Post-operative fall - using an ABCDE assessment to identify risks

ANSWER: Call for help and perform an ABCDE assessment (primary survey)

Prioritisation during clinical emergencies

There are several things to prioritise in this type of scenario, including determining the cause of the fall, and assessing for any ongoing concerns, injuries and complications?

Both the ABCDE and DRSABC can be helpful to guide decision making for the first moments of response. As you enter the scene, scan the environment for any dangers including body fluids, obstacles and access. Call for additional help including appropriate equipment to extricate Marjory from the bathroom.

Any patient who has had a fall needs to be assessed for head and neck injuries. Maintaining C-spine immobilisation with manual in-line stabilisation until injuries can be assessed and cleared helps to reduce the risk of further injury. Further assessment to determine the risk of cerebral bleed should include a review of medications such as antiplatelet, and antithrombolitic. We know that Marjory is on a DOAC - and this may increase her risk of bleeding.

After using the hover-jack and hover-mat to get Majory from the bathroom floor to her bed safely. A primary and secondary survey using the ABCDE assessment tool is conducted to determine the cause of the fall, if there are any further injuries and to prioritise her care.

A - Airway

Look: no facial trauma or swelling. No drooling or cyanosis

Listen: Majory is speaking clearly indicating a patient airway

Feel: trachea is midline

Interpretation: Airway is currently intact. No immediate intervention required. - Move on to assess B

B - Breathing

Look: respiratory rate 22, equal chest rise, no signs of respiratory distress

Listen: clear breath sounds bilaterally

Feel: chest expansion is symmetrical. No subcutaneous emphysema

Interpretation: No compromise in breathing. Continue to monitor, especially given the anticoagulant therapy which increases the risk of bleeding complications such as pulmonary contusion in blunt trauma. Move on to assess C

C - Circulation

Look: pale, no visible external bleeding. No bruising noted yet (ongoing assessment)

Listen: heart sounds present and regular - S1 S2

Feel: peripheral pulses equal, irregular, capillary refill 3 seconds, BP 105/65, HR 108

Interpretation: Red Flag - Marjory is on xarelto so occult bleeding (e.g. retroperitoneal or into the surgical site) must be considered. She is pale, tachycardic and hypotensive. Check Hb, consider fluid bolus monitor for delayed haematoma or signs of internal bleeding. Cardiac monitoring for irregular pulse.

D - Disability

Look: pupils equal and reactive to light

Listen: Marjory is oriented to person, place and time. No slurred speech or confusion

Feel: no motor deficits, reports pain 6/10 at surgical site, no limb weakness

Interpretation: Concern - Neurological status is normal, but Marjory has increased pain at surgical site, combined with her circulation status, this could be an indication of bleeding. Ongoing assessment for possible head injury is also important due to her fall and anticoagulation status

E - Exposure

Look: visual inspection reveals no head wound or lacerations. bruising over the hip noted 

Feel: tenderness around the surgical site with mild swelling

Measure: Temp 35.9oC

Interpretation: Possible surgical site bleed or infection, organise imaging (x-ray of hip and CT head due to fall + anticoagulant therapy), bloods including full blood count and coagulation profile, 12 lead ECG due to irregular pulse

Communicating findings of ABCDE assessment

The ABCDE assessment tool provides a clear, structured approach that supports early recognition of deterioration. In high-risk situations like Majory’s - recent THR, anticoagulation, and a fall - a systematic approach enables rapid escalation of care.  Communication of the identified concerns and flags for Marjory should be via a clinical handover tool like ISBAR. From the assessment conducted, the clinical concerns that may have led to the fall or now be as a result of the fall include:

• post-operative bleeding at surgical site

• post-operative infection and sepsis

• head injury/bleed

• syncope from arrhythmia

Learn more and apply this approach to patient case studies in the following courses:

PREPARED

Lunch & Learn - Met call mayhem

Lunch & Learn - Anticoagulant management in surgical patients