Fall or unwitnessed fall
at the bedside
- do not move the patient until assessed: airway, breathing, circulation; full vitals, SpO₂; glucose now → hypoglycemia
- consciousness → GCS, pupils, limb power, speech; not back to baseline within minutes is not a simple fall → altered mental status
- head strike → ask the patient and the witness; scalp hematoma, laceration or boggy swelling; unwitnessed and cannot say → treat as a possible head strike
- pain and deformity → hip, pelvis, spine, wrist, shoulder, ribs; a shortened, externally rotated leg or pain on moving the hip → hip fracture until the film says otherwise; neck or back pain → keep the spine still
- drug chart and MAR → anticoagulant or antiplatelet and the last dose; sedatives, opioids, antihypertensives, insulin or sulfonylurea given tonight
- how found → witnessed or not, what they were doing (toileting, getting out of bed, reaching), how long on the floor, lines, drains or catheters pulled; the nurse’s account before, during and after
escalate now if
- reduced GCS, new focal deficit, seizure after the fall, or vomiting more than once → CT head now → neurological deficit; GCS falling, not protecting the airway → anesthesia and ICU now
- head strike, or unwitnessed fall with a possible head strike, with headache, vomiting, drowsiness, amnesia or confusion → CT head now; on an anticoagulant or antiplatelet with none of these → consider CT head within 8 h (NICE NG232) → head strike
- suspected hip, femur, pelvis or spine fracture, or cannot weight-bear → do not mobilize, immobilize, analgesia, orthopedics tonight → fracture
- hypotension, tachycardia, pallor, melena or a hemoglobin drop → the fall may be the bleed → hypotension, GI bleed; long bone or pelvic fracture bleeds too
- loss of consciousness, no prodrome, palpitations or chest pain before the fall → syncope until proven otherwise, ECG now → syncope
- tongue bite, sustained jerking, prolonged confusion after → seizures
- on the floor for an hour or more, cold, or dark urine → rhabdomyolysis, hypothermia, pressure injury → long lie
differentials
a fall is a symptom: find the cause and the injury
- mechanical or environmental → tripped, slipped, reached, bed too high, rails, wet floor, poor lighting, no footwear, lines and catheters; no loss of consciousness and recalls the whole event
- orthostatic → on standing, toileting or soon after a new antihypertensive, diuretic or opioid; dehydration, bleeding → syncope: orthostatic
- syncope → loss of consciousness with fast full recovery; no prodrome, exertion or palpitations point to a cardiac cause → syncope
- seizure → lateral tongue bite, sustained tonic-clonic activity, slow recovery, incontinence does not decide → seizures
- delirium or sedation → fluctuating inattention, climbing out of bed, a hypnotic or opioid given at night → delirium and agitation
- hypoglycemia → insulin or sulfonylurea, missed meal, sweaty and confused → hypoglycemia
- stroke → new weakness, speech or visual change, or the leg gave way: the deficit came first, the fall second → neurological deficit
- infection → fever or a new confusion in the frail; pneumonia, urinary infection, sepsis → fever
- drugs → benzodiazepines and hypnotics, opioids, antipsychotics, antihistamines and anticholinergics, antihypertensives and nitrates, insulin and sulfonylureas, alcohol withdrawal; anything new or increased this admission
- weakness and the ward itself → deconditioning, poor vision, no glasses or hearing aids, urgency with a distant toilet, an unfamiliar room at night
focused check
- history → witnessed or not; what they were doing; prodrome (dizziness, palpitations, chest pain, warmth and nausea) or none; loss of consciousness and for how long; recall of hitting the floor; how long down; previous falls this admission; why admitted and the baseline mobility and cognition
- injury survey, head to toe → scalp (hematoma, laceration, depression), bruising behind the ear or around the eyes, blood or clear fluid from the ear or nose; neck and whole spine for midline tenderness; chest wall and ribs; pelvis; hips: shortening, external rotation, pain on rolling the leg or on gentle axial pressure, can they lift the straight leg; wrists, shoulders, knees; skin tears and pressure areas; lines, drains and catheters
- neurological → GCS, pupils, limb power and sensation, speech, gait only if the injury survey is clear
- lying and standing BP → once an injury is excluded and the patient can stand with help; the numbers and the method are on the syncope page → syncope
