›Temperature 38.0 C or higher with concerning source
High risk head injury features
›High risk head injury features
›GCS under 15 at 2 hours
›Repeated vomiting
›Severe worsening headache
›New focal neurologic deficit
›Suspected open skull fracture
›Basilar skull fracture signs
›Anticoagulated or bleeding disorder
High risk spine and neuro features
›High risk spine and neuro features
›Midline cervical tenderness
›Neurologic deficit
›Paresthesias
›New bowel or bladder dysfunction
›High energy mechanism
›Intoxication with unreliable exam
High risk orthopedic and bleeding features
›High risk orthopedic and bleeding features
›Open fracture
›Compartment syndrome concern
›Hip pain with inability to bear weight
›Pelvic instability
›Anticoagulant associated hematoma expanding
03Medications/meds26
Medication reconciliation
›Medication reconciliation
›Anticoagulants
›Antiplatelets
›Insulin and hypoglycemics
›Antihypertensives
›Diuretics
›Opioids
›Benzodiazepines
›Antidepressants
›Antipsychotics
›Antiepileptics
Recent changes and adherence
›Recent changes and adherence
›New medication within 7 days
›Dose increase within 7 days
›Missed doses
›Double dosing
High risk interaction and reversal considerations
›High risk interaction and reversal considerations
›Warfarin
›Bleeding risk
›INR guided management local protocol dependent
›DOAC
›Bleeding risk
›Specific reversal agent availability local protocol dependent
›Sedatives
›Fall risk
›Delirium risk
04Diet/diet13
Intake and hydration
›Intake and hydration
›Poor oral intake
›Vomiting
›Diarrhea
›Dehydration symptoms
Alcohol and substances
›Alcohol and substances
›Recent alcohol
›Cannabis
›Stimulants
›Opioid use
Caffeine and energy drinks
›Caffeine and energy drinks
›Heavy caffeine use
›Energy drinks
05Review of Systems/ros29
Neurologic
›Neurologic
›Headache
›Confusion
›Seizure
›Weakness
›Numbness
›Speech difficulty
›Vision change
›Gait change
Cardiopulmonary
›Cardiopulmonary
›Chest pain
›Palpitations
›Dyspnea
›Orthopnea
›Hemoptysis
Infectious and inflammatory
›Infectious and inflammatory
›Fever
›Chills
›Dysuria
›Cough
›New rash
Musculoskeletal
›Musculoskeletal
›Neck pain
›Back pain
›Hip pain
›Knee pain
›Ankle pain
›Wrist pain
›Shoulder pain
06Collateral History and Family History/chafh14
Collateral source and reliability
›Collateral source and reliability
›Witness account
›EMS report
›Family report
›Video evidence
Family history relevant to fall and syncope
›Family history relevant to fall and syncope
›Sudden cardiac death
›Inherited arrhythmia syndromes
›Early coronary disease
Social support and supervision
›Social support and supervision
›Lives alone
›Caregiver availability
›Baseline cognitive impairment
›Home safety concerns
07Risk Factors/rf23
Falls risk and frailty
›Falls risk and frailty
›Age 65 or older
›Prior falls
›Mobility impairment
›Visual impairment
›Polypharmacy
›Dementia
Bleeding and bone health risk
›Bleeding and bone health risk
›Anticoagulation
›Antiplatelet therapy
›Thrombocytopenia history
›Osteoporosis
›Chronic steroid use
Syncope and arrhythmia risk
›Syncope and arrhythmia risk
›Structural heart disease
›Heart failure
›Known arrhythmia
›Family sudden death
Environmental and exposure risks
›Environmental and exposure risks
›Ice and slip hazard
›Poor lighting
›Workplace fall risk
›Intoxication exposure
08Differential Diagnosis/ddx51
Life threatening
›Life threatening
›Intracranial hemorrhage
›Anticoagulation increases risk
›Worsening headache
›Cervical spine fracture
›Midline tenderness
›Neurologic deficit
›Hip fracture
›Inability to bear weight
›Shortened externally rotated leg
›Pelvic fracture with hemorrhage
›Hemodynamic instability
›Pelvic pain
›Cardiac syncope
›Exertional syncope
›Abnormal ECG
›Aortic stenosis
›Exertional syncope
›Systolic murmur
