In an adult who experienced an unwitnessed fall, what initial imaging and laboratory studies should be ordered?

Initial Assessment and Workup After an Unwitnessed Fall

All geriatric patients presenting after an unwitnessed fall require a comprehensive head-to-toe physical examination, low-threshold neuroimaging, basic laboratory studies, ECG, and medication review—regardless of whether they appear to have isolated injuries. 1

Mandatory History Components

Document the following critical elements that predict injury severity and guide management:

• Time spent on the ground – Prolonged downtime indicates higher severity and risk of complications including rhabdomyolysis and pressure injuries 1
• Loss of consciousness or altered mental status during or after the fall 1
• Syncope, near-syncope, or orthostatic symptoms that may have precipitated the fall 1
• Presence of melena – gastrointestinal bleeding can cause falls and requires investigation 1
• Anticoagulant or antiplatelet use – 70% of elderly patients on these medications who develop subdural hematoma deteriorate within 24 hours 2
• Medication burden – document all prescription, over-the-counter, and supplement medications, as polypharmacy (≥4 medications) independently increases fall risk 1

Complete Physical Examination

Perform a full head-to-toe examination on every patient, even those presenting with seemingly isolated complaints. Failure to do so is a common pitfall that leads to missed occult injuries including bilateral fractures and subdural hematomas. 1, 3

Key examination components include:

• Neurologic assessment with attention to Glasgow Coma Scale (document individual Eye, Motor, Verbal components rather than sum scores), focal deficits, peripheral neuropathies, and proximal motor strength 1, 2
• Orthostatic vital signs to identify postural hypotension 1
• Musculoskeletal examination with palpation of all extremities for tenderness, deformity, or occult fractures; examination of all joints for arthritis and range of motion limitations 1
• Signs of head trauma including scalp hematomas, lacerations, or contusions 4
• Pupillary size and reactivity 2

Neuroimaging Decision-Making

Head CT Indications

Maintain a low threshold for obtaining head CT in elderly fall patients. The following factors significantly predict intracranial injury:

• Loss of consciousness (OR 2.02) 4
• Physical signs of head trauma (OR 2.6) 4
• Male sex (RR 2.19) 5
• Consciousness impairment (RR 1.56) 5
• Focal neurological deficit (RR 6.36) 5
• Past history of traumatic brain injury (RR 7.17) 5
• GCS <15 (even if patient appears at baseline) 6

The combination of loss of consciousness and signs of head trauma has 86.5% sensitivity and 97.3% negative predictive value for intracranial injury. 4

Critical timing consideration: Optimal detection of traumatic lesions occurs when CT is performed ≥5 hours after head trauma. 5

For anticoagulated patients: Even with initially negative CT, delayed hemorrhage occurs in 1.4-4.5% of cases. These patients require mandatory 24-hour observation with repeat CT at 20-24 hours post-initial scan. 2

Spine Imaging

Clinical evaluation in multiply injured or obtunded patients is unreliable—screening imaging of the spine is mandated. 6

• CT is superior to plain radiography for detecting spinal injury, with sensitivity approaching 100% versus 52% pooled sensitivity for plain films 6
• Plain radiography has no role in the obtunded or multiply injured patient when CT is available 6
• MRI is the gold standard if there is any abnormal neurological examination referable to the spinal cord 6

Extremity Imaging

Obtain radiographs for any area with focal tenderness, deformity, or inability to bear weight:

• Ankle: Apply Ottawa Ankle Rules—radiographs indicated if point tenderness over malleoli, talus, or calcaneus, or inability to walk 6
• Foot: Apply Ottawa Foot Rules—radiographs indicated if point tenderness over navicular, base of 5th metatarsal, or inability to walk 6
• Knee: Radiographs mandatory for focal joint line tenderness regardless of weight-bearing ability 7

Common pitfall: Do not defer imaging based on ability to bear weight alone when other criteria are met. 7

Laboratory Studies

Maintain a low threshold for obtaining:

• Complete blood count – to assess for anemia from occult bleeding 1
• Basic metabolic panel – to evaluate electrolyte abnormalities that may have precipitated the fall 1
• Measurable medication levels (e.g., digoxin, anticonvulsants) if applicable 1
• Vitamin D level – deficiency is a modifiable risk factor 1
• ECG – to identify arrhythmias or ischemia that may have caused syncope 1

Medication Review

All patients must have medications reviewed and altered or stopped as appropriate. 1

High-risk medication classes requiring special attention:

• Vasodilators, diuretics (OR 1.1 for falls) 1
• Antipsychotics, sedative-hypnotics, benzodiazepines (OR 1.7 for falls) 1
• Antidepressants 1
• Class 1a antiarrhythmics (OR 1.6 for falls) 1
• Digoxin (OR 1.2 for falls) 1

Polypharmacy (≥4 medications) is an independent risk factor and should trigger comprehensive medication reconciliation. 1

Disposition Decision-Making

Safety Assessment Before Discharge

Perform a "Get Up and Go Test" to assess patient safety. Patients who fail this test should not be discharged without further reassessment or admission. 1

The test involves:

• Patient rises from chair
• Walks 3 meters
• Turns, returns, and sits
• Time >12 seconds indicates increased fall risk requiring comprehensive evaluation 1

Admission Criteria

Admit patients when safety cannot be ensured at home, including: 1

• Inability to ambulate steadily or failure of "Get Up and Go Test"
• Unsafe home environment
• Abnormal CT findings (subdural hematoma, intracranial hemorrhage, significant fractures)
• GCS <15 with any intracranial abnormality
• Anticoagulated patients requiring 24-hour observation

For patients with subdural hematoma: Immediate admission to monitored setting with serial neurological assessments and neurosurgical consultation is mandatory, regardless of GCS score. 2

Monitoring Protocol for Admitted Patients

• GCS monitoring every 15 minutes for first 2 hours, then hourly for 12 hours 2
• Document individual GCS components (Eye, Motor, Verbal) 2
• Assess pupillary size and reactivity at each evaluation 2
• Monitor for focal neurological deficits hourly 2
• Critical threshold: Decrease of ≥2 points in GCS warrants immediate repeat CT and neurosurgical consultation 2

Discharge Planning

For patients safely discharged:

• Arrange expedited outpatient follow-up within 1-2 weeks including home-safety assessment 1
• Provide structured fall-prevention education 1
• Recommend home modifications: remove loose rugs, ensure adequate lighting, install handrails and grab bars, address slippery surfaces 1

Common Pitfalls to Avoid

• Never discharge patients who fail the "Get Up and Go Test" without further evaluation—this markedly increases immediate fall risk 1
• Never perform incomplete examination in patients with reduced cognitive function or dementia—these patients require full ATLS assessment as they may have multiple occult injuries including bilateral fractures 3
• Never attribute falls solely to "old age" or "accident" without investigating underlying multifactorial causes 1
• Never administer long-acting sedatives or paralytics before neurosurgical evaluation in patients with head trauma, as this masks clinical deterioration 2
• Never overlook medication review, especially in patients on ≥4 medications or psychotropic drugs 1