A patient has fallen
Look for the injury, then ask why they fell. Anyone on anticoagulants who hits their head needs a CT head.
"Mr Ali in bed 8 has been found on the floor." He is 84, admitted with a UTI, on apixaban for AF, furosemide and doxazosin. He says he got up to pass urine. He has a bruise on his forehead and pain in his right hip. GCS 15. The nurses want to lift him back into bed.
What do you check before he is moved, does he need a CT tonight, and why did he fall?
- Don't move them until assessedUnless in danger. Protect the neck if neck pain or an unwitnessed fall with head injury.
- A–E, GCS, pupils, sugarBefore anything else.
- Head injury on anticoagulantsCT head within 8 hours even if GCS 15.
- Look for injuriesHead, neck, hip (short, rotated leg), wrist, ribs, face, pelvis.
- Safe liftingFlat lifting equipment if hip or spinal injury possible.
- Why did they fall?Lying and standing BP, ECG, sugar, infection, drug chart, delirium, urgency.
- Neuro observationsAfter any head injury.
- Document, tell the family, prevent the next fallIncident report per hospital policy.
- Head injury on anticoagulants or antiplatelets
- Drowsy, confused or new weakness
- Suspected hip, spinal or other fracture
- Collapse with chest pain or palpitations
- Falling GCS
- Subdural haematoma (may appear days later)
- Hip fracture (can walk with an impacted fracture)
- Cervical spine injury
- Cardiac syncope or arrhythmia
- Postural hypotension from drugs
- Infection or delirium
- Hypoglycaemia
- Stroke
- Rhabdomyolysis after a long lie
| CT head within 1 hour | GCS below 13 initially or below 15 at 2 hours, open, depressed or basal skull fracture signs, seizure, focal deficit, more than one vomit |
| CT head within 8 hours | Anyone on an anticoagulant who hit their head (even if well), or loss of consciousness or amnesia with age 65+, bleeding disorder or dangerous mechanism |
| Postural drop | Systolic fall of 20 or more, or diastolic 10 or more, on standing |
| Neuro observations | Every 30 minutes until GCS 15, then hourly for 4 hours, then 2-hourly |
| Paracetamol | 1 g every 6 hours |
Check every dose against a current drug reference and your hospital protocol.
On this page
Why it matters
Falls in hospital are common, especially in elderly, confused and post-operative patients. A fall is a symptom. You need to find two things: any injury, and the reason for the fall. Both can be serious.
On the phone
- Did the patient hit their head? Any loss of consciousness? Witnessed?
- On anticoagulants or antiplatelets (warfarin, rivaroxaban, apixaban, enoxaparin, clopidogrel, aspirin)?
- Observations and GCS? Pain, especially in the hip or neck?
- Ask the nurse not to lift the patient if a neck or hip injury is possible, and to check the sugar.
Assessment
- Danger, response, airwayTalking? GCS? Neck pain or tenderness?
- HeadBruises, wounds, basal skull signs, pupils.
- Limbs and spineHip (short, externally rotated leg, pain on movement), wrists, shoulders, ribs, spine, pelvis.
- Sugar and observationsIncluding lying and standing BP once safe.
- CauseDrug chart, ECG, urine, infection signs, delirium screen.
- ImagingCT head and X-rays as indicated.
Head injury after a fall
CT head within 1 hour
CT head within 8 hours
- Neuro observations
- review if any change
- Subdural haematomas in elderly patients and alcohol users can appear days later. Ask the team to watch for new confusion, drowsiness or headache.
- Bleed on CT in an anticoagulated patient: reverse urgently (vitamin K and prothrombin complex for warfarin; specific reversal or PCC for DOACs) and call neurosurgery.
Hip fracture
- Shortened, externally rotated leg; pain on moving the hip; can't bear weight.
- Impacted fractures may still allow walking.
- X-ray the hip (AP pelvis and lateral). If normal but suspicion remains: MRI or CT.
- See hip fracture.
Why did they fall?
- DDrugsSedatives, opioids, BP tablets, diuretics, alpha-blockers, insulin, sulfonylureas
- RRetention or urgencyNight-time toilet trips, diuretics, UTI
- OOrthostatic hypotensionPostural drop, dehydration
- PPoor vision, perception and environmentNo glasses, unfamiliar ward, wet floor, bed height
- SSyncope and sepsisArrhythmia, aortic stenosis, infection, delirium
| Cause | Clues | Test |
|---|---|---|
| Postural hypotension | BP drop on standing, BP tablets, diuretics, dehydration | Lying and standing BP |
| Cardiac syncope | No warning, palpitations, abnormal ECG, murmur | ECG, monitor, echo |
| Delirium or infection | New confusion, fever | 4AT, bloods, cultures |
| Low sugar | Insulin or sulfonylurea | Capillary sugar |
| Stroke | New weakness, speech problems | CT |
| Sedatives or opioids | Recently given | Drug chart |
| Trip or slip | Environment, footwear, poor vision | History |
Investigations
| Test | Why |
|---|---|
| CT head | Per criteria |
| X-ray of hip, wrist or other injured part | Fractures |
| ECG | Arrhythmia, heart block |
| Sugar, CBC, electrolytes, CRP, CK | Causes, rhabdomyolysis |
| INR or clotting | If on warfarin or bleeding |
| Lying and standing BP | Postural hypotension |
Treatment
Preventing the next fall
- Review sedatives, BP tablets, diuretics and alpha-blockers.
