Headache, confusion s/p ground level fall – student assessment


• Scene – C-collar, assessment, vitals, EKG

• En route – IV, O2, CBG, secondary assessment, detailed

• Hospital – CT-scan


• Response to treatment – pt did respond to O2.

• Disposition – pt uses a walker to ambulate at the retirement center where she lives. She has had an increase in her morphine dose, and now takes morphine 3x/day (30mg), and also has a lidocaine patch (unk dose).


Elliot Williams, Paramedic Woodburn Ambulance

Matthew Hansen, MD Associate Professor Oregon Health & Science University


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


• Ground level fall (GLF)

Differential Diagnosis

  • Concussion
  • Skull fracture
  • Cervical spine injury
  • Hematoma
  • CVA
  • Assess for an underlying etiology for the fall (eg, arrhythmia).

Patient Workup History

  • Patient states – that she does not remember falling, but did not lose consciousness. Does not know why or how she fell.
    Caregiver states – pt was found on the floor. Pt is not acting normal, i.e., not able to carry on a normal conversation for her.
  • Pt was not complaining of any pain anywhere except a headache en route to the hospital.

Physical Exam

  • Physical findings – pt hit wall and put a hole in the sheet rock with her head, but there was not any noticeable trauma to her head.
  • CBG-124
  • GCS-14-15; eyes would be closed, but would open when talked to.
  • EKG-sinus
  • Sat -92% woth O2 98%

Editor’s Notes

This patient did not have any pain complaints in her neck or back; her pelvis was stable. No head trauma was noted; no marks at all. En route pt complained of headache that got worse with time. Pain was described as dull and throbbing.

-Mark Shelton, Paramedic

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


  • Gender: Female
  • Age: 96 years
  • Height: Not Available


  • Temperature: 98.2 F/36.8 C
  • Blood Pressure: 164/80
  • Heart Rate: 98
  • Respiratory Rate: 14
  • Pulse Oximetry: 92% RA

Signs and Symptoms

Headache worsening with time

History Medical

  • PHM: CHF, chronic back pain, HTN
  • Allergies: Codeine
  • Dispatch info: GLF with head injury


  • Lives at assisted living facility
  • Medication
  • O2 via nasal cannula

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