Makindo Medical Notes

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:

Head injury
Spinal injury
Hip fracture
Vertebral fracture
Rib fracture
Humeral fracture
Distal forearm fracture
Pelvic ring fracture
Other fracture