- Treat delirium, infection and retention.
- Bed at low height, call bell in reach, non-slip footwear, glasses on, light at night.
- Help to the toilet, especially at night. Bedside commode if needed.
- Physiotherapy and walking aids.
Common mistakes
- Lifting a patient with a possible hip or spine injury without assessment.
- Not scanning an anticoagulated patient who hit their head.
- Missing a hip fracture because the patient can walk.
- Treating the injury and not asking why the patient fell.
- Restarting the same sedatives and BP tablets the next day.
Document
Time, witnessed or not, injuries, GCS, neuro observation frequency, investigations, cause found, family informed, incident form.
Frequently asked questions
Does every patient who falls in hospital need a CT head?
No. CT is needed for head injuries meeting the criteria, and for anyone on an anticoagulant who hit their head, even if they seem well.
How often should neuro observations be done after a fall with head injury?
Every 30 minutes until GCS is 15, then hourly for 4 hours, then every 2 hours.
How do I check for a hip fracture after a fall?
Look for a shortened, externally rotated leg, pain on moving the hip and inability to bear weight. X-ray the hip; if normal but suspicion remains, MRI or CT.
What are common causes of falls in hospital?
Drugs (sedatives, BP tablets, diuretics), postural hypotension, infection and delirium, night-time toilet trips, arrhythmias, low sugar and an unfamiliar environment.
Test yourself
Exam-style questions on this guide, from our two question banks. Choose an answer to see why each option is right or wrong.
1. An 84-year-old on apixaban fell and hit his head. GCS is 15. When does he need a CT head?
Answer: Within 8 hours. Anticoagulated patients with head injury need CT within 8 hours even with no other features.
- In 1 week: Too late.
- Only if GCS drops: Too late.
- Not needed: Anticoagulation is an indication.
- Within 1 hour: Unless other high-risk features.
2. A patient on doxazosin and furosemide falls at night on the way to the toilet. What test helps find the cause?
Answer: Postural BP. Alpha-blockers and diuretics cause postural hypotension, a common cause of falls.
- Thyroid scan: No.
- MRI brain: Not first.
- EEG: Not first.
- Bone scan: No.
3. An elderly patient can walk after a fall but has groin pain. The hip X-ray is normal. What next?
Answer: MRI or CT of the hip. An occult hip fracture should be excluded with MRI or CT.
- Physiotherapy: Not until fracture excluded.
- Discharge: Impacted fractures can allow walking.
- Repeat X-ray in 3 months: Too late.
- Ultrasound: Not the test.
4. An 82-year-old woman on 9 regular medicines has had three falls in 2 months. Which is the most useful step in falls assessment?
Answer: Multifactorial falls assessment. Falls in older people are multifactorial: medications (sedatives, antihypertensives, diuretics, anticholinergics, polypharmacy), postural hypotension, visual impairment, gait/balance problems, cognitive impairment, continence and home hazards. A multifactorial risk assessment and intervention (strength and balance training, medication review, home modification, vision correction) reduces falls. Assess bone health (osteoporosis) to prevent fractures.
- Prescribe a sleeping tablet: Sleeping tablets cause sedation and increase falls.
- Advise bed rest for a week: Bed rest causes deconditioning and makes falls more likely.
- CT head after every fall: Only for head injury criteria.
5. After a displaced intracapsular fracture of the femoral neck, the femoral head is at risk of avascular necrosis. Which artery is its main blood supply?
Answer: Medial circumflex femoral artery. Retinacular branches of the medial circumflex femoral artery run up the neck within the capsule to supply most of the femoral head. Displaced intracapsular fractures tear them, causing avascular necrosis; such fractures are usually treated by hemiarthroplasty in older patients. The artery of ligamentum teres is significant mainly in children.
- Lateral circumflex femoral artery: Contributes less, mainly to the anterior neck.
- Artery of the ligamentum teres (obturator): Important in children; minor in adults.
- Superior gluteal artery: Supplies the gluteal muscles.
- Femoral artery directly: Gives the circumflex arteries via the profunda.
6. An elderly alcoholic on warfarin has fluctuating confusion over two weeks after a minor fall. CT shows a crescent-shaped collection crossing suture lines. Which vessels bled?
Answer: Bridging veins (subdural haematoma). Subdural haematoma: tearing of bridging veins between cortex and dural sinuses; crescent-shaped, crosses sutures; risk in elderly, alcoholics (brain atrophy) and anticoagulated patients; may be chronic with fluctuating consciousness. Extradural: middle meningeal artery after temporal fracture, lens-shaped, does not cross sutures, lucid interval.
- Middle meningeal artery: Extradural: lens-shaped.
- Berry aneurysm of the circle of Willis: Subarachnoid haemorrhage.
- Lenticulostriate arteries: Hypertensive intracerebral bleed.
- Superior sagittal sinus: Not the usual source.
References and dose sources
- Paracetamol dosing: Drugs.com: Acetaminophen (paracetamol) dosage (see also our paracetamol dose page)
- Morphine dosing: Drugs.com: Morphine dosage (see also our morphine dose page)
International guidance is linked where it reflects good practice. Where your hospital’s protocol differs, follow your hospital.