The Hallway Consult — Issue #20: Geriatric Head Injury Risk Factors, Trigger Point Injections for Low Back Pain, and Presyncope vs. Syncope

Geriatric Ground-Level Falls and Head Injury: What Actually Predicts a Bleed?

The older adult who fell and hit their head is one of the most common — and most variable — presentations in emergency medicine. You can have two patients with near-identical mechanism and identical mild traumatic brain injury presentations and end up with completely different imaging decisions, because the clinical approach to this population has never had a strong evidence base behind it. Head CT in every patient over 65 with head injury has become reflexive in many departments, despite a true intracranial hemorrhage prevalence of roughly 5 to 7 percent in the relevant population.

A 2025 systematic review and meta-analysis in Annals of Emergency Medicine finally takes a rigorous look at which risk factors actually predict traumatic intracranial hemorrhage (tICH) in this group. Dubucs and colleagues pooled 17 observational studies covering 22,520 ED patients aged 65 and older who sustained a ground-level fall with suspected or confirmed head or facial trauma and had a GCS of 13 or above. The primary outcome was new intracranial hemorrhage or expansion of a chronic hemorrhage on CT. About 6.8% of patients had a traumatic ICH.

The key finding is what was and was not associated with hemorrhage after multivariate analysis. Confirmed independent risk factors included focal neurologic signs, external signs of head trauma, loss of consciousness, and male sex. The counterintuitive result: anticoagulation — including DOACs and warfarin — did not independently predict traumatic ICH in the adjusted analysis. Neither did alcohol intoxication. The authors note this likely reflects selection bias: patients on anticoagulants are more likely to get scanned regardless of other features, which inflates the denominator of anticoagulated-but-negative CT scans in the pooled studies.

There are real limitations here. These are mostly monocentric retrospective studies with variable quality. No prospective clinical decision rule exists yet, and the authors explicitly say one is needed. But the risk factor signal is useful even without a validated rule. A patient with focal deficits, visible head trauma, or loss of consciousness after a fall has a meaningfully different risk profile than one who simply fell and can't remember clearly. The reflex to scan every anticoagulated patient regardless of exam and history gets weaker here.

Bottom line: In this meta-analysis of 17 studies and over 22,000 older adults with ground-level fall-related head injury, the independent predictors of traumatic intracranial hemorrhage were focal neurologic signs, external signs of head trauma, loss of consciousness, and male sex. Anticoagulant use was not independently predictive. A validated clinical decision rule for this population does not yet exist, but these findings can meaningfully inform your gestalt.

Dubucs X, Gingras V, Boucher V, et al. Risk Factors for Traumatic Intracranial Hemorrhage in Older Adults Sustaining a Head Injury in Ground-Level Falls: A Systematic Review and Meta-analysis. Ann Emerg Med. 2025 Jul 22:S0196-0644(25)00313-0.

Trigger Point Injections for Low Back Pain: The Three-Arm Trial That Says No

Myofascial low back pain is one of those ED presentations that practitioners manage differently almost by attending preference. Standard treatment — NSAIDs, muscle relaxants, topical agents, a brief course of activity modification — works for a lot of patients. But for patients in real distress with identifiable trigger points, the question of whether to add an injection has lingered without a direct ED-specific answer.

Lajeunesse and colleagues published a three-arm, partially blinded RCT in Annals of Emergency Medicine to address exactly this question in the ED setting. Adult patients presenting to the ED with myofascial low back pain were randomized to trigger point injection with bupivacaine, sham trigger point injection with normal saline, or standard therapy alone. The primary outcome was pain reduction, and the study also measured functional outcomes — which prior ED trigger point trials had not specifically evaluated.

The result: trigger point injections, whether with bupivacaine or as sham injection with saline, provided no additional clinical benefit over standard therapy. Pain reduction did not significantly differ between the groups, and neither did functional outcomes. This was a reasonably well-designed trial specifically targeting the ED population with myofascial low back pain, making it more directly applicable than prior studies that pooled various pain distributions or primarily outpatient populations.

The practical takeaway is not that trigger point injections are useless. Patients who receive a solid initial analgesic strategy — including ketorolac, methocarbamol, topical agents, and appropriate reassurance — do well in a substantial proportion of cases. The question had always been whether the injection added anything beyond what the standard package provides. In this trial, for the ED encounter, it did not.

For the provider who occasionally does trigger point injections because it "seems to help": that impression may be real, but it may be tracking the overall treatment effect of the full analgesic bundle rather than the needle specifically.

Bottom line: In this three-arm RCT of ED patients with myofascial low back pain, trigger point injection with bupivacaine and sham injection with normal saline both failed to provide additional pain reduction or functional benefit compared with standard therapy alone. For most ED visits with myofascial low back pain, optimizing the standard pharmacologic approach is the evidence-supported strategy.

Lajeunesse MD, Olivera TR, April MD, et al. Trigger Point Injection for Myofascial Pain Syndrome of the Low Back: A Partially Blinded Three-Arm Randomized Controlled Trial. Ann Emerg Med. 2025;86:606–615.

Presyncope Is Not Safer Than Syncope. Treat It That Way.

The word "presyncope" does a lot of work in emergency medicine, and most of what it does is signal to the clinician that the patient almost fainted but didn't. The implicit translation at the bedside has long been: this is probably benign, a step down from actual syncope. A 2025 Annals of Emergency Medicine study from Suh and colleagues says that translation is wrong.

This was a secondary analysis of a large, prospective, multicenter cohort study of adults 40 years and older presenting to the ED with presyncope or syncope. The primary outcome was serious cardiac events at 30 days, including myocardial infarction, arrhythmia, and cardiac death. Serious ED diagnoses found at the initial visit were excluded, so the analysis focused on the patients sent home or admitted in whom outcomes developed over the next month.

The numbers are direct: 30-day serious cardiac outcomes occurred in 4.7% of the 721 syncope patients and 5.2% of the 542 presyncope patients. The odds ratio was 1.13 with a 95% confidence interval of 0.66 to 1.79 — no statistically significant difference. Presyncope did not confer less cardiac risk than syncope at 30 days.

The second finding is equally important. Physicians systematically underestimated presyncope risk. They estimated a 5.3% serious outcome probability for presyncope patients versus 7.6% for syncope patients — a statistically significant difference in clinical gestalt despite a non-significant difference in actual outcomes. And they backed that gestalt with action: presyncope patients were admitted at a rate of 38.2% versus 49.5% for syncope patients.

This is an observational study with limitations: it cannot determine whether different admission rates changed outcomes, and the secondary-analysis design means it should inform risk stratification rather than directly dictate disposition. But the message is clinically important. The known risk stratification tools for syncope — including the Canadian Syncope Risk Score — apply to presyncope patients as well. Checking a box called "presyncope" and downgrading your concern is not justified by the outcomes data.

Bottom line: In this prospective multicenter study, presyncope carried the same 30-day serious cardiac outcome rate as syncope (approximately 5%), yet physicians consistently underestimated presyncope risk and admitted presyncope patients less often. Apply the same risk stratification framework to presyncope that you use for syncope — the distinction between the two symptoms does not justify a different cardiac risk threshold.

Suh EH, Sacco DL, Winskill C, et al. Serious Cardiac Outcomes and Physician Estimation of Risk in Emergency Department Patients With Presyncope Versus Syncope. Ann Emerg Med. 2025 Sep 23:S0196-0644(25)01155-2.

The Hallway Consult is built for EM clinicians who want the useful version of the literature. Forward it to a colleague if it helped.

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— The Hallway Consult team