Pre-Hospital Interventions for Fall Patients
In the pre-hospital setting, EMS should focus on immediate life-threatening injury assessment, basic trauma stabilization, and rapid transport to definitive care rather than extensive on-scene evaluation, as the comprehensive fall assessment described in guidelines is designed for the emergency department, not the field.
Critical Pre-Hospital Priorities
The evidence provided primarily addresses emergency department management of fall patients 1, not pre-hospital care. However, applying trauma principles to fall patients, the pre-hospital approach should follow this algorithm:
1. Primary Survey and Life-Threatening Injury Management
For fall patients, particularly geriatric adults, EMS must:
- Secure airway while protecting cervical spine - Falls can cause occult spinal injuries even from standing height 1
- Assess and support breathing - Look for tension pneumothorax from rib fractures
- Control external hemorrhage - Direct pressure for any bleeding wounds
- Assess circulation and perfusion - Hypotension may indicate internal bleeding or the cause of the fall (syncope, cardiac event)
2. Spinal Immobilization
Apply cervical collar, head immobilization, and spinal board for any fall patient where mechanism suggests potential spinal injury 2. This is particularly critical because:
- Geriatric patients can sustain significant injuries from seemingly minor falls 1
- Traumatic injuries may be "occult" without classic signs 1
- High-risk injuries include blunt head trauma, spinal fractures, and hip fractures 1
Important caveat: Transfer patients off spine boards as soon as feasible to prevent pressure injuries 2.
3. Rapid Secondary Assessment
Quickly document:
- Mechanism: Height of fall, what patient struck
- Time on ground: Prolonged immobility suggests inability to self-rescue
- Loss of consciousness: Suggests head injury or syncope as cause
- Patient report of symptoms: Chest pain, palpitations, dizziness before fall
4. Transport Decision
Transport all geriatric fall patients (age >65) to appropriate facilities for comprehensive evaluation 1. The extensive assessment required—including medication review, orthostatic vitals, gait testing, cognitive assessment, and evaluation for occult injuries—cannot be performed in the field 1.
What NOT to Do Pre-Hospital
- Do not attempt comprehensive fall risk assessment on-scene - This requires multidisciplinary evaluation including physical therapy, occupational therapy, and medication review 1
- Do not perform extensive diagnostic workup - EKG, labs, and imaging are hospital-based 1
- Do not delay transport for non-critical interventions - Field time should be minimized for trauma patients 3, 4
Key Clinical Pearls
Ask the critical question: "Would a healthy 20-year-old have fallen in this situation?" 1. If no, the fall likely resulted from medical causes requiring hospital evaluation.
High-risk features requiring trauma center transport:
- Fall from height (not standing)
- Severe mechanism
- Altered mental status
- Signs of major trauma 5
Recognize that older adults, particularly females falling from standing height, often have significant injuries despite appearing stable 5. Transport for evaluation is warranted even without obvious injury.
Common Pitfalls
- Underestimating injury severity - Geriatric patients have higher mortality despite lower injury severity scores compared to younger patients 6
- Assuming "ground level fall" is benign - These cause significant morbidity and mortality in older adults 1
- Attempting to "clear" patients on-scene - The comprehensive evaluation needed cannot be done pre-hospital 1
The pre-hospital role is stabilization and transport, not comprehensive fall evaluation. The detailed assessment protocols in the guidelines 1 are explicitly designed for emergency department implementation with physician oversight, multidisciplinary teams, and diagnostic capabilities unavailable in the field.