2 Managing Falls

Question 1

What needs to be considered when taking a history from a patient who has had a fall in terms of what happened?

Answer 1

Before- symptoms prior, chest pain, trip/slip?

During- Loss of consciousness (beware in unwitnessed falls), incontinence, tongue biting, shaking, injuries?

After- regaining consciousness, get up without help, confusion/neurological symptoms

Question 2

Define syncope.

Answer 2

Transient loss of consciousness characterised by fast onset and spontaneous recovery

-Cause by reduced perfusion pressure in brain =self limiting

Question 3

What are the symptoms of pre-syncope?

Answer 3

Light-headedness, sweating, pallor, blurred vision

Question 4

What happens to the incidence of epilepsy past the age of 50 yrs?

Answer 4

Increases after 50 yrs- BE AWARE OF NEW EPILEPSY IN ELDERLY

Question 5

What are the 3 broad categories for syncope?

Answer 5

1) Reflex syncope 2) Orthostatic hypotension 3) Cardiac disease

Question 6

Outline how reflex syncope occurs.

Answer 6

Disorder of autonomic regulation of postural tone- fall in CO

e.g.: Vasovagal ‘faint’ from prolonged standing, coughing/straining, carotid sinus massage

Question 7

Outline how orthostatic hypotension syncope occurs.

Answer 7

Standing up from sitting or lying down- greater than 20mmHg drop in BP with pre-syncopal symptoms

Question 8

Why might the baroreceptor reflex fail?

Answer 8

1, Baroreceptors less sensitive with age

2, Medications e.g. anti-hypertensives impair response

3, Dehydration (chronic dehydration= common in older people)

Question 9

Outline how cardiac syncope occurs. (3)

Answer 9

Electrical, structural or coronary

Question 10

What are the red flags of a syncope history which indicate a cardiac issue?

Answer 10

Exertional syncope

Family history of cardiac disease

Preceding chest or palpitations

PMH of heart disease

Abnormal ECG

DO ECG on any patient coming in with a fall

Question 11

Give examples of causes of non-syncopal falls. (Many= multifactorial)

Answer 11

LOC following head trauma

Trips and slips

Multifactorial often: infection, diabetic nephropathy, osteoarthritis

Question 12

What medications might be particularly relevant when taking the history of a patient who has had a fall?

Answer 12

Anti-hypertensives

Anti-arrythmials

New medications

Drugs that induce drowsiness e.g. antidepressants

Any polypharmacy

Question 13

What social history might be particularly relevant for a patient who has had a fall?

Answer 13

Stairs

Furniture walking- furniture pulled together

Walking aids (right one?- wheels often not good)

Are they housebound?

Alcohol/smoking?

Family close by?

Question 14

What % of falls result in a fracture (presenting at ED? So what examinations do we need to do?

Answer 14

1%- so need to do neurovascular examination, cranial nerve, CVS, respiratory (not just MSK/where patient says it hurts)

Question 15

What investigations should potentially be done if a patient presents with a fall?

Answer 15

LSBP (lowest systolic blood pressure)

ECG

Creatine kinase (long lie- rhambdomyolysis)

FBC and U&Es

Head CT

X-ray

Question 16

Why might we do a creatinine kinase investigation for a patient following a fall with long lie?

Answer 16

To check for rhabdomyolysis - CK levels 5 times upper limit of normal

Rhabdomyolysis results from: traumatic/medical injury to sarcolemma

–> Release of intracellular ions, myoglobin, CK and rates into circulation

–> can lead to electrolyte disturbances, DIC, renal failure

Question 17

How do we decide whether to CT to not CT a patient who presents with a fall?

Answer 17

Question 18

An elderly patient is ready to be discharged from ED after presenting with a fall, what steps should be taken before they are discharged?

Answer 18