Key learning points:
– The impact of a fall and falls related injury
– How to manage a falls related bleed
– Managing a falls related bleed in a patient on anticoagulation
Falls are a major public health problem; according to data from the World Health Organisation there are an estimated 424,000 fatal falls that occur each year and approximately 37.3 million falls that are significant enough to require medical attention.1 It is predicted that in the year 2030, if current trends continue falls related injuries will be 100% higher. The next section of this article will focus on the management of bleeding as a result of a fall.
Management of bleeding
Uncontrolled bleeding is responsible for 40% of early in hospital trauma mortality2 and is the principle cause of preventable death.3 Older patients are more liable to injury from minor mechanisms and less able to compensate from any injury. Older patients are also more likely to take several medications, some of which may blunt their response to the physiologic stress of trauma and result in an increase of risk for complications.4
Haemorrhage is the most common cause of shock in the injured patient.5 The Advanced Trauma Life Support (ATLS) manual describes four classes of haemorrhage to highlight the early signs of the shock state. It is important that healthcare professionals are aware that significant drops in blood pressure are generally not exhibited until class III haemorrhage develops, and up to 30% of a patient's blood volume can be lost before this occurs.6 The British Committee for Standards in Haematology state that arbitrary definitions of major bleeding may be difficult to apply in an emergency situation and are not particularly helpful because they are retrospective. “Our arbitrary definition for major haemorrhage is bleeding which leads to a heart rate more than 110 beats/min and/or systolic blood pressure less than 90 mmHg.”7 Severe traumatic injury and haemorrhagic shock are often related with disruptions of coagulation function, such as trauma-induced coagulopathy and activation of inflammatory cascades. Trauma-induced coagulopathy is associated with 4-fold increase in mortality, increased rates of late death from sepsis and multiple organ failure, and worsened outcomes from traumatic brain injury.8
The first step in pre hospital management of the patient in shock is recognition.9 However; recognising shock in geriatric patients is more difficult as they are more likely to take medications that affect the haemodynamic response to injury e.g. beta blockers. Therefore, it is important that healthcare professionals take into consideration the patient’s normal baseline during assessment.10
A systematic approach for assessing the patient is advised in order to recognise life threatening conditions, identifying injuries and determining priorities of care based on assessment findings.11 Guidelines published by the United States Centers for Disease Control (CDC) call for direct transfer to a trauma centre for any patient 65 or older with a systolic blood pressure <110 mmHg measurement post injury.12
Regardless of the bleeding or wound type, the primary intervention by healthcare professionals is to control bleeding. Bleeding can occur internally, where blood leaks from blood vessels inside the body, or externally, either through a natural opening such as the mouth, nose, ear, or through a break in the skin. Bleeding can be classified into three types: arterial, venous and capillary.
The American Heart Association and Red Cross Association have produced guidelines in first aid and make the following recommendations in relation to the control of bleeding:
1. Direct pressure
The control of bleeding is most effective with the application of direct pressure until the bleeding stops or emergency rescuers arrive.
– Manual pressure should be applied over the site of bleeding using gauze. It is recommended that the gauze should not be removed; additional gauze should be applied if bleeding continues.
– In circumstances where a healthcare provider cannot maintain continuous manual pressure, an elastic bandage can be placed over the gauze to ensure it stays in place.
There is evidence that use of tourniquets can control bleeding effectively during surgery and when used by trained paramedics. However, there are no studies on control of bleeding without complication when used by first aid providers. Potential risks of prolonged use of tourniquets include temporary or permanent harm to the underlying muscles and nerves, and complications resulting from limb ischaemia. It is only recommended to use a tourniquet when direct pressure is not successful or possible. The use of a tourniquet should only be by personnel who have had proper training. If a tourniquet is applied, ensure that the time of application is documented and emergency service personnel are informed.