Common
›Common
›Mechanical trip and fall
›Clear environmental trigger
›No prodrome
›Vasovagal syncope
›Prodrome
›Triggered by pain or emotion
›Orthostatic hypotension
›Standing trigger
›Volume depletion
›Concussion
›Headache
›Photophobia
›Soft tissue contusion
›Localized tenderness
›Preserved function
Less common
›Less common
›Seizure
›Post event confusion
›Tongue bite
›Stroke or TIA
›Focal deficits
›Speech disturbance
›Hypoglycemia
›Diaphoresis
›Altered mental status
›Medication adverse effect
›Sedatives
›Antihypertensives
›Pulmonary embolism
›Dyspnea
›Pleuritic chest pain
09Past Medical History/pmh18
Chronic conditions and baseline
›Chronic conditions and baseline
›Coronary artery disease (I25.10)
›Heart failure (I50.9)
›Atrial fibrillation (I48.91)
›Seizure disorder (G40.909)
›Diabetes mellitus type 2 (E11.9)
›Chronic kidney disease (N18.9)
›Osteoporosis (M81.0)
›Dementia (F03.90)
Prior procedures and devices
›Prior procedures and devices
›Pacemaker
›ICD
›Valve replacement
›Recent surgery within 30 days
Prior injuries and recovery
›Prior injuries and recovery
›Prior hip fracture
›Prior intracranial bleed
›Prior cervical spine injury
10Physical Exam/exam49
Initial survey and general
›Initial survey and general
›Airway patency
›Work of breathing
›Perfusion
›Mental status
›Pain behaviors
Vital signs interpretation
›Vital signs interpretation
›Orthostatic vitals when safe
›Fever pattern
›Persistent tachycardia
Head and face
›Head and face
›Scalp hematoma
›Lacerations
›Periorbital ecchymosis
›Hemotympanum
›Septal hematoma
Neck and spine
›Neck and spine
›Midline cervical tenderness
›Range of motion limitation
›Thoracolumbar tenderness
›Step offs
Neurologic
›Neurologic
›GCS components
›Pupils size and reactivity
›Cranial nerves gross screen
›Motor strength symmetry
›Sensation to light touch
›Coordination
›Gait if safe
Cardiopulmonary
›Cardiopulmonary
›Heart rate and rhythm
›New murmurs
›Lung sounds
›Chest wall tenderness
Abdomen and pelvis
›Abdomen and pelvis
›Abdominal tenderness
›Seatbelt sign
›Pelvic stability
Extremities and skin
›Extremities and skin
›Deformity
›Point tenderness
›Range of motion
›Neurovascular status distal
›Compartment firmness
›Skin tears
Pitfalls and subtle findings
›Pitfalls and subtle findings
›Occult hip fracture with normal x ray
›Delayed intracranial hemorrhage risk in anticoagulated
›Distracting injury masking spine pain
11Lab Studies/labs19
Core screening based on presentation
›Core screening based on presentation
›Point of care glucose
›CBC
›Electrolytes
›Creatinine
Bleeding and anticoagulation assessment
›Bleeding and anticoagulation assessment
›INR for warfarin
›Platelets
›Type and screen if major trauma concern
Cardiac and syncope workup when indicated
›Cardiac and syncope workup when indicated
›Troponin when ACS concern
›BNP when heart failure concern
›Magnesium for QT risk
Infection and metabolic triggers when indicated
›Infection and metabolic triggers when indicated
›Urinalysis when urinary symptoms or delirium
›TSH when unexplained bradycardia or arrhythmia concern
Interpretation pitfalls
›Interpretation pitfalls
›Troponin elevation non ACS etiologies
›Normal labs do not exclude intracranial hemorrhage
12Imaging/img41
Scoring Systems
›Clinical decision tools for imaging
›Canadian CT Head Rule
›Use in minor head injury with GCS 13 to 15 and loss of consciousness or amnesia or disorientation
›High risk factors include age over 65 and suspected open skull fracture and basilar skull fracture signs and vomiting more than 2 and GCS under 15 at 2 hours
›Not validated in anticoagulated patients
›New Orleans Criteria
›Alternative minor head injury rule
›Tends to increase CT utilization compared with Canadian CT Head Rule
›Canadian C Spine Rule
›Use in alert stable trauma patients