- ECG → whenever syncope is possible, the fall was unwitnessed, or there was no clear trip → ECG on call
- drug chart and MAR → anticoagulant or antiplatelet and the last dose; any sedative, hypnotic, opioid, antihypertensive, diuretic, insulin or sulfonylurea started or increased this admission, and when the last dose was given; what is due in the next hours
- chart → vitals trend, fluid balance, last glucose, last hemoglobin and creatinine, mobility and falls risk assessment on admission, cognition at baseline
send now
- nothing routinely → witnessed trip, no head strike, no anticoagulant or antiplatelet, alert, normal vitals and glucose, no injury on the survey: document, falls precautions and reassess; no bloods or films tonight
- CT head within the hour → GCS below 13 at first assessment or below 15 at 2 h, suspected skull fracture or basal skull signs, seizure after the fall, focal deficit, vomiting more than once (NICE NG232, fallback)
- consider CT head within 8 h on an anticoagulant or antiplatelet → head strike, or unwitnessed with a possible head strike, with no other CT indication: a risk-based decision by the drug, the mechanism and the findings, not an automatic scan; within the hour instead if the fall was more than 8 h ago or any of the criteria above is present; aspirin alone does not trigger this on its own (NICE NG232, fallback when there is no local protocol); no decision tool safely excludes bleeding in an anticoagulated patient (ACEP 2023)
- X-ray by findings → hip pain, cannot weight-bear or a shortened rotated leg: pelvis and lateral hip; wrist, shoulder, ribs and spine as the survey directs; a normal hip film with pain on weight-bearing is not cleared: keep off the leg, CT or MRI is a treating team and orthopedics decision
- ECG and glucose → as above; bloods → CBC and RFT if bleeding is possible, on an anticoagulant, or on a drug that may have caused the fall; coagulation profile and INR if on warfarin → coagulation profile; CK and RFT after a long lie
- not tonight → CT spine without midline tenderness or deficit, echo, Holter, bone density, formal gait assessment: treating team decisions by day
treat
suspected fracture
- do not mobilize; hip or femur: keep the leg still, do not test it further; spine: keep flat and log-roll only
- analgesia before the film: paracetamol 1 g QDS, max 4 g/day, less if under 50 kg, frail or liver disease; opioid by weight, renal function and age → analgesia; a fascia iliaca block for hip fracture is an anesthesia or orthopedics decision
- IV access, CBC, group and save; nil by mouth once a hip fracture is likely; fluids by the chart → hypotension if the BP falls
- orthopedics tonight for hip, femur, pelvis or spine; wrist and rib fractures by their advice
- the next anticoagulant or antiplatelet dose is a treating team and orthopedics decision tonight; document when it is due and what was decided → anticoagulation
head strike
- no head strike, none suspected → no CT and no head-injury observations: routine vitals, treat the cause, precautions
- neurological observations → for an actual or suspected head injury, not every fall: GCS, pupils, limb power, respiratory rate, heart rate, BP, temperature and SpO₂ every 30 min for 2 h, hourly for 4 h, then every 2 h while GCS stays 15 or at baseline (NICE NG232 when there is no local protocol; cross-check current local policy)
- back to half-hourly and CT within the hour → any drop in GCS, new or worsening headache, further vomiting, new drowsiness, agitation, unequal pupils or a focal sign → neurological deficit
- on an anticoagulant or antiplatelet → CT decision as in send now; the next dose is a decision, not a reflex: review the drug, its indication, the last dose given, bleeding elsewhere and the head-injury findings
- suspected intracranial bleed or significant traumatic bleeding → withhold; reversal discussed now with the treating team and hematology when indicated → anticoagulation
- otherwise → an individualized decision with the treating team, especially with a mechanical valve, recent VTE or a coronary stent; document what was decided and when the next dose is due → syncope: injury
- bleed on the CT → neurosurgery and the treating team now; reversal is their call with hematology, agents and orientation → anticoagulation; stop the anticoagulant and antiplatelet, keep the head up, treat hypertension only as they direct
