Altered mental status, s/p fall off bed

Treatment

• Scene – VS, EKG, assessment

• En route – IV, BG, vitals, oral temp, assessment, O2

Disposition

• Response to treatment – pt has COPD and did not respond to O2.

• Disposition – Social service will be contacted.

Authors:

• Mark Shelton Paramedic Woodburn Ambulance

• Matthew Hansen, MD Associate Professor Oregon Health & Science University

Editors:

• David M. Spiro, MD, MPH Professor of Pediatrics University of Arkansas Medical Center

Diagnosis

• Fall
• Possible overdose (OD)
• Trail house (garbage house)
• Failure to thrive

Differential Diagnosis

• Ground level fall (GLF)

• Restless legs syndrome

• Dehydration

• Failure to thrive

• CVA/stroke

• Concussion

• Intracranial bleed (e.g., subdural hematoma)

• Arrhythmia

• Poor medical compliance (e.g., under/overdosed)

Patient Workup History

• Patient states – that he fell off bed and could not get up, he is too weak.

• Caregiver (niece) states – that he is not acting normal, and his leg (RLS) is worse than usual.

Physical Exam

• GCS – 14-15

• EKG – NSR

• CBG – 94

• All vitals normal

• No marks/trauma noted

Editor’s Notes

One of the key thoughts around this case – what may have precipitated the fall? Some of these potential diagnoses are considered in the differential dx section. What else might you consider? Then, consider any injuries the fall itself may have caused – like a subdural hematoma. Social concerns are also addressed in this case.

-Dr. David Spiro

Suggested Approach Notes

• The algorithm for trauma stabilization in the elderly is similar to that for younger patients with a few extra cautions. Generally speaking, the approach should be more conservative than for younger patients. For example, the existing cervical spine clearance protocols have not been studied in the elderly, so “clearing” the cervical spine in an injured elderly patient usually requires imaging and should not be done in the field. Elderly patients with seemingly minor injuries in the initial assessment may be hiding significant injuries such as fractured ribs, intracranial hemorrhage, or a fractured pelvis.

• Elderly patients suffer much higher morbidity and mortality from trauma, so providers should take care in not under-triaging elderly patients and consider transporting elderly patients to trauma centers though the injuries may not initially seem significant. A brief AMPLE (allergies, medications, past history, last meal, and events) history should be taken with focus on potential anticoagulant use, insulin use, and cardiac medication use.

• GLF are common, therefore it is important to decipher 2 things on scene and en route: 1) why the person fell, and 2) consequences of the fall. Many factors contribute to the “why”: Lost balance and agility due to aging, medication side effects, loss of postural tone, occult bleeding (GI or retroperitoneal), dysrhythmia, acute coronary syndrome, TIA, dehydration, and other factors all can lead to near syncope or syncope. EMS personnel must put thought into the cause as well as the consequence.

Suggested references

• Falls in the elderly

• Restless legs syndrome

Patient

• Gender: Male

• Age: 74 years

• Height: Not Available

Vitals

• Temperature: 98.8 F/37.1 C

• Blood Pressure: 118/82

• Heart Rate: 77

• Respiratory Rate: 16

• Pulse Oximetry: 92% RA

Signs and Symptoms

Weakness; leg shaking

History Medical

• PMH: COPD, CHF, chronic back pain, restless legs syndrome (RLS)

• Allergies: PCN, sulfa, amoxicillin

• Dispatch info: Fell out of bed and can not get up

Social

• Pt lives with his niece and her spouse. The house is unsanitary and very cluttered, with only trails through the house, and two dogs. The house has a very strong odor of pet feces, rotten food, and human waste and urine.