›High risk factors include age 65 or older and dangerous mechanism and paresthesias
›NEXUS C Spine
›Imaging if any of midline tenderness or intoxication or altered alertness or focal neurologic deficit or distracting injury
›Caution in older adults
›Ottawa Ankle Rules
›Ankle x ray criteria include malleolar zone pain plus bone tenderness or inability to bear weight
›Foot x ray criteria include midfoot pain plus base of fifth metatarsal or navicular tenderness or inability to bear weight
›Ottawa Knee Rule
›Knee x ray criteria include age 55 or older or isolated patellar tenderness or fibular head tenderness or inability to flex to 90 or inability to bear weight
MRI
›MRI indications after fall
›Occult hip fracture suspected with negative x ray
›Spinal cord injury concern with normal CT
›Ligamentous cervical injury concern with persistent midline pain and negative CT local protocol dependent
›Contraindications screening
›Non compatible implanted device
›Unstable patient
CT
›CT indications after fall
›CT head for high risk head injury features
›CT cervical spine for high risk criteria or unreliable exam
›CT chest abdomen pelvis for high energy trauma or concerning exam
›Contrast considerations
›Prior severe contrast reaction
›Renal impairment risk assessment local protocol dependent
Ultrasound
›Ultrasound applications after fall
›eFAST in significant trauma
›POCUS cardiac in syncope with shock
›POCUS lung for pneumothorax
›DVT ultrasound when leg swelling and PE concern
›Pitfalls
›FAST sensitivity lower in early small volume bleeding
›Operator dependent findings
13Special Tests/spec12
Bedside maneuvers and functional tests
›Bedside maneuvers and functional tests
›Orthostatic blood pressure and heart rate
›Dix Hallpike when positional vertigo suspected
›Romberg
›Timed up and go when safe
Neuro and concussion screening
›Neuro and concussion screening
›Serial GCS
›Symptom triggered neuro checks
›Vestibulo ocular symptom triggers
Procedural diagnostics
›Procedural diagnostics
›Wound exploration for foreign body concern
›Joint aspiration when septic arthritis concern after fall related trauma
14ECG/ecg20
When to obtain
›When to obtain
›Syncope or presyncope
›Palpitations
›Chest pain
›Dyspnea
High risk patterns
›High risk patterns
›ST elevation or depression
›New left bundle branch block
›Brugada pattern
›Pre excitation
›QT prolongation
›High grade AV block
›Ventricular tachycardia
Rhythm interpretation pearls
›Rhythm interpretation pearls
›Atrial fibrillation with rapid ventricular response
›Bradycardia with pauses
›Frequent ectopy
Serial ECG logic
›Serial ECG logic
›Repeat if ongoing symptoms
›Repeat with troponin pathway when ACS concern
15Assessment/ax22
Problem representation
›Problem representation
›Mechanical fall with isolated injury pattern
›Fall with possible syncope
›Fall with altered mental status
Working diagnoses with codes when applicable
›Working diagnoses with codes when applicable
›Concussion without loss of consciousness (S06.0X0)
›Traumatic intracranial hemorrhage suspected
›Cervical strain (S16.1)
›Hip fracture suspected (S72.00)
›Syncope and collapse (R55)
Severity and risk stratification
›Severity and risk stratification
›Head injury risk high if anticoagulated or neuro deficit
›Spine injury risk high if midline tenderness or neuro deficit
›Hip fracture risk high if unable to bear weight
Complications to rule out
›Complications to rule out
›Delayed intracranial hemorrhage
›Rhabdomyolysis after prolonged down time
›Compartment syndrome
Uncertainty and alternatives
›Uncertainty and alternatives
›Mixed mechanism
›Medication contribution
›Occult infection contribution
16Plan/plan33
Approach to the critical patient
›Approach to the critical patient
›First 5 minutes workflow
›Continuous monitoring
