1. Assess patient for any injury. Any focality on exam must be worked up in the appropriate manner (e.g. head CT, plain films, immobilization, etc.). In particular, look for:
- Ecchymoses, abrasions, fractures, pain, asymmetry, deformity, decreased range of motion.
- Look at head, hands, shoulders, hips, knees, feet.
- Do a complete neuro exam including gait, strength, and cerebellar tests.
- Mental status testing may be necessary if patient is confused or altered.
2. Try to find out the circumstances of the fall.
- Witnessed? By whom?
- Loss of consciousness (does patient remember hitting the ground?).
- Was this a syncopal episode, a mechanical fall, or related to altered mental status?
- Mechanism (getting out of bed, going to bathroom, standing up, turning around, etc.).
- Associated symptoms (premontory aura, incontinence, dizziness, headache, visual symptoms, palpitations, chest pain, dyspnea).
- Preceding actions (coughing, urinating, straining, standing suddenly).
- Past medical history (diabetes, heart disease, CVA, sensory deficits, Parkinsonism, arthritis, depression, new medications, prior falls).
- Check chart for recent platelets and PT/PTT to try to determine risk for bleed.
3. Broad differential diagnosis, with appropriate workup. Don't forget the following:
- Neuro: seizures, CVA/TIA (bleed, embolus, ischemia), gait disorder, Parkinson's, vertigo, dementia, normal pressure hydrocephalus, poor proprioception.
- Cardiac: arrhythmia, MI, vasovagal, hypovolemia, orthostasis, valvular disease.
- Meds: sedative/hypnotics, antidepressants, vasodilators, alcohol, diuretics (requiring frequent trips to bathroom).
- Musculoskeletal: arthritis, pain, deconditioning, weakness.
- Other: anemia, poor eyesight, dim lighting, room change, bed rails left down, wet floor.
4. Helpful hints:
- Although witnesses' (including nurses' and family member) accounts of the fall can be helpful, remember to evaluate the patient as objectively as possible.
- Have a low threshold for head CT if the patient hit their head during the fall. If the patient has a focal neurologic deficit that is new, you must get a head CT. If the patient lost consciousness or doesn't remember falling, strongly consider a head CT.
- Extrapolating from the ER literature, any patient with loss of consciousness and any one (1) of the following characteristics should get a head CT: headache, vomiting, age > 60, intoxication, short-term memory deficits, physical evidence of trauma above the shoulders, or seizure.
- Serial neuro exams after the fall are a must to rule out progressive neuro deficits from head injury (i.e. subdural hematoma).
- By law, you are required to write a note in the chart and fill out an incident report.
Haydel MJ, Preston CA, Mills TJ, Luber S, Blaudeau E, DeBlieux PM. Indications for computed tomography in patients with minor head injury. N Engl J Med 2000; 343:100-5.
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