Overview #
- Falls are common in hospital setting
- Important to identify patients at higher risk of bleeding, as they are at higher risk of intracranial haemorrhage
- Note that delayed intracranial haemorrhage can occur up to 48 hours post fall
- 3 main considerations: cause, consequence, and prevention of fall
Triage #
- If ≥2 decrease in GCS score: MET call + review immediately (1)
- If obvious/suspected injuries or patient at risk of bleeding: review within 1 hour (1)
- All others: review within 4 hours (1)
Causes #
Causes of falls are either mechanical or non mechanical.
Non mechanical causes of falls are often multifactorial, and there are a wide range of causes and risk factors (2).
Medical risk factors (2)
- CNS:
- Visual impairment
- Peripheral neuropathy
- Impaired balance e.g. vertigo
- Cognitive impairments: including dementia, delirium, depression
- Seizure
- Stroke or TIA
- CVS:
- Syncope
- Orthostatic hypotension
- MSK:
- Muscle weakness (e.g. deconditioning)
- Arthritis
- Other:
- Polypharmacy and certain medications e.g. antihypertensives, psychotropics, sedatives, opioids
- Incontinence
- Infection
- History of falls
- Age >65
Environmental risk factors
- Inappropriate footwear
- Environmental clutter
- Poor lighting
Investigations #
Initial investigations (if appropriate)
Investigation | Significance |
Coagulation profile | If on anticoagulation therapy; assess risk of bleeding + need for reversal |
CT brain without contrast (4) | Urgent CT brain within 1 hour if:Reduced GCSSigns of head injuryFocal neurological deficits>1 episode of vomiting post fall CT brain within 8 hours if:High risk of bleedingLoss of consciousness or amnesia |
CT cervical spine | If headstrike observed/suspected, with neck pain/tenderness or focal neurological deficit Determine need for CT C-Spine with Canadian C-Spine Rule, available from: https://www.mdcalc.com/canadian-c-spine-rule (3) |
Would recommend discussing need for CT scan with registrar if uncertain
Further investigations (if non-mechanical fall/suspicious of underlying pathology)
Investigation | Indication |
ECG | If preceding palpitations or chest pain |
Septic screen* | If sepsis suspected as cause of fall |
X-rays | If fracture suspected |
BSL | Hypoglycaemia |
FBE +/- Iron studies | If anaemia |
Clinical features #
History:
- Determine mechanism of fall
- Consider cause of fall:
- Prodromal symptoms e.g. dizziness, infective symptoms, incontinence
- Identify risk factors (mentioned above), including medication review
- Identify risk factors for delirium
- Consider consequence of fall:
- Identify risk factors for bleeding e.g. anticoagulation/antiplatelet therapy, chronic liver disease
- Identify any injuries from fall, especially headstrike or loss of consciousness
- Identify any symptoms of raised intracranial pressure e.g. headache, changes in vision, nausea/vomiting
Examination:
- Aim: assess for cause (especially if non-mechanical) and consequence of fall
- Tips:
- Take into account the patient’s baseline GCS when assessing post fall GCS
- Expose patient to ensure no hidden injuries
- Thorough top to toe examination of all systems, especially taking into account of:
- Vitals, including postural BP if appropriate
- Neurological examination: GCS (and any changes in GCS), pupillary reflexes if any suspicion of headstrike
- Musculoskeletal injuries
- Examination of surrounding environment to identify any risk factors for falls
Management #
Initial steps
- DRS ABCDE, removing any potential environmental hazards to prevent further falls
- If ≥2 drop in GCS, initiate MET call and conduct medical review for injuries asap
- Do not move the patient until assessment is completed (esp of cervical spine and any bony fractures/injuries). Move patient in accordance with local hospital protocols (5)
- Analgesia
- If on anticoagulant/antiplatelet therapy, consider suspending – discuss with registrar if unsure
If headstrike (observed or suspected)
- Apply cervical collar if any signs of cervical spine tenderness or focal neurology until able to clinically and/or radiologically clear cervical spine – discuss with registrar and/or radiologist
Monitor patient
- More frequent obs for the next 24 hours, as guided by local hospital protocol
- E.g. Monash Health Post Fall Protocol (1):
“Repeat observations (including neurological observations):
- Every 15 minutes for one hour, then
- Every 30 minutes for 4 hours then
- Medical staff to review patient and document plan… for clinical observations post 4 hours
Neurological observations continued 2 hourly for 24 hours”
Prevention
Identify risk factors for fall and implement preventative strategies as able.
Risk management strategies may include:
- Minimise environmental hazards e.g. room clutter
- Ensure appropriate walking aids close by
- Bed modifications: bed rails up (but caution as risk of fall from greater height if patient able to climb over), low-low bed
- Alert systems: ensure patient buzzer close by, crash mat
- Consideration of more restrictive measures in discussion with seniors e.g. specials, physical restraints in extreme cases
Post fall follow up
- Ensure documentation about falls assessment completed as per hospital protocol (5)
- Handover to home team and update patient’s family as appropriate
- Complete RiskMan (or other form of incident reporting (5)) – often nursing staff are able to complete this
- Investigate underlying cause of fall and treat as able (5)- discuss with registrars if concerned
- May include postural BPs, geriatric screen if recurrent falls
- Consider referrals to allied health e.g. physiotherapy, occupational therapy
References #
- Monash PROMPT: Post Fall
- Factora R. Assessment of falls in the elderly. BMJ Best Practice [Internet]. London: BMJ Publishing Group; 2021 [cited 2021 September 27]. Available from: https://bestpractice.bmj.com
- Stiell, I. Canadian C-Spine Rule – MDCalc. [Internet] Mdcalc.com. 2021 [cited 2021 November 1]. Available from: https://www.mdcalc.com/canadian-c-spine-rule
- National Institute for Health and Care Excellence. Head injury: assessment and early management [Internet]. [London]: NICE; 2014 [updated 2019 September; cited 2021 September 27]. (Clinical guideline [CG176]). Available from: https://www.nice.org.uk/guidance/cg176/chapter/1-Recommendations
- Australian Commission on Safety and Quality in Health Care. Preventing Falls and Harm from Falls in Older People: Best practice guidelines for Australian hospitals [Internet]. [Sydney]: ACSQHC; 2009 [cited 2021 September 27]. (Clinical guideline). Available from: https://www.safetyandquality.gov.au/publications-and-resources/resource-library/preventing-falls-and-harm-falls-older-people-best-practice-guidelines-australian-hospitals
Contributors
Reviewing Consultant/Senior Registrar
Dr Kathy Liu
A/Prof. Louisa Ng