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Surgical sieve
🤸 Falls
Two questions, not one: WHY did they fall, and WHAT did they break? This answers the first — then survey the head, the neck, the hips and the ribs.
| Intracranial haemorrhage Must exclude | The bleed AFTER the fall, not before it. Anticoagulation, a head strike, vomiting, a falling GCS, or a lucid interval.CT head within 1 hour if on an anticoagulant and any head injury — see the head injury pathway. |
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| Arrhythmia Must exclude | Collapse with no warning and no memory of falling, particularly if injured because they made no attempt to protect themselves.ECG in everyone. A fall with no prodrome is a cardiac fall until proven otherwise. |
| Sepsis (any source) Must exclude | In the frail and the elderly, a fall is frequently the FIRST sign of infection — before the fever, and often instead of it.Full set of observations and a septic screen, not just an injury survey. |
| Stroke Must exclude | New focal weakness, facial droop or speech disturbance. Posterior circulation strokes present as ataxia or dizziness and are routinely missed.ROSIER and an urgent CT. Check the glucose first. |
| Hypoglycaemia Must exclude | Sweaty, confused, aggressive or drowsy. Insulin, sulfonylureas, poor intake, alcohol, liver disease.A glucose in every single faller. It takes seconds and it is the most reversible cause on this list. |
| Seizure Time-sensitive | Tongue biting (lateral), incontinence, a postictal period, or a witnessed convulsion. Brief jerking after a faint is NOT a seizure.Collateral history is the investigation. Ask whoever saw it. |
| Orthostatic hypotension Time-sensitive | Fell on standing, or on getting up at night. A drop of 20 systolic or 10 diastolic within three minutes of standing.Lying and standing blood pressure — actually done, at three minutes. Then review the drug chart. |
| Drug toxicity or withdrawal Time-sensitive | Sedatives, opioids, antihypertensives, anticholinergics, alcohol — and alcohol WITHDRAWAL in an inpatient on day 2 or 3.Read the chart as a cause, not as a background. Four or more medicines is itself a falls risk factor. |
| Delirium Time-sensitive | Acute, fluctuating confusion with inattention. The fall is a symptom of the delirium, and the delirium is a symptom of something else.Find the cause — infection, drugs, retention, constipation, pain, hypoxia. 4AT to detect it. |
| Anaemia Time-sensitive | Progressive exertional dizziness and falls. A slow GI bleed presents like this long before it presents as melaena.FBC, and ask about the bowels. New anaemia in an older person needs a cause, not just a transfusion. |
| Vasovagal syncope Common | Clear prodrome — hot, nauseated, tunnel vision — with an obvious trigger, and a rapid full recovery on the floor.Reassuring only once the cardiac and neurological causes have been considered. |
| Aortic stenosis Time-sensitive | Exertional syncope with an ejection systolic murmur radiating to the carotids and a slow-rising pulse.Echo. Exertional syncope in aortic stenosis is a red flag, not a coincidence. |
| Urinary tract infection Common | Common, over-diagnosed, and the reflex answer. In an older patient a positive dipstick alone does NOT make this the cause of the fall.Look for a better explanation before treating the urine. Asymptomatic bacteriuria is common and does not cause falls. |
| Mechanical fall Common | A genuine trip or slip with a clear mechanism, no prodrome, no loss of consciousness and a normal examination.A diagnosis of exclusion in anyone over 65 — and still needs a multifactorial falls assessment. |
| Peripheral neuropathy / poor mobility Consider | Repeated falls with no syncope. Diabetes, alcohol, B12 deficiency, Parkinsonism, deconditioning, poor footwear, poor vision.The reason for a recurrent faller is usually several small things at once, not one big one — physiotherapy and occupational therapy assessment. |
15 differentials · 9 open a full pathway in the app.