Critical Alerts

• Falls are a leading cause of death in patients ≥65 years
• Always assess for underlying cause - not just injuries
• Low threshold for imaging - occult fractures common
• Anticoagulation increases risk of intracranial and internal bleeding
• Multifactorial assessment is key to prevention

Key Diagnostics

• CT head (on anticoagulation or head trauma)
• C-spine imaging (mechanism or neck pain)
• X-rays of painful areas
• ECG (arrhythmia, syncope)
• Labs: CBC, BMP, glucose, troponin (if cardiac suspected)

Emergency Treatments

• Trauma assessment: Complete evaluation for injuries
• Reverse anticoagulation: If significant bleeding
• Pain management: Multimodal approach
• Treat underlying cause: Infection, cardiac, dehydration
• Fall prevention: PT referral, home safety, medication review

A fall is defined as an event resulting in a person coming to rest inadvertently on the ground or floor. In elderly patients (≥65 years), falls are often multifactorial and represent a geriatric syndrome requiring comprehensive evaluation beyond just injury assessment.

Epidemiology

• Incidence: 30% of adults ≥65 fall each year; 50% of those ≥80
• ED visits: 3 million elderly fall ED visits annually in US
• Deaths: ~36,000 deaths per year from falls (US)
• Leading cause: Unintentional injury death in elderly
• Recurrence: 50% of fallers will fall again within 1 year

Classification

Impact

Critical Presentations

"Long Lie" Complications

When patient unable to get up for extended period:

• Pressure injuries
• Rhabdomyolysis
• Dehydration
• Hypothermia
• Aspiration
• Psychological trauma

Causes of Falls

Mechanical/Environmental

• Trip or slip
• Improper footwear
• Environmental hazard

Medical (Non-Syncopal)

Syncopal

Imaging

CT Head (Non-Contrast)

C-Spine Imaging

• Midline tenderness
• Neurological symptoms
• Dangerous mechanism
• Intoxication impairing exam
• Use Canadian C-spine or NEXUS rules

X-rays

• Any area of pain or tenderness
• Hip (AP pelvis + lateral hip if pain with ROM)
• Wrist (common fall injury)
• Consider CT if X-ray negative but high suspicion

Laboratory Studies

Cardiac Workup

Admission Criteria

• Significant injury requiring treatment
• New intracranial pathology
• Undiagnosed syncope with concerning features
• Unable to ambulate safely
• Inadequate social support
• Unsafe to return home
• Observation for delayed deterioration (anticoagulated)

Discharge Criteria

• Minor or no injuries
• Stable vital signs
• Able to ambulate (or return to baseline)
• Safe home environment
• Caregiver available
• Follow-up arranged

Discharge Planning

Essential Components

1. Injury precautions
2. Fall prevention education
3. Physical therapy referral
4. Medication review recommendation
5. Follow-up with PCP
6. Home safety assessment referral
7. Clear return precautions

Understanding Falls

• Falls are not a normal part of aging
• Many falls can be prevented
• It's important to find out why you fell
• Multiple small changes can significantly reduce fall risk

Fall Prevention Strategies

Exercise

• Strength training
• Balance exercises
• Tai Chi

Home Safety

• Remove throw rugs
• Improve lighting
• Install grab bars in bathroom
• Keep walkways clear
• Use non-slip mats

Medications

• Review with doctor/pharmacist
• Avoid sedatives when possible
• Take blood pressure medications as prescribed

Other

• Annual vision check
• Wear proper footwear
• Use assistive devices if recommended

When to Return

• Worsening headache or confusion
• New weakness or numbness
• Dizziness or syncope
• Worsening pain
• Unable to ambulate

Anticoagulated Patients

• CT head for any head trauma (even minor)
• Consider observation period (6-24h)
• Delayed bleeding can occur
• Low threshold for reversal if active bleeding
• Clear instructions on delayed symptoms

Dementia

• May not report symptoms
• History from caregivers essential
• Higher fall risk
• Comprehensive safety assessment
• May need increased supervision

Nursing Home Residents

• Often recurrent fallers
• Communication with facility
• Document baseline function
• Consider palliative approach if appropriate
• Report fall to facility

Frail/End of Life

• Goals of care discussion
• Consider risks of invasive workup/treatment
• Focus on comfort and quality of life
• May decline extensive imaging

Performance Indicators

Documentation Requirements

• Mechanism and circumstances of fall
• Pre-fall symptoms
• Complete injury evaluation
• Orthostatic vital signs (or reason not done)
• Cognitive status assessment
• Home safety/social situation
• Medication list reviewed
• Fall risk assessment
• Disposition rationale
• Follow-up plan

Diagnostic Pearls

1. Falls are a symptom - find the underlying cause
2. CT head if anticoagulated - even with minor trauma
3. Orthostatic vitals in all patients - common finding
4. Check for UTI - common atypical presentation
5. ECG for unexplained falls - arrhythmias often undiagnosed

Treatment Pearls

1. Treat injuries AND underlying cause
2. Multimodal pain management - limit opioids
3. Review medications - polypharmacy is modifiable
4. Physical therapy referral reduces recurrence
5. Home safety assessment can prevent future falls

Disposition Pearls

1. Low threshold for observation in anticoagulated patients
2. Safe discharge requires safe environment
3. PT/falls clinic referral is essential intervention
4. PCP follow-up for comprehensive fall evaluation
5. Document functional status for future comparison