Weakness, Paralysis & Falls

“What if I fall?”, Tim cried.
Maerlyn laughed. “Sooner or later, we all do.”
— Stephen King, The Wind Through the Keyhole

CAP 13 – Falls

EM Curriculum: (click to view)


Each year in the UK there are approximately:

  • 650,000 older people attending emergency departments for fall-related injuries, and

  • 82,000 hip fractures

Falls cost the NHS billions of pounds, therefore preventing falls is a national priority.

People who have fallen should have a basic assessment. A multi-factorial assessment is required if the patient has an abnormal gait and balance, or if they have fallen more than once in the last 12 months.


Approximately 20,000 transient ischaemic attacks (TIAs) occur each year in England. Making the diagnosis of TIA is important because the patient is at high risk of suffering a stroke. The results of several large studies have shown that over 10% of TIA patients subsequently had a stroke within 90 days. More importantly, half of these occurred within 2 days of the TIA. The consequences were grave, as 21% of these strokes were fatal and 64% disabling. The risk was even greater in some sub-groups.

Emergency physicians have an opportunity to recognise patients who have had a TIA and ensure they are promptly treated and investigated, thereby reducing the proportion that will suffer a stroke.

There is recent evidence that active intervention in patients who are at high risk of stroke recurrence will reduce this risk. The EXPRESS study reported a highly significant reduction in the 90-day recurrent stroke rate in patients seen in the open access study clinic (4.4% vs 12.4%; p<0.0015).

By using a validated scoring system to evaluate risk, emergency physicians can identify and manage these patients effectively.


Approximately 110,000 strokes occur each year in England and Wales. Stroke is the third most common cause of death in the UK, and the largest cause of adult physical disability.

With the licensing of thrombolysis for acute ischaemic stroke, the lack of evidence-based therapeutic intervention has changed dramatically.

Emergency department (ED) staff need to have excellent stroke recognition skills, and agreed care bundles in place for the diagnosis, and treatment, of cerebrovascular events.

In addition, there should be an increased awareness that good, basic medical and nursing care is vitally important in preventing complications, and optimising outcomes.

A suspected stroke should be treated as a medical emergency. A national stroke strategy was published in 2007 by the Department of Health.

Learning Outcomes from completing the tasks

  • List examples of relevant assessment and scoring tools for stroke.

  • Describe the appropriate investigation and therapeutic options of acute stroke.

  • Explain the balance of risk and benefit of thrombolytic therapy for stroke.

  • Outline an appropriate strategy of investigation for TIA.

  • List and differentiate possible mimics of TIA.

  • Recognise the common causes of syncope.

  • Describe the reasons why older people fall.

  • Plan and interpret appropriate investigations in patients with syncope and determine which patients require admission and which can be safely discharged from the Emergency Department.

  • Assess a patient who has presented after a fall, using a focused history and examination.

  • Devise a management plan to prevent future falls.

  • Follow the National Institute for Clinical Excellence (NICE) guidelines for the assessment and management of falls.

Learning Outcome from face-to-face teaching

  • Consolidate knowledge on stroke and TIA management.

  • Risk stratify stroke and TIA patients for further therapy and treatments.

  • Understand local protocols for stroke and TIA management.

  • Identify at risk patients who fall.

  • Appreciate the link between patients that fall and subsequent injuries.


Complete the following before the face to face session:

Task 1: Strokes and TIA

Duration: 2 hours

These two modules from RCEM Learning cover TIAs and Stroke they cover the epidemiology and map the signs and symptoms to vascular territories. They also cover risk assessment and management.

Task 2: Preventing Falling to Pieces

Duration: 30 mins

This podcast covers the definition of a fall and discusses some of the consequences of falls. It then moves on to look at a paper trying to answer the question - Can we predict those at risk of further falls in the ED?

Te opening 5:30 of the podcast covers some housekeeping matters which if you have listened to the SGEM before can be skipped.

Bonus Task: Geriatric Review Preventing Re-presentation

Duration: 8 mins

This video discusses the use of specialist geriatric review to prevent frail patients re-presenting within 90 days. It is based on research carried out in Leicester and Nottingham.

Task 4: Mobility Assessment IPE Session [#EM3]

Duration: 15 mins

This summary from the Inter-Professional Education (IPE) session run locally covers some tips and some pitfalls on assessing mobility in the ED. It also contains a summary of the Timed Up and Go Test (TUG Test)

#EM3 Content


You should familiarise yourself with relevant Local Guidelines, for East Midlands Trainees we are aiming to host these on the website shortly (although this may password protected).

In the meantime please review your local guidelines relevant to chest pain.


We have written a series of interactive cases (wikis) with short answer questions to be answered by trainees prior to the face to face teaching sessions. Currently this is only available to East Midlands Trainees.

Answer one or two questions before attending the face-to-face teaching session. Add comments to answers already given if you think it's appropriate. We will also provide tutor comments. If you find good resources that answer a question why not include links in your comment.

Part of the face-to-face teaching will be spent discussing the case(s) below:

A 62 year old gentleman has come to your department. This morning his wife noticed he had slurring of his speech ad he reports his right arm feeling heavy and weak.
An 86 year old lady attends your ED for the fourth time this year, having fallen at home. She remembers getting up from her chair and ending up on the floor.


Here are some extra resources to review if you want more information:

Life in the Fast Lane – The Elderly and Critical Care:

A guide to getting old and critical care, this article discusses some of the physiological changes associated with ageing, as well as the conditions that affect people as they become older. Finally it discusses critical care in the elderly including survival figures for Australia.


Once you have worked through the exercises, discussed the example cases and attended the face-to-face teaching, please complete the following form:

Updated: 19th October 2016