Falls
Patient has fallen, please review. Vani talks to Geriatrician and fall expert Dr Cheryl Johnson about an approach to falls and when to order that head CT.
Fall causes
Common
- Delirium
- Visual impairment
- Peripheral sensory neuropathy
- Stroke/TIA
- Joint buckling/instability
- Deconditioning
- Medication effect or polypharmacy
- Enviromental hazards
Uncommon
- Vestibular dysfunction
- Gait disorder
- Dementia
- Depression
- Seizure
- Subdural haematoma
- Syncope
- Orthostatic hypotension
- Mechanical mobility/gait disorder
- Substance abuse
- Carotid sinus hypersensitivity
- Postprandial hypotension
Approach
- Eyeball the patient / ABCs
- History
- Is this a collapse or a fall?
- From patient and witness
- What were they doing before the fall?
- Do they remember it happening?
- Do they remember hitting the ground?
- What part of the body hit the ground first?
- How did they get back up again?
- “And then what happened?”
- Any other falls?
- Any near falls?
- Using walking aid? On their own?
- Preceding symptoms?
- LOC?
- Any injury or pain?
- Head injury?
- Review of symptoms
- Red flags
- Medications
- Sleeping tabs, opiates
- Head injury/alterered neurological status
- Non-weight bearing
- Don’t be reassured by a normal plain film
- Factors that increase risk of fall in hospital
- Poor lighting
- Slippery floors
- Equipment in rooms and hallways that gets in the way
- Being weak from illness or surgery
- Being in new surroundings
- Vitals + Examination
- General inspection
- Top to bottom – squeeze everywhere and everything
- Scalp
- Joints
- Ribs
- Pelvis
- Cardiorespiratory examination
- Abdomen for signs of intraabdominal haemorrhage (peritonism)
- Neurological exam/peripheral neuropathy
- Lying and standing BP, can be deferred to next day
- Check for injury, such as cuts, scrapes, and bruises. Always visualise and palpate the scalp (a significant injury can be easily obscured by hair).
- Investigations
- FBC, U&E, glucose, vitamin B12/folate, TFT, ECG, septic screen (if indicted)
- Head CT (if head impact, neurological change, altered mental state/delirium, anticoagulant/antiplatelets, worried)
- Management
- Treat skin tears
- Dressing/sutures
- Analgesia
- Hospital fall protocol
- Review and withhold meds/flag for team review
- Lying and standing BP
- Infection/delirium management
- ACC paperwork
- Risk reduction
- Bed height/remove rails
- Hip protectors
- Grippy socks
- Hearing aid/glasses
- Watch or increased frequency of observations
- Document
- Review past notes
- Basics (date/time/name/reason for review)
- Positives and pertinent negatives
- Impression and differential with justification. Have you eliminated intracranial haemorrhage?
- Clear and specific plan
- Consider discussion with senior and escalation, especially if called back to patient again