3. Pressure points and elevation
Pressure points and elevation are not recommended to control bleeding. Evidence suggests that other methods of bleeding control are more valuable. There have been no studies on the haemostatic effect of elevation. The use of pressure points was found to be ineffective on distal pulses and the use of these unproven procedures could be harmful to the patient. These procedures may also compromise the use of direct pressure which has proven to be effective.13
Skin wounds and abrasions
Apart from those wounds requiring intervention due to significant bleeding; wound irrigation may be considered the most important intervention for enhancing wound healing. Wound irrigation and exploration may assist in the identification of the specific bleeding site. This will inform the healthcare provider of any acute surgical concerns. Wound healing is optimised through immediate evidence-based wound management and involves the removal of harmful debris, exploration of underlying issues, limiting infection risk and appropriate wound closure.14 In the older patient the aging changes result in a loss of thermoregulatory abilities, an impaired barrier to infection, and prolonged wound healing.11
Traumatic brain injury
A traumatic brain injury is one that interrupts the normal function of the brain. It may be as a result of a blow or a jerk to the head or a penetrating head injury.15 The normal aging process results in decreased cerebral flow. Brain mass shrinks with cerebral atrophy, and the dura adheres more tightly to the skull. The bridging veins are more stretched between the brain and the dura, making older people more susceptible to injury. In addition, older adults have a higher incidence of coagulopathies as well as co morbid conditions treated with anticoagulant medications. For these reasons, a minor blow to the head may result in a subdural haematoma.11 Coagulopathy in patients with severe traumatic brain injury requires rapid reversal to allow for safe neurosurgical intervention and prevents worsening of the primary injury. Reversal of coagulopathy is accomplished with the use of plasma or recombinant factor VIIa.3 A neurological examination, including Glasgow Coma Scale, should be completed as soon as possible to establish the clinical severity of a traumatic brain injury. Signs of neurological deterioration include complaints of a worsening headache, confusion, focal neurological signs and lethargy that may advance to loss of consciousness.17 Patients that have sustained a traumatic brain injury should be assessed for cervical spine injury with or without neurological deficits.5 In nearly all cases of head trauma in geriatric patients, it is prudent to obtain a computerised axial tomography (CT) scan of the head.18 The primary goal of pre hospital management for severe head injury is to prevent hypotension and hypoxia. Prevention of hypotension in the pre hospital setting is best achieved by adequate fluid resuscitation using isotonic crystalloids.19 An aggressive treatment approach is advised with the older patient to ensure the best long-term survival and functional outcomes.11
Anticoagulation, falls and bleeding
While falls risk is not a contraindication to the use of oral anticoagulation, it should only be considered after a full risk/benefit analysis. It is reported that a patient needs to fall approximately 300 times per year for the risk of intracranial haemorrhage to outweigh the benefit of oral anticoagulants in stroke prevention.20 It is assumed that a similar risk would apply to the use of novel oral anticoagulants. However, if a patient does have a bleed secondary to a fall while on oral anticoagulation the following advice applies:
Patients with non-major bleeding can be managed with a reduction or temporary discontinuation of warfarin alongside the use of vitamin K. For bleeding in the mouth, antifibrinolytic drugs e.g. tranexamic acid mouthwash, are often useful. All patients on warfarin presenting in emergency departments with any type of head injury require an international normalised ratio (INR) check. If an intracerebral haematoma is suspected the patient should have their INR reversed immediately with prothombin precipitate even before the CT and INR results are available. In the event of a major bleed anticoagulation reversal should be immediate and achieved with the use of intravenous vitamin K and prothrombin complex concentrate.21
Other oral antithrombotic agents
There is no fully effective antidote available for use in patients with major or life-threatening bleeding on dabigatran, rivaroxaban or apixaban.
For minor bleeding, in view of the short half-life, supportive measures should be tried, such as direct pressure, minor surgical intervention and fluid replacement. In situations with ongoing life-threatening bleeding, prothombin precipitate complex, activated prothrombin complex concentrate and recombinant human factor FVIIa should be considered.22
Falls and risk assessment
Patients attending healthcare professionals for bleeding injuries post fall present an opportunity for healthcare professionals to assess risk, intervene and reduce future falls. Amnesia for loss of consciousness is a common feature in elderly patients. One study demonstrated that 42% of adults over the age of 60 had amnesia for loss of consciousness during an induced vasovagal episode.23 A witness account may only be available in approximately 40% of elderly patients who have a fall; it is important to obtain this when it is available.24 The witness account will help establish the presence or absence of loss of consciousness in order to place the patient on the correct pathway for investigations. Often there is more than one risk factor present and falls in older adults are often not attributable to one single cause. Falls in older adults can often occur when there is the addition of a falls risk in a person with age related issues such as gait or balance difficulties or neurocardiovascular instability.25 According to recommendations by The National Institute for Health and Care Excellence (NICE) all older patients in touch with healthcare professionals should be questioned routinely about any falls they may have had in the past year.26 If they attend due to a fall or a falls related injury they should be offered a multifactorial falls risk assessment.
1. World Health Organization. WHO global report on falls prevention in older age. Geneva, Switzerland: 2007.
2. Sauaia A. Moore FA. Moore EE et al. Epidemiology of trauma deaths: a reassessment. Journal of Trauma 1995; 38:185-193.
