Patient founded on the floor. Long Lye.

When an elderly patient is found on the floor after spending a prolonged period lying on a hard surface, it raises concerns about potential complications such as rhabdomyolysis, dehydration, pressure sores, and hypothermia. As a junior doctor in the emergency department (ED), it is crucial to assess and manage these patients promptly and comprehensively.

Initial Assessment

History Taking

• Duration on the Floor: Determine how long the patient was on the floor.

• Reason for Fall: Explore whether the fall was due to a trip, syncope, or another medical event.

• Symptoms Before and After the Fall: Ask about any dizziness, weakness, or loss of consciousness before the fall and any pain or inability to move afterward.

• Medical History: Review chronic conditions such as cardiovascular disease, diabetes, or neurological disorders.

• Medication Review: Identify medications that may contribute to falls or prolonged immobility.

Physical Examination

• Vital Signs: Check for hypotension, tachycardia, hypothermia, or fever.

• Neurological Assessment: Evaluate for any focal deficits or signs of head injury.

• Musculoskeletal Examination: Inspect for signs of fractures (e.g., hip fractures) or joint dislocations.

• Skin Examination: Look for pressure sores or signs of skin breakdown.

• General Condition: Assess for signs of dehydration or malnutrition.

Diagnostic Workup

• Blood Tests:

  • Complete Blood Count (CBC): To assess for infection or anemia.

  • Electrolytes and Renal Function Tests: To evaluate for dehydration and kidney function.

  • Creatine Kinase (CK): To check for rhabdomyolysis due to prolonged immobility.

  • Liver Function Tests: To assess overall metabolic status.

• Electrocardiogram (ECG): To rule out cardiac causes such as arrhythmias.

• Imaging: Perform X-rays if fractures are suspected; a CT scan may be necessary if there is a head injury or altered mental status.

Management Strategies

Immediate Care

1. Stabilization:

   • Ensure airway patency and provide supplemental oxygen if needed.

   • Establish intravenous access for fluid resuscitation to address dehydration and potential rhabdomyolysis.

2. Address Acute Injuries:

   • Immobilize fractures with appropriate splinting and provide pain management.

   • Treat pressure sores with appropriate wound care.

3. Monitor for Complications:

   • Monitor urine output and renal function closely in cases of suspected rhabdomyolysis.

   • Address electrolyte imbalances promptly.

Supportive Care

1. Rewarming Measures: If hypothermia is present, use warm blankets and fluids to gradually rewarm the patient.

2. Nutritional Support: Provide nutritional support if there are signs of malnutrition.

Monitoring and Follow-up

• Continuous monitoring in the ED for any deterioration in clinical status.

• Arrange follow-up with primary care or geriatric services for comprehensive assessment and management of fall risk factors and prevention strategies.

Challenges and Considerations

Prolonged immobility in elderly patients can lead to serious complications such as rhabdomyolysis, acute kidney injury, pressure ulcers, and hypothermia. It is crucial to address both immediate medical needs and underlying causes that contributed to the fall. Comprehensive discharge planning with a focus on preventing future falls is essential.

By taking a systematic approach to the assessment and management of elderly patients found on the floor after prolonged immobility, you can effectively address immediate concerns while ensuring appropriate follow-up care.