealed that factors drawn from patient history and physical examination were associated with significant acute traumatic intracranial hemorrhage in older adults after a ground-level fall. Incorporating these factors into decision rules could provide a reliable strategy to stratify risk and reduce unnecessary CT scan. We hypothesize that the PIWI 1 rule could be used in patients with a clear history of the fall, while the PIWI 2 rule could be applied in other cases. Such rules need to be validated externally and independently for their implementation in clinical practice, but may already be of aid for identifying high-risk patients.