Multiple Lacerations, S/P Fall


• Scene – exam, VS, EKG, 12-lead, IV, bandage.

• En route – EKG monitored, 50mcg fentanyl, 1000ml fluid wide open, 150ml bolus to allow for fentanyl

• Hospital – not known


• Response to treatment – Pain improved with fentanyl. EKG fluctuated without intervention.

• Disposition – Not known. Patient should be referred to cardiologist for follow up.


  • Elliot Williams, Paramedic Woodburn Ambulance
  • Daniel Neazor, Paramedic Woodburn Ambulance Service
  • 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


• Ground level fall (GLF)
• Laceration

Differential Diagnosis

• Ground level fall (GLF)

• Lacerations

• R/O cardiac cause

• Bundle branch block (BBB)

• Sick sinus syndrome

• Orthostatic BP changes

Patient Workup History

• Patient states – She stood up, just felt weak and fell forward. Denies LOC, states that she felt some nausea just after fall but feels fine now.

• States that she has been having issues with blood pressure lately, as low as 56/36. BP measured daily and ranging from systolic of 70’s to 150’s depending on the day.

• Patient has had several falls lately, last was 4 days ago. A fall 4 weeks ago caused a T10 fracture.

• Patient saw her primary care provider earlier today for a 12-lead but hasn’t heard anything.

• Patient states no history of cardiac arrhythmia, but patient found in LBBB with 1 degree block.

• En route, patient’s QRS complex narrows, but BP drops down. Denies any chest pain throughout, denies SOB.

Physical Exam

• Cardiac findings as listed in patient history.

• Patient has bite laceration on tip of tongue; a cut lower lip; 5cm laceration on left knee just below patella; bruise just above left breast, and pain just below left scapula in her back.

• GCS – 15

• CBG – 154

Suggested Approach Notes

• 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: 80 years

• Height: Not Available


• Temperature: Not Available

• Blood Pressure: 123/82

• Heart Rate: 58

• Respiratory Rate: 16

• Pulse Oximetry: 97% RA

Signs and Symptoms Multiple abrasions; pain

History Medical

• PMH: Frequent falls; recent low blood pressure.

• Dispatch info: Fall, bleeding from knee.


• Lives at home with husband, who is a smoker.


• No blood thinners

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