›Two large bore IV if shock concern
›Point of care glucose within minutes if altered mental status
›ECG within 10 minutes if syncope with concerning features
›Immediate actions if unstable
›If systolic blood pressure under 90 mmHg then resuscitation bay
›If oxygen saturation under 90 percent then oxygen titration
›If GCS under 13 then airway readiness and CT head trigger
Diagnostic sequencing
›Diagnostic sequencing
›Imaging guided by decision tools and red flags
›Labs guided by syncope and bleeding risk
›Reassessment loop
›Repeat vitals within 30 to 60 minutes
›Repeat neuro exam after analgesia and after imaging
Therapeutics and symptom control
›Therapeutics and symptom control
›Acetaminophen PO 1000 mg once
›Ibuprofen PO 400 mg once
›Avoid NSAIDs if significant bleeding risk or severe renal disease
›Ondansetron ODT 4 mg once for nausea
Anticoagulation related management
›Anticoagulation related management
›Head strike on anticoagulation
›Low threshold CT head local protocol dependent
›Observation consideration local protocol dependent
›Major bleeding concern
›Reversal pathway local protocol dependent
›Hematology consult threshold local protocol dependent
Consults
›Consults
›Trauma surgery for major mechanism or multi system injury
›Neurosurgery for intracranial hemorrhage
›Orthopedics for suspected hip fracture
›Cardiology for high risk syncope features
17Disposition/dispo23
ICU criteria
›ICU criteria
›Need for airway or ventilatory support
›Persistent shock despite initial resuscitation
›Intracranial hemorrhage with declining exam
Inpatient admission criteria
›Inpatient admission criteria
›Intracranial hemorrhage on imaging
›Unstable fracture requiring operative management
›New neurologic deficit
›High risk syncope features with abnormal ECG
›Inability to ambulate safely
Observation pathway criteria
›Observation pathway criteria
›Concussion symptoms requiring serial neuro checks
›Syncope evaluation with intermediate risk features
›Pain control and mobility reassessment
Discharge criteria
›Discharge criteria
›Normal mental status at baseline
›Stable vitals
›No concerning imaging findings
›Ambulation safe with baseline device
›Reliable supervision and follow up
Time sensitive considerations
›Time sensitive considerations
›Older adults higher occult injury risk
›Anticoagulated head strike delayed bleed risk local protocol dependent
18Discharge Instructions/di23
Copy discharge instructions
›Copy discharge instructions
›You were seen today after a fall
›Your tests did not show an emergency injury that needs admission today
›Pain control
›Acetaminophen as directed on label
›Avoid NSAIDs if you take blood thinners or have kidney disease unless told otherwise
›Activity
›Rest today
›No driving if dizzy or drowsy from medications
›Avoid alcohol for 24 hours
›Head injury precautions
›Return now for worsening headache
›Return now for repeated vomiting
›Return now for confusion
›Return now for weakness or numbness
›Return now for seizure
›Bleeding precautions if on blood thinners
›Return now for new severe headache
›Return now for new vomiting
›Return now for new confusion
›Follow up
›Primary care follow up within 2 to 7 days
›Earlier follow up within 24 to 72 hours if dizziness or repeated falls
19References/r7
Guidelines and decision tools
›Guidelines and decision tools
›NICE Head injury assessment and early management NG232 2023
›Stiell IG et al Canadian CT Head Rule derivation 2001
›Stiell IG et al Canadian C Spine Rule derivation 2001
›Hoffman JR et al NEXUS cervical spine rule 2000
›Ottawa Ankle Rules validation studies 1990s
›American College of Surgeons best practices guidelines spine injury
Evidence & Review
Reviewed by SymptomDx Medical Team·Last reviewed
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.