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Post‑fall management: Concerns for the On‑Call Team
This page lists red‑flags and concerns that should trigger on‑call medical review after an inpatient fall. Keep it SBAR‑ready.
Call immediately (aim review ≤30 minutes)
- Head injury or unwitnessed fall with any of: GCS <15, new confusion/agitation, amnesia >30 min, persistent vomiting, seizure, worsening headache, focal neurology, anticoagulated/antiplatelet use.
- Suspected fracture or dislocation: severe pain, deformity, leg shortened/external rotation (hip), inability to weight‑bear, pelvic instability, neurovascular compromise of a limb.
- Neck pain or neurological symptoms (numbness, weakness, paraesthesia) → treat as potential C‑spine injury; keep immobilised.
- Haemodynamic compromise: NEWS2 ≥5, systolic BP <90 mmHg, HR >120 or <40, new hypoxia, new chest pain, syncope, or concern for bleed.
- Anticoagulated with any concern for intracranial or major bleeding (warfarin, DOAC, heparin, dual antiplatelets).
- Uncontrolled pain despite initial measures, or pain preventing adequate assessment/positioning.
- Acute delirium (4AT ≥4) or markedly changed behaviour placing the patient or staff at risk.
- Head‑strike on therapeutic anticoagulation even if currently asymptomatic (start neuro‑observations and escalate for senior decision on imaging).
Escalate urgently (same‑day)
- New inability to mobilise or step‑change in function vs baseline.
- Persistent abnormal observations below NEWS2 escalation threshold but not resolving with initial measures.
- Potential medical precipitants: syncope prodrome, chest pain/ACS features, arrhythmia on ECG, fever or sepsis features, severe postural drop (≥20/10 mmHg) with symptoms.
- Wound/bleeding not controlled with basic measures; expanding scalp haematoma; large bruise on anticoagulation.
- Safeguarding concerns, recurrent unwitnessed falls on the ward, or environment/equipment issues causing repeated risk.
Information to have when you call (SBAR)
- S: Time/mechanism (or unwitnessed), current concern, whether head‑strike occurred.
- B: Reason for admission, baseline mobility/cognition, relevant comorbidities, ceiling of care (if known).
- A: Latest NEWS2, GCS, capillary glucose, pain score, neuro‑obs started?, cervical spine protected?
- R: What you need (senior review, imaging, analgesia plan, admission to monitored bed).
- Medicines: Anticoagulants/antiplatelets (drug, dose, last dose), antipsychotics, sedatives, opioids given.
Immediate first steps while waiting
- Begin neuro‑observations if unwitnessed/head‑strike/AC/AP use.
- Provide basic analgesia and immobilise suspected fractures; keep NBM if hip/pelvis/long‑bone fracture suspected pending imaging.
- Protect C‑spine if any neck pain/neurology/high‑risk mechanism.
Note: This list supports, not replaces, clinical judgement. Follow local NAIF/NICE head‑injury and anticoagulation policies.
