Post-Fall Red Flags
Findings that should prompt provider notification, escalation, or transfer. Use alongside facility policy.
Critical — transfer / immediate action High — urgent provider eval Moderate — investigate cause
Neurologic
CNS injury indicators — lowest threshold for transfer.
| Finding | Criteria | Action | Severity |
|---|---|---|---|
| Loss of consciousness | Any duration, witnessed or suspected | Transfer + CT head | CRITICAL |
| GCS < 15 | Any decrease from baseline | Transfer + CT head | CRITICAL |
| Focal deficit | New weakness, facial droop, slurred speech | Transfer — stroke workup | CRITICAL |
| Abnormal pupils | Asymmetry, sluggish/non-reactive | Transfer — possible ↑ICP | CRITICAL |
| Post-fall seizure | Any seizure activity after fall | Transfer + neuro imaging | CRITICAL |
| Severe headache | Sudden onset, worst-ever, or escalating | Provider eval; consider CT | HIGH |
| Vomiting | ≥1 episode post-fall, no other cause | Provider eval; consider CT | HIGH |
Head Strike + Anticoagulation
Combined risk dramatically elevates delayed bleed risk.
| Finding | Criteria | Action | Severity |
|---|---|---|---|
| Head strike on anticoagulant | Warfarin, DOAC, heparin, dual antiplatelet | Transfer — even if asymptomatic; observe ≥24h | CRITICAL |
| Unwitnessed fall + suspected head strike | Found on floor, mechanism unclear | Treat as head strike | HIGH |
| Scalp hematoma, large | >2 cm or boggy | Provider eval; CT consideration | HIGH |
Musculoskeletal
Suspect fracture if mechanism + pain + functional loss.
| Finding | Criteria | Action | Severity |
|---|---|---|---|
| C-spine tenderness | Midline tenderness or pain on movement | Immobilize + transfer for imaging | CRITICAL |
| Hip pain / shortened-rotated leg | Classic hip fracture presentation | Do not mobilize; transfer for imaging | HIGH |
| Unable to bear weight | New inability vs. baseline | Imaging before mobilization | HIGH |
| Obvious deformity | Visible angulation, open wound | Immobilize; transfer | HIGH |
Vital Signs
May identify cause (syncope, sepsis) or consequence of fall.
| Finding | Criteria | Action | Severity |
|---|---|---|---|
| SBP < 90 or > 200 | Outside safe range | Provider notification urgently | HIGH |
| HR < 50 or > 120 | Brady/tachycardia | ECG; provider eval | HIGH |
| RR < 10 or > 24 | Respiratory compromise | Provider eval; O₂ as needed | HIGH |
| SpO₂ < 92% | Hypoxemia on room air | Supplement O₂; provider eval | HIGH |
| Glucose < 70 or > 400 | Hypo/hyperglycemia | Treat per protocol; investigate cause | MODERATE |
| Orthostatic changes | SBP drop ≥20 or DBP ≥10 on standing | Hydration review; med review | MODERATE |