- scan normal or not indicated → continue the observation schedule; a normal scan with new symptoms later is a new call, not reassurance
- scalp laceration → feel for a depression or boggy swelling before closing; pressure, clean, close or glue, tetanus per local policy
treat the cause
- orthostatic → fluids, what to hold tonight and how to mobilize → syncope: orthostatic
- syncope → ECG, telemetry by risk, cardiology if the escalate box on that page is met → syncope
- seizure → recovery position, what to send and when to treat → seizures: after the event
- hypoglycemia → treat before anything else; sulfonylurea or long-acting insulin means it recurs → hypoglycemia
- delirium or sedation → no sedative to stop the climbing out of bed; cause, environment and a sitter first → delirium and agitation
- drugs → review each one: hold what is new or escalated (hypnotic, opioid dose, antihypertensive, diuretic, sliding scale); do not stop a chronic benzodiazepine, baclofen or opioid abruptly, taper with the treating team; the next antihypertensive dose waits for the lying and standing BP
- infection → cultures, source, antibiotics if septic → fever, empiric antibiotics
- stroke → time last seen well, CT now → neurological deficit
long lie
- an hour or more on the floor → temperature and warm if cold; CK, RFT, potassium, glucose; urine color; pressure areas and compartments (calf, buttock, forearm) now and again in a few hours
- rhabdomyolysis or a rising creatinine → IV fluids and monitoring as on the AKI page → acute kidney injury; potassium → potassium
- pressure injury or skin tear → clean, dress, off-load the area, tissue viability in the morning
safe mobilization and falls precautions
- back to bed or chair → only after the injury survey is clear; with two staff and a hoist or slide sheet if they cannot get up themselves; first mobilization with nursing assistance after the lying and standing BP
- tonight → bed low and brakes on, call bell and water in reach, non-slip footwear, night light, glasses and hearing aids on, a toileting round and a commode by the bed, clear the floor of lines and leads, a sitter or one-to-one if confused
- not a precaution → restraints and raised bed rails do not prevent falls and add injury; a sedative to keep the patient in bed makes the next fall more likely
- for the treating team → review sedatives, hypnotics and night-time medications, antihypertensives and hypoglycemics; physiotherapy and a gait and balance review; vision; a multifactorial falls assessment before the patient leaves the ward (AGS/BGS, World Falls Guidelines)
reassess
- when → within the hour, after any analgesia or fluid, at each neurological observation if there was a head strike, then each round
- what → GCS and pupils; pain and whether they can now move the hip or weight-bear; vitals and urine output; hemoglobin if it was sent; new headache, vomiting or drowsiness; the floor and the bed set-up
- not settling → a second fall, new confusion, a GCS drop, pain that will not let them move, or a BP that stays low → back to the escalate box; the second fall is the same page with a lower threshold for everything
- hand over → how the fall happened and the working cause, injuries found and films sent, CT decision and result, neurological observations due and until when, the next-dose decision for an anticoagulant or antiplatelet and who made it, drugs held and why, precautions in place, incident report per local policy
evidence
| source | type |
|---|---|
| ACEP 2023 · Clinical policy, adult patients with mild traumatic brain injury (Annals of Emergency Medicine) ↗︎ | specialty-society guideline |
| Montero-Odasso et al. 2022 · World guidelines for falls prevention and management for older adults (Age and Ageing) ↗︎ | international guideline |
| AGS/BGS 2011 · Clinical practice guideline for prevention of falls in older persons, summary (JAGS) ↗︎ | specialty-society guideline |
| CDC STEADI · Older adult fall prevention, screening, assessment and intervention ↗︎ | national program |
| NICE NG232 2023 · Head injury: assessment and early management (CT timing, observation schedule; UK fallback) ↗︎ | national guideline |
Verify indication, dose, allergies, interactions, renal/hepatic function and local protocols before prescribing.
go deeper the full MOC+ Acute Medicine set covers the on-call essentials.
free the on-call checklist covers the whole shift on one printable page.
studying for the IM exam? the IM Rapid Review covers this in the same format. see the sample chapter.
updated Oct 2026file complaint/falls