3. Gruen RL. Jurkovich GJ. McIntyre LK et al. patterns of errors contributing to trauma mortality: lessons learned from 2,594 deaths. Annals of Surgery 2006: 244;371-380.
4. Jacobs DG. Special considerations in geriatric injury. Current Opinion Critical Care 2003;6:535-9.
5. American College of Surgeons Committee on Trauma. Shock: In Advanced trauma life support for doctors (Student Course manual) 7th Edition; Chicago; American College of Surgeons Committee; 2004.
6. American College of Surgeons. Advanced Trauma Life Support (Student Manual). Chicago: American College of Surgeons: 1997.
7. Hunt JB. Allard S. Keeling D et al. A practical guideline for the haematological management of major haemorrhage. British
Journal of Haematology 2015. DOI: 10.1111/bjh.13580 (accessed 1 September 2015).
8. Reynolds SP. Michael JM. Cochran DE et al. Prehospital use of plasma in traumatic hemorrhage (The PUPTH Trial): study protocol for a randomised controlled trial. Trials 2015;16:321.
9. Parks JK. Elliot AC. Gentilello LM et al. Systemic hypotension is a late marker of shock after trauma: a validation study of advanced Trauma Life Support principles in a large national sample. The American Journal of Surgery 2006: 192:727.
10. Oyetunji TA. Chang DC. Crompton JG et al. Redefining hypotension in the elderly: normotension is not reassuring. Archives of Surgery 2011;146:865.
11. Emergency Nurses Association. Trauma Nursing Core Course (TNCC) Provider Manual (6th ed); Des Plaines, IL. Emergency Nurses Association: 2007.
12. Sasser SM, Hunt RC, Faul M, et al. Guidelines for field triage of injured patients: recommendations of the National Expert Panel on Field Triage, 2011. MMWR Recommendations and Reports 2012; 61:1.
13. Markensen D. Ferguson GD. Chameides L et al. First aid: 2010, American Heart Association and American Redcross Guidelines for First Aid. Circulation 2010: 122;S934-S946.
14. Nicks AB. Ayello AE. Woo K et al. Acute Wound Management: Revisiting the approach to assessment, irrigation, and closure considerations. Internal Journal of Emergency Medicine 2010; 3:399-407.
15. Marr, A.L., and Coronado, V.G. Central nervous system injury surveillance data submission standards. Atlanta, GA. Centers for Disease Control and Prevention; National Center for Injury. Prevention and Control: 2004.
16. Stein DM. Dutton RP. Kramer ME et al. reversal of Coaguopathy in critically ill patients with traumatic brain injury: recombinant factor VIIa
is more cost-effective than plasma. The Journal of Trauma 2009;66(1):63-72.
17. Liau LM, Bergsneider M, Becker DP. Pathology and pathophysiology of head injury. In: Neurological surgery: A comprehensive reference guide to the diagnosis and management of neurosurgical problems, 4th ed. Philadelphia: Saunders; 1996.
18. Mack LR. Chan SB. Silva JC at al. the use of head computed tomography in elderly patients sustaining minor head Trauma. The Journal of Emergency Medicine 2003;24:157.
19. Cooper DJ. Myles PS. McDermott FT et al. Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury: a randomized control trial. JAMA 2004;291:1350.
20. The task force for the management of atrial fibrillation of the European society of cardiology. Guidelines for the management of atrial fibrillation. European Heart Journal 2010; 31: 2369-2429..
21. Keeling D. Baglin T. Tait C et al. Guidelines on oral anticoagulation with warfarin – fourth edition. British Journal of Haematology 2011;154: 311–324.
22. Makris M. Van Veen JJ. Tait C et al. Guidelines on the management of bleeding of patients on antithrombotic agents. British Journal of Haemotology 2012:160;35-46.
23. O'Dwyer C. Bennett K. Langan Y et al. Amnesia for loss of consciousness is common in vasovagal syncope. Europace 2011;13:1041-1045.
24. McIntosh S. Da Costa D. Kenny RA. Outcome of an integrated approach to the investigation of dizziness, falls and syncope in elderly patients referred to a ‘syncope’ clinic. Age Ageing 1993;22:53–8.
25. Tinetti ME. Inouye SK. Gill TM et al. Shared risk factors for falls, incontinence, and functional dependence. Unifying the approach to geriatric syndromes. JAMA 1995;273:1348.
26. National Institute for Clinical Excellence. Falls: assessment and prevention of falls in older people, 2013. nice.org.uk/guidance/cg161/chapter/about-this-guideline (accessed 1 September 2015).
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