Initial Evaluation of Falls

Final project submission 

2021 by Madeleine Hunter, Columbia P&S

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Falls are a common presenting compliant to the Emergency Department, especially with the aging population. However, this chief compliant can be overwhelming to medical students since it is uncommonly encountered in other contexts and includes many parts, from why the patient fell to the myriad of possible sequela of the fall. 


The following guide was designed to serve as a framework or prompt for students, which they can reference as they speak to the patient. More detail is included for parts of the body more often involved in my experience. It is submitted as a Word Document so students may tailor the framework to their own experiences (and cut out this explanation).


Initial Evaluation of Fall with and without LOC


ABCDEs, Vital Signs Stable? – This guide was NOT designed for unstable patients, those with major trauma, or penetrating injuries.


Diagram Description automatically generated with low confidence

Part 1: Cause of the Fall – Witnessed?

  1. Mechanical: Are you sure? …. Are you really sure?

  2. Loss of consciousness: You need to figure out why

    1. Cardiogenic plus

      1. Blood/O2 to heart: MI

      2. Electricity: Arrhythmia

      3. Obstruction: Tamponade, Aortic Stenosis, PE

    2. Neurogenic

      1. Blood/O2 to the brain: Orthostasis, Stroke/TIA, Hypoxia, Hyperventilation

      2. Electricity: Seizure

      3. Reflex syncope: Vasovagal, Emotion, Pain

      4. Toxic/Metabolic: *Hypoglycemia, BMP, Carbon Monoxide


Part 2: Sequela of the Fall – Move from head to toe, then medially to laterally

  1. Head strike: 

    1. Non-contrast head CT if any of the following are positive

      1. Active or Risk for hemorrhage: HA, N/V, pupils, a/c, anti-platelets?

      2. Base of Skull fx (raccoon eyes, Battle sign, hemotympanum, oto- or rhinorrhea)

      3. AMS? AOx__, GCS

      4. Focal deficit? Numbness, tingling, weakness, face changed, “saying weird things” or “speaking weirdly,” cranial nerves, extremity strength and sensation, reflexes, cerebellar (gait can be tricky during initial evaluation, may need to defer at first)

      5. Clinical decision aids: Canadian CT Head Rule, NEXUS II

    2. N.b.: Warfarin and clopidogrel increase the risk for delayed ICH, including 2 weeks beyond injury; Observation vs providing return precautions is controversial. (Mellville et al and Nishijima et al, below) 

    3. Check for nasal septal hematoma

  2. Neck trauma: CT C-spine if positive

    1. Midline tenderness, pain with neck movement, paresthesia/numbness/weakness

    2. Risk for fx: osteoporosis, advanced arthritis, cancer, degenerative bone disease

    3. Clinical decision aids: Canadian Cervical Spine Rule, NEXUS

  3. Thorax trauma – 

    1. What you worry about: Rib fractures, flail chest, (tension) pneumothorax, hemothorax, aortic injury, myocardial contusion or infarct

    2. Tools: Physical Exam (breath sounds, (paradoxical) chest rise), NEXUS Chest, CT, FAST

  4. Abdominal trauma

    1. When to worry: ABD pain (absence not sufficient to rule out), ABD distension, guarding, signs of extra-ABD injury, femur fx/distracting injury

    2. Tools: FAST, CT, DPL

  5. Pelvic trauma

    1. What to worry about: Unstable pelvis (hemorrhage much more likely), bowel/bladder incontinence, numbness, weakness, bleeding (urine, vaginal, rectal), sign of external injury, ROM

    2. Tools: FAST, plain XRs, pelvic CT, retrograde cystourethrogram

  6. Hip trauma (fracture)

    1. When to worry: hip pain, can’t bear weight, shortened + externally rotated leg 

    2. Tools: XR (AP with max rotation and lateral)

  7. Extremities:

    1. When to evaluate further: Bruising, pain

    2. Tools: Physical exam (must establish intact relevant pulses, ROM/strength, sensation, swelling), if concern f/u doppler, XRs compartment pressure

  8. Lacerations: Establish if neurovascularly intact, last tetanus, suture




















Author: Madeleine Hunter



References

Anjum et al. Ottawa Handbook of Emergency Medicine, 2nd Edition, 2020.


Columbia and Cornell Emergency Medicine attending and resident physicians who guided me through my patients, pointing me to important history elements, exam findings and research articles.


Melville LD and Shah K. Is Antiplatelet Therapy an Independent Risk Factor for Traumatic Intracranial Hemorrhage in Patients With Mild Traumatic Brain Injury? Ann Emerg Med. 2017;70:910-911.


Nishijima DK et al. Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and preinjury warfarin or clopidogrel use. Ann Emerg Med. 2012;59:460-8.e1-7.


Uptodate.com, several pages and linked articles


Walls et al. Rosen’s Emergency Medicine Concepts and Clinical Practice 9th Edition, March 2017.


Image taken from: https://line.17qq.com/articles/ffkgkgsy_p6.html 


https://drive.google.com/file/d/1DkR8zEIh9cVkz4OfHkj1nU69Unawepg6/view?usp=sharing

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