Potential causes

Acute medical

Myocardial infarction

Arrhythmias

Stroke

Seizures

Hypotension (rule out gastrointestinal bleed, sepsis, dehydration, drug-induced orthostasis, myocardial infarction)

Chronic medical

Electrolyte abnormalities

Metabolic disorders

Vasovagal attacks

Psychiatric

Delirium (particularly in patients taking narcotics, sedatives, tricyclic antidepressants, tranquilizers, cimetidine, and antihypertensives)

Psychotropic-induced orthostatic hypotension and/or sedation (trazodone, quetiapine, chlorpromazine, tricyclic antidepressants)

Dementia

Purposeful fall, whether conscious or unconscious (such as psychotic, manic, patients with personality disorders, and somatoform disorders)

Nonepileptiform seizures

Other

Mechanical (patient disabled or ataxic)

Visually impaired

Multiple sensory deficits

Environmental causes, including sun downing, wet floor, unassisted falls out of bed, walking without assistance

Evaluation

Initial assessment

Vital signs, including orthostatics

Check heart rate and rhythm

Oxygen saturation

Fingerstick blood glucose

Assess level of consciousness

History

Warning symptoms prior to fall

Activity and location before fall

Patient’s perception of why he or she fell

Details of fall from any witnesses

History of previous falls

History of hypoglycemia/diabetes

Administration of any PRN medications, especially sedatives, low-potency neuroleptics, and tricyclic antidepressants

Subjective experience of pain, including location and intensity

Any perceived/witnessed loss of consciousness

Examination

Signs of volume depletion, including hydration status (skin turgor, oral moistness)

Entire body for lacerations, bruises, and/or bleeds

Mental status examination for signs of delirium and/or stupor

Head for meningismus, cerebrospinal fluid (CSF) leak, raccoon eyes, Battles sign

Fundi for papilledema or retinal hemorrhages

Neurologic exam for sensory or motor deficits, gait and coordination

Cardiologic examination for carotid bruits, irregular heartbeat, weak pulses

Musculoskeletal examination to rule out fractures

Possible complications

Head injury

Limb, hip, and wrist fractures

Lacerations, bruises, and bleeds (especially in patients with chronic liver disease, history of alcoholism, antiplatelet/anticoagulant treatment)

Management

Studies

Complete blood cell count (CBC) with differential, CHEM 7, Ca, Mg, PO4, hepatic function, urinalysis, toxicology screen, drug levels, cultures if indicated, stool guaiac, coagulation studies

Other studies if indicated include EKG, x-rays of limb(s), brain imaging

Treatment

Manage contributory cause

Address any sequelae of the fall, including lacerations (pressure, Derma bond, surgery consult as needed), fractures (immobilize limb or patient and page orthopedics)

Rule out any covert coexisting etiologies, such as substance withdrawal/intoxication

Prevention

Safety precautions, such as call bell, 1:1 observation, call light

Evaluate medication, particularly administration of sedating and hypotensive medications, timing, and dosing

Identify patients in need of assistive devices and consider physical therapy referral

For patients at repeated risk of harm due to volitional falls, consider safety devices such as padded helmets