⚠️ Table: Issues Not to Miss After a Fall
| ⚑ Issue / Red flag | ❗ Why it matters | 🚑 Immediate actions | 🧪 Imaging / Tests | ⏫ Escalation |
|---|---|---|---|---|
| 🧠 Intracranial injury (esp. on anticoagulants/antiplatelets) | Risk of ICH or delayed bleed → deterioration after apparent stability | Start neuro‑obs; keep NBM; IV access; senior review | CT head per NICE; INR if warfarin; FBC, U&E; consider repeat CT if symptoms evolve | Urgent senior; consider reversal per policy; involve neurosurgery if ICH |
| 🦴 C‑spine injury (neck pain, neuro signs, high‑risk mechanism) | Missed instability → cord injury | Immobilise; avoid neck movement | CT C‑spine if criteria met; MRI if neuro deficit | Trauma/orthopaedics/neurosurgery per findings |
| 🦿 Hip fracture (shortened/external rotation, inability to weight‑bear) | Morbidity/mortality rises with delay | Analgesia; NBM; pressure care; delirium prevention | Pelvis/hip X‑ray; MRI/CT if X‑ray negative but high suspicion | Orthogeriatrics/trauma; theatre planning |
| 🩸 Pelvic fracture or haemorrhage (pain, instability, hypotension) | Occult major bleed, especially on AC/AP | Stabilise; IV access; group & save; TXA if major bleed (per policy) | Pelvic X‑ray; CT abdo/pelvis if unstable or high suspicion | Major haemorrhage protocol; senior review |
| 🫀 Long‑bone fracture with neurovascular compromise | Limb ischaemia/compartment syndrome | Immobilise; elevate; check pulses/sensation/cap refill; analgesia | X‑rays of affected limb; lactate/CK if concern for compartment/rhabdo | Urgent ortho review; consider fasciotomy pathway if compartment syndrome |
| 🫁 Chest injury (rib/sternal fractures, flail, pneumothorax) | Respiratory compromise; pneumonia risk | Oxygen if needed; pain control; incentive spirometry if appropriate | CXR; consider CT chest if significant trauma; ABG if hypoxic | Escalate to outreach/ICU if increasing oxygen needs |
| 🧪 Rhabdomyolysis (long lie, muscle pain, dark urine) | AKI risk from myoglobinuria | IV fluids; monitor urine output | CK, U&E, bicarbonate; urinalysis | Renal involvement if CK very high or worsening AKI |
| 🩸 Occult internal bleeding (retroperitoneal, GI) | Hidden haemorrhage on AC/AP or frailty | IV access; monitor Hb and haemodynamics; stop/hold AC as per senior plan | Serial Hb; CT abdo/pelvis if indicated; stool/NG if GI suspected | Major haemorrhage/escalation; haematology input for reversal |
| 🧠🩸 Spinal cord/epidural haematoma (new neuro deficit, severe back pain, AC/AP) | Time‑critical decompression | Immobilise; urgent senior review | MRI spine | Neurosurgery/ortho spine urgently |
| 🌀 Delirium (4AT ≥4 or acute change) | Worse outcomes; impedes assessment; safety risk | Treat pain, hypoxia, sepsis; orientate; minimise deliriogenic drugs | 4AT; screen for precipitants (infection, retention, constipation, drugs) | Senior review if severe/agitated or diagnostic uncertainty |
| 🦠 Sepsis precipitating the fall | Missed source → deterioration | Sepsis 6 as indicated | FBC, CRP, cultures; CXR/urinalysis; lactate | Early senior input; antibiotic stewardship |
| ❤️🩹 Syncope/arrhythmia as cause | Recurrent risk, sudden death if untreated | Telemetry if needed; correct electrolytes | ECG, troponin, electrolytes; orthostatic BP | Cardiology advice if concerning features |
| 🧂 Hyponatraemia/electrolyte disorders | Delirium, seizures, falls risk | Address causes; cautious correction | U&E, osmolality, urine Na/osm if needed | Senior review for severe or symptomatic cases |
| 🛏️ Pressure injury risk after long lie | Tissue necrosis within hours | Mattress upgrade; offload heels/sacrum | Skin check head‑to‑toe | Inform tissue viability if pressure damage present |
| 💊 Anticoagulation reversal needs | Delay increases bleeding harm; reversal also carries thrombotic risk | Follow local reversal policy; record indication/last dose | INR, anti‑Xa if available; FBC | Senior/haematology decision; document restart plan |
| 🛡️ Safeguarding/environmental hazards | Prevents recurrent inpatient falls | Address hazards; observe if high risk | Incident report; MDT review | Escalate to senior nurse/ safeguarding if concerns |
📋 NAIF‑Eligible Injuries After an Inpatient Fall
Tick all that apply. Any of the following injuries are classed as eligible for NAIF if they occurred as a result of an inpatient fall: