What are the signs and evaluation of internal bleeding after a fall?

Signs and Evaluation of Internal Bleeding After a Fall

Patients presenting after a fall with hemorrhagic shock require immediate clinical assessment and imaging to identify bleeding sources, with FAST ultrasound or CT scan as the primary diagnostic modalities, followed by urgent intervention for hemodynamically unstable patients. 1

Initial Clinical Assessment

Vital Signs and Shock Classification

Assess the extent of hemorrhage using the ATLS classification system based on initial presentation 1, 2:

• Class I: <750 mL blood loss, pulse <100 bpm, normal blood pressure
• Class II: 750-1,500 mL loss, pulse 100-120 bpm, normal blood pressure but decreased pulse pressure
• Class III: 1,500-2,000 mL loss, pulse 120-140 bpm, decreased blood pressure, respiratory rate 30-40/min, urine output 5-15 mL/h, anxious/confused mental status
• Class IV: >2,000 mL loss, pulse >140 bpm, severely decreased blood pressure, respiratory rate >35/min, negligible urine output, confused/lethargic 1, 2

Critical Clinical Signs

Look for these specific indicators of internal bleeding:

• Hemodynamic instability: Systolic blood pressure <110 mmHg (particularly significant in adults ≥65 years) 3
• Tachycardia: Pulse rate >100 bpm or Shock Index ≥1.4 4
• Altered mental status: Any decrease from baseline Glasgow Coma Scale 5
• External trauma markers: Bruising or lacerations on the head (associated with 4.3-fold increased risk of intracranial bleeding) 5
• Neurologic abnormalities: New focal deficits (associated with 4.4-fold increased risk of intracranial bleeding) 5

Laboratory Evaluation

Obtain these tests immediately upon presentation 1, 2:

• Coagulation studies: PT/INR, aPTT, fibrinogen level (target ≥1.5-2 g/L)
• Hematocrit: Note that single measurements should NOT be used as an isolated marker for bleeding 2
• Serum lactate: Essential for estimating and monitoring extent of bleeding and shock 2
• Base deficit: Critical for assessing severity of hemorrhage and shock 2
• Calcium levels: Required for coagulation management 1

Imaging Strategy

Immediate Imaging Decision Algorithm

For hemodynamically UNSTABLE patients with unidentified bleeding source 1, 6:

• Perform FAST (Focused Assessment with Sonography for Trauma) immediately at bedside
• FAST has high specificity (0.97-1.0) but lower sensitivity (0.56-0.71) for detecting free fluid 2
• If significant free intra-abdominal fluid is detected → proceed directly to urgent surgical intervention 2, 6

For hemodynamically STABLE patients 6, 1:

• Proceed to CT scan for comprehensive assessment
• CT is the gold standard for detecting organ injuries and bleeding sources 7
• Whole-body CT can be completed in <30 seconds with modern multi-slice scanners 6, 1
• CT provides superior sensitivity compared to ultrasound for detecting hemorrhage 6

Specific Anatomic Considerations

Assess these major potential bleeding sources 1:

• Chest: X-ray and/or CT for hemothorax
• Abdomen: FAST or CT for solid organ injury (liver and spleen most commonly injured) 7
• Pelvis: X-ray to identify pelvic ring disruption; unstable fractures associated with massive hemorrhage in 75% of cases 1, 2
• Intracranial: CT head for patients with head trauma, altered mental status, or neurologic deficits 5

Special Populations

Older Adults (≥65 years)

This population requires heightened vigilance 3, 5:

• Mortality increases by 2.7% for each year of life even when risk-stratified 3
• 2.3% mortality rate even in ground-level falls with initially normal vital signs 3
• Lower threshold for imaging: systolic BP <110 mmHg (not <90 mmHg) should trigger concern 3
• Chronic kidney disease increases intracranial bleeding risk 2.4-fold 5
• Critical pitfall: 61% of severely injured older adults are undertriaged despite specific protocols 3

Anticoagulated Patients

Document anticoagulation history immediately 1:

• Vitamin K antagonists (warfarin)
• Direct oral anticoagulants (apixaban, rivaroxaban, edoxaban, dabigatran)
• Antiplatelet agents (aspirin, clopidogrel)

Note: One study found no significant association between anticoagulant use and intracranial bleeding after falls, though this remains controversial 5

Immediate Intervention Triggers

Proceed to urgent bleeding control if 1, 2:

• Hemorrhagic shock with identified bleeding source (unless initial resuscitation successful)
• Significant free intra-abdominal fluid on FAST with hemodynamic instability
• Pelvic ring disruption with ongoing shock despite stabilization
• Active contrast extravasation ("blush") on CT scan

Time is critical: Median time to identify substantial bleeding can be 20 minutes before hospital arrival when vital sign patterns are analyzed systematically 4

Common Pitfalls to Avoid

• Do not rely on single hematocrit values to exclude significant bleeding 2
• Do not assume hemodynamic stability excludes bleeding: Older adults may not mount typical tachycardic response 3
• Do not delay imaging in stable patients with high-risk mechanisms (high-energy trauma, falls from height) 6, 1
• Do not undertriage older adults: Age ≥65 years with any hemodynamic abnormality warrants aggressive evaluation 3