Recognising Neurological Deterioration After a Fall
Learn how to identify neurological changes following a fall, compare observations with baseline and recognise when deterioration requires prompt clinical escalation.
Start with the patient, not the fall
When a patient falls, establish immediate safety and assess their clinical condition systematically rather than focusing only on how the fall occurred.
Are they alert?
Check whether the patient is responding normally and compare this with their usual level of consciousness.
Any immediate threat?
Reduced consciousness may affect airway protection, so begin with a systematic ABCDE assessment.
Could the head or neck be involved?
Consider the mechanism of the fall and whether there may have been head, neck or other significant injury.
Where does it hurt?
Ask about headache, neck pain and other pain while avoiding unnecessary movement if significant injury is suspected.
What was normal before the fall?
Compare current cognition, speech, movement and behaviour with the patient's normal presentation.
What happened and when?
Establish when the fall occurred, whether it was witnessed and what was noticed immediately afterwards.
Look for deterioration from baseline
Increasing drowsiness
A patient who becomes harder to wake or less responsive requires urgent reassessment.
New cognitive change
New confusion, agitation or unusual behaviour may indicate neurological or physiological deterioration.
New communication difficulty
Listen for slurred speech, new word-finding difficulty or reduced ability to understand.
New pupil abnormality
Observe pupil size, symmetry and response according to local neurological observation procedures.
New weakness
Compare movement on both sides when appropriate and note new limb or facial weakness.
New seizure activity
Seizure activity following a fall requires prompt clinical assessment and escalation.
Assess systematically after the fall
Airway
Check airway patency. Reduced consciousness can increase the risk of airway compromise.
Breathing
Assess respiratory rate, oxygen saturation, breathing pattern and work of breathing.
Circulation
Assess pulse, blood pressure, perfusion and evidence of bleeding or circulatory deterioration.
Disability
Assess consciousness, pupils and relevant neurological findings. Check blood glucose when clinically appropriate.
Exposure
Look for injury or bleeding and assess the wider patient while maintaining dignity and avoiding unnecessary movement.
Escalate
Escalate concerning neurological or physiological findings according to local emergency and post-fall procedures.
Trend matters more than one isolated observation
A patient may initially appear relatively well after a fall and then deteriorate. Reassessment helps identify change over time.
Compare repeated assessments
A declining level of responsiveness is more important than a single observation taken in isolation.
Watch for change
New differences in pupils should be interpreted alongside the rest of the neurological picture.
Look for new asymmetry
New weakness or altered movement compared with an earlier assessment should be escalated.
Listen for deterioration
New slurring or language difficulty may become apparent during repeat assessment.
Ask what is changing
New or worsening headache, nausea, vomiting, dizziness or visual symptoms should be communicated.
Connect neurological and physiological change
Use NEWS2 and ABCDE alongside neurological observations rather than treating them as separate assessments.
Important information to communicate
- Whether the fall was witnessed or unwitnessed.
- Approximate time of the fall.
- Whether the patient may have struck their head.
- Whether there was loss of consciousness or a period of unresponsiveness.
- Any seizure-like activity.
- Any new headache, vomiting, dizziness or visual disturbance.
- Any change in speech, strength, sensation, pupils or behaviour.
- The patient's usual cognitive and neurological baseline.
- Relevant medication history, including medicines that affect bleeding risk.
- Any deterioration in vital signs or NEWS2 observations.
When neurological change after a fall needs urgent escalation
- Reduced or deteriorating consciousness.
- New confusion or significant behavioural change.
- New limb or facial weakness.
- New speech or language disturbance.
- New pupil abnormality with neurological deterioration.
- New seizure activity.
- Severe or worsening headache.
- Repeated vomiting alongside neurological symptoms.
- New significant visual disturbance.
- Suspected significant head or neck injury.
- Abnormal breathing, circulation or other physiological deterioration.
- Any patient who appears seriously unwell after the fall.
Avoid creating additional harm
Do not rush to get the patient up
Assess for injury and follow local post-fall procedures before attempting mobilisation.
Prevent another fall
New weakness, dizziness, confusion or visual disturbance can make further mobilisation unsafe.
Seek appropriate help early
Ask for senior or emergency clinical support when the patient's condition or mechanism of injury causes concern.
A patient becomes drowsier after an unwitnessed fall
Example
An older patient is found on the floor beside their bed after an unwitnessed fall. Initially they are awake and talking.
During subsequent assessment you notice they are becoming increasingly drowsy and are slower to answer questions than they were shortly after the fall.
You also notice that they now report a worsening headache.
You recognise the pattern: recent fall + change in consciousness + worsening neurological symptom.
You repeat an ABCDE assessment, obtain appropriate observations and escalate the deterioration urgently according to local procedures.
Report the trend, not just the fall
Example escalation
“I'm concerned about Mrs Lewis following an unwitnessed fall at approximately 16:20. She was initially alert and speaking normally, but over the last 20 minutes she has become increasingly drowsy and is now reporting a worsening headache.”
This clearly communicates the mechanism, timeline, baseline and direction of neurological change.
Post-fall assessment errors to avoid
- Focusing only on visible injury and missing neurological change.
- Assuming a patient is safe because they initially appear well.
- Failing to establish the patient's neurological baseline.
- Not recognising that the fall itself may have resulted from acute deterioration.
- Ignoring new confusion or drowsiness in an older patient.
- Failing to trend neurological observations over time.
- Mobilising before appropriate assessment after a significant fall.
- Delaying escalation while trying to determine the exact diagnosis.
Protect → assess → compare → escalate
Prevent further harm
Keep the patient safe and avoid unnecessary movement until appropriate assessment has taken place.
Use ABCDE and neurological observations
Compare consciousness, pupils, speech, movement and symptoms with baseline and earlier findings.
Report deterioration promptly
Communicate what happened, what has changed and how the patient's condition is progressing.
Neurological deterioration is often recognised through change over time
Build confidence by establishing baseline, repeating appropriate observations and recognising when a patient's condition is moving in the wrong direction after a fall.
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