Falls are an incredibly common presentation. You will see them as GP referrals, A+E presentations, and countless times on the ward.
Exactly how you examine and manage the patient will depend on the situation. For example, a 16 year old presenting with a fall / seizure might be lot different to Doris, the 93 year old inpatient who keep falling over going to the toilet at night.
Regardless of this there are several things that you should rule out for everybody who has a fall.
The causes of fall can be divided into:
- Cardiac – e.g. arrhythmia
- Neurological – e.g. seizure, stroke, peripheral neuropathy
- Intoxication / alcohol / pharmacological
- BPPV (Benign Paroxysmal Positional Vertigo)
- Environmental (poor lighting / uneven surface) – rare!
You will often see “Mechanical fall” written as a diagnosis in the notes. Be wary of this. I don’t fall over all the time. Do you? Probably not. There is almost always a cause, despite Doris adamantly saying she tripped over the carpet.
As usual, probably the most important part. Try to differentiate from the possible causes. Ask about:
- Loss of Consciousness (LOC)
- Duration of LOC
- Tongue biting
- Did they bang their head?
- Onset (sudden, gradual)
- Previous similar episodes
- Alcohol / drug use
- Any injuries as a result
Examination and Investigations
EVERYBODY who falls over, as a bare minimum should have:
- Cardiovascular and respiratory exam – do the basics. Feel the pulse. Listen to the heart. Listen to the chest. Take the temperature. Do they have an arrhythmia? Signs of a chest infection? Are they dehydrated? Is the mouth dry? (Skin turgor is not a very useful sign, particularly in the elderly)
- Basic GALS examination – check the joints in all the limbs. Check for any signs of head injury. Particularly check the hips. Can they walk? Are they able to weight bear? Is one leg shortened and externally rotated? (Hip fracture!)
- ECG – check for arrhythmias. Most commonly AF.
- Lying and standing BP – make sure you know how to do this properly, and make sure the nurse knows how to do this properly. Ideally the patient should be lying down for 10 minutes. Take their blood pressure. Keep the blood pressure cuff on. Ask them to stand up. Take the BP again at 1 minute, 3 minutes, and 5 minutes.
- Significant postural drop is: >20 systolic or >10 diastolic from the lying position.
- Urine dipstick – UTI is very common cause of falls, especially in the elderly. Ketones in the urine can also be a sign of dehydration
Neuro observations – anyone with a head injury should have ‘neuro obs.’ The nurses wont thanky ou for it as it can be time consuming. Your hospital should have a protocol for their frequency but it will be something like:
- Every 15 minutes for 1 hour
- Every half an hour for the next two hours
- Every hour for the next two hours
- After this time anything other than a subdural haematoma (which can take weeks to develop symptoms) will be unlikely.
- Basic blood tests - U+Es (dehydration), CRP and WCC (any signs of infection), CK (creatinine kinase – can be used to diagnose rhabdomyolysis if patient has been immobile on the floor for a long time after the fall)
- X-rays – of any damaged parts as necessary
- CT / MRI head – if stroke is suspected you will need to do it urgently. If there is a head injury, you may do one if there are any new or late onset neurological signs.
Other fancy tests
- Short Synacthen Test (ACTH stimulation test) – tests for true postural hypotension secondary to adrenal insufficiency. Treated with fludrocortisone