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

 

Resources

* Health Quality & Safety Commission New Zealand. Falls in people aged 50 and over.