What is the management approach for a patient who has fallen in a sitting position?

Management of a Patient Who Has Fallen in a Sitting Position

If a person has fallen while sitting and is injured, leave them in the position found unless the area is unsafe or their airway is compromised—moving them risks worsening potential spinal injuries. 1

Immediate Safety Assessment

• Assess scene safety first. If the area is unsafe for you or the patient, move to a safe location only if possible and safe to do so. 1
• Call for help immediately if the patient has a potentially serious illness or injury by activating the emergency response system (9-1-1). 1
• Remain with the patient until trained rescuers arrive as long as it is safe to do so. 1

Critical Decision Point: Assess Responsiveness and Breathing

If Unresponsive with Absent or Abnormal Breathing:

• Position the patient supine immediately and follow the CPR algorithm. 1
• This takes priority over all other positioning considerations—chest compressions and rescue breathing require supine positioning. 1

If Unresponsive but Breathing Normally:

• It may be reasonable to place the patient in a lateral side-lying recovery position if there is no suspicion of spinal injury. 1
• However, monitor continuously for signs of airway occlusion, inadequate or agonal breathing, and changes in responsiveness. 1
• If the recovery position impairs your ability to assess breathing or responsiveness, reposition the patient supine immediately. 1

If Responsive and Breathing Normally:

Suspected Spinal Injury (Critical Consideration)

• Do NOT move the patient if the nature of the injury suggests neck, back, hip, or pelvic injury. Leave them in the sitting position in which they were found to avoid potential further injury. 1
• The sitting position from a fall raises concern for potential spinal injury, particularly if the fall involved significant force or the patient landed awkwardly. 1
• Only move the patient if:
  • The position is causing airway obstruction 1
  • The area is unsafe 1
  • Movement causes pain—in which case, do not proceed 1

No Suspected Spinal Injury

• Allow the patient to assume the most comfortable position. For patients with difficulty breathing, this will typically be sitting up. 1
• For patients showing evidence of shock (responsive and breathing normally), it is reasonable to place or maintain them in a supine position. 1
• If no evidence of trauma exists (simple fainting, nontraumatic bleeding, sepsis, dehydration), raising the feet 6-12 inches (30°-60°) from supine may be considered while awaiting EMS. 1
• Do not raise the feet if movement or position causes pain. 1

Specific Assessment for Fall Patients

High-Risk Features Requiring Immediate Medical Evaluation:

• Age ≥65 years (this alone warrants CT imaging if head injury occurred) 2
• Focal neurologic deficits 2
• Vomiting or severe headache 2
• GCS <15 2
• Physical signs of basilar skull fracture 2
• Coagulopathy or anticoagulant use 2
• Dangerous mechanism (fall >3 feet or 5 stairs) 2

Environmental Protection:

• Protect the patient from hyperthermia or hypothermia due to exposure while awaiting help. 1

Common Pitfalls to Avoid

• Do not assume a sitting fall is "minor"—the mechanism and patient factors (age, medications, comorbidities) determine injury severity, not just the position. 3, 4
• Do not move patients with suspected spinal injury to a "better" position unless absolutely necessary for airway management or safety. 1
• Do not delay activating EMS to perform detailed assessments if high-risk features are present. 1, 2
• Do not leave high-risk patients unmonitored—someone should check on them every 2-3 hours during the first 24 hours, including waking them from sleep. 2

Special Populations

Elderly Patients (≥65 years):

• Lower threshold for imaging and medical evaluation due to higher risk of delayed bleeding and serious injury from seemingly minor mechanisms. 5, 2
• Comprehensive fall risk assessment should follow, including medication review (focus on vasodilators, diuretics, antipsychotics, sedatives), vision assessment, cognitive screening, and home safety evaluation. 5
• Multifactorial interventions including physical therapy for gait training, balance exercises 3+ days/week, strength training twice weekly, and home modifications are recommended. 5

Trauma Patients:

• Risk factors for serious injury include older age, male gender, blunt mechanism, lower GCS, ICU admission need, and mechanical ventilation requirement. 4
• Maintain high suspicion for spinal injury and follow spinal precautions until cleared. 6