Head injury s/p fall


• Scene – bandaged head with 4×4 and Kerlix
• En route – oxygen, IV attempt


• Response to prehospital treatment – pain remained constant at 4-5/10, bleeding controlled with bandage
• Taken to hospital
• Disposition unknown


• Mark Shelton Paramedic Woodburn Ambulance
• David Jones, MD Associate Professor Oregon Health and Science University


• David M. Spiro, MD, MPH Professor of Pediatrics University of Arkansas Medical Center
• Ritu Sahni, MD, MPH Oregon Health & Science University

• Scalp laceration
• Closed head injury
• Ground level fall (GLF)

Differential Diagnosis

• Concussion
• Laceration
• Intracranial bleeding (subdural hematoma, epidural hematoma).
• Skull fracture
• Cervical spine injury
• Assess for an underlying etiology for the fall.

Patient Workup

• Physical findings – 2″ scalp laceration, otherwise atraumatic.
• Damage to wall noted (see photo in Supporting Materials).

Editor’s Notes

With elderly ground level falls, it’s crucial to rule out potentially serious underlying conditions occurring/causing the fall. Many new medics tend to focus just on the resulting injury but do not do a thorough history to rule out underlying issues, such as M.I. or arrhythmias, that caused the fall – especially one such as this, where the patient has a history of arrhythmia. Continuous ECG monitoring would be advantageous in this patient to ensure she was not experiencing intermittent brady/tachy arrhythmias. Looking at the PHCR, it appears the EMS team did do this during transport and she remained in a normal sinus rhythm.

Suggested Approach

• In bleeding patients, try and control the bleeding as soon as possible. The scalp is a very vascular area, and patients can lose a lot of blood very quickly from a scalp wound.
• Make sure to ask about aspirin (salycilate), Plavix (clopidogrel), Coumadin (warfarin), Pradaxa (dabigatran), or other blood thinners the patient may be on. Blood thinners increase the risk of life-threatening bleeds. In a patient like this, the blood thinners may make it hard to control the scalp bleed.
• Patients with histories of dementia may seem very sharp, but this is not always the case. You should be extra cautious about looking for injuries and monitoring for clinical deterioration in patients with dementia.
• Even patients who seem like they are mechanical falls should get an EKG, stroke screen and blood glucose level. Cardiac ischemia or stroke could masquerade as a mechanical fall, and if you don’t look you’ll never find the real cause of their fall.
• Low mechanism injuries can also lead spinal injuries in the elderly. The spine should be carefully examined and any indication of possible injury should lead to proper spinal precautions (which varies by local protocol).

Suggested references

• Falls in the elderly


• Gender: Female
• Age: 87 years
• Height: Not Available


• Temperature: Not Available
• Blood Pressure: 143/74
• Heart Rate: 81
• Respiratory Rate: 16
• Pulse Oximetry: 94% RA

Signs and Symptoms

Head laceration


• Fell while using walker that “kind of got away” from her. Denies loss of consciousness.
• PMH: Dementia, diabetes, UTI, hypertension, depression.
• Allergies: Vicodin
• Dispatch info – GLF with head injury, no thinners.


• None


• Lisinopril, Glucophage, Dyazide, Ditropan, Cymbalta, glucosamine, MiraLax, Zocor, Tylenol, tramadol

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