FALLS Flashcards
etiologic of falls
cardiovascular arrhythmia orthostatic hypotension bradycardia valvular heart disease - aortic stenosis anemia - hypoxia
resp
copd
neurological stroke / TIA delirium parkison disease peripheral neuropathy
genitourinary
infection
endocrine
hypoglycaemia - medication for diabetes such as insulin
or adrenal insufficiency
GI
chronic diarrhea
musculoskeletal
disuse atrophy
arthritis
fractures
ent
benign paroxysmal positional vertigo
ear wax
social history
alcohol intake
mobility - use of mobility aids
benzodiazepines and antidepressants
beta blockers - can cause bradycardia diabetic medication - hypoglycaemia antihypertensives - hypotension benzodiazepines - sedation antibiotics - for infection
who have the highest risk of falls ?
> 65
when someone present with falls what is it we have to do first ?
general inquiry of the falls
When did you fall?
Where did you fall?
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What happened before/during and after the fall?
before
Was there any warning?
Was there any dizziness/chest pain or palpitations?
During
Was there any incontinence or tongue biting? (indicating seizure activity)
Was there any loss of consciousness?
After
What happened after the fall?
Was the patient able to get themselves up off the floor?
How long did it take them?
Was the patient able to resume normal activities afterwards?
Was there any confusion after the event? (head injury)
Was there any weakness or speech difficulty after the event? (e.g. stroke/TIA)
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Why do you think you fell?
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How many times have you fallen over the last 6 months?
what is the next step after the general inquiry questions ?
system based medical history
systemic based enquiry according to cardiac what you don’t know
orthostatic hypotension
Lightheadedness or dizziness upon standing.
Blurry vision.
Weakness.
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bradycardia
Chest pain. Confusion or memory problems. Dizziness or lightheadedness. Easily tiring during physical activity. Fatigue. ========
valvular problems- aortic stenosis
Dyspnea - exertional
Angina pectoris
Dizziness and syncope
Weak and delayed distal pulse (pulsus parvus et tardus)
systolic thrill over the bifurcation of the carotids and the aorta
Auscultation
Harsh crescendo-decrescendo (diamond-shaped), late systolic ejection murmur that radiates bilaterally to the carotids
Early systolic ejection click
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anemia
Pallor (e.g., on mucous membranes, conjunctivae)
Exertional dyspnea
fatigue
Pica (craving for ice or dirt)
Jaundice (in hemolytic anemia)
Muscle cramps
Features of hyperdynamic state
Bounding pulses
Tachycardia/palpitations
system based enquiry according to genitourinary
Lower urinary tract infection Hematuria Increased urinary frequency Urinary urgency Suprapubic tenderness Dysuria
Upper urinary tract infection Symptoms of lower urinary tract infection Fever Flank pain Fatigue/malaise
system based inquiry according to endocrine
hypoglycaemia
Increased sympathetic activity: tremor, pallor,
anxiety, tachycardia,
sweating, and
palpitations
Increased parasympathetic activity:
hunger,
paresthesias,
Neuroglycopenic Agitation, confusion, Fatigue Seizure, focal neurological signs
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adrenal insufficiency
deficiency of cortisol , aldosterone , and androgens = all three
causing hypogonadism : decreased libido and impaired spermatogenesis
hypocortisolism : hypoglycemia Skin hyperpigmentation - in only primary GIT : vomiting , diarrhea , weight loss orthostatic hypotension
hypoaldosternosim : Salt craving - in only primary Hyponatrameia hypotension - shock Hyperkalemia - in primary only Myalgia and joint pain
in general falls what test is usually done?
can perform the timed ‘up and go’ test
ask patient to get up walk 3 meters and retrace - Used to assess musculoskeletal function and postural stability in a patient who has fallen.
in all patent who has fallen we have to do full falls risk assessment ?
falls risk status recent falls medications eg sedatives psychological problems - anxiety depression cognitive status according to AMT
falls risk factor checklist visual iapirement safe transfer status behaviour - agitated or confused observe activity of living - risk taking behaviours , unsafe use of equipment ,unsafe footwear environment - difficult to orientate and navigate environment nutrition - underweight continence - urinar urgency / nocturne
treatment of orthostatic hypotension
orthostatic hypotension
Nonpharmacological treatment
Fluid management: Increase fluid (2–3 liters/day) and sodium intake (6–9 g of salt/day)
Medication adjustment: Consider discontinuing or decreasing the dosage of offending or contributing drugs (e.g., diuretics, antihypertensives).
Advise patients to lie down when prodrome is detected (to avoid injuries from falls).
Compression stockings (at least thigh high): Consider for patients with orthostatic syncope
Pharmacological therapy
Indications
Consider for patients with recurrent VVS or orthostatic hypotension that is affecting their quality of life
Midodrine
Consider if the patient has no history of heart failure, hypertension, or urinary retention.
Fludrocortisone : Consider for patients with no contraindications to sodium and water retention (e.g., hypertension, cirrhosis, renal failure).
Beta blockers: e.g., propranolol
treatment of bradycardia ?
bradycardia
symptomatic and stable - atropine
patient continues to have severe symptoms, prepare for transvenous pacing and follow the algorithm for unstable bradycardia.
Symptomatic second-degree AV block or third-degree AV block: Start transcutaneous pacing.
AV block due to acute myocardial infarction
Avoid atropine.
Aminophylline
Recent heart transplant
Avoid atropine.
Aminophylline
unstable with pulse
If IV access is available, give atropine.
If atropine is ineffective, prepare for emergency transvenous pacing while considering the following temporizing measures:
Epinephrine
Dopamine
treatment of aortic stenosis
aortic valve replacement
decompensated heart failure
carefully titrated to avoid hypotension.
diuretics
= ACE-inhibitors may be beneficial in the prevention of cardiac remodeling.
= Beta blockers are preferable in patients with concurrent coronary artery disease.
Diuretics
Cardiogenic shock
Fluid management: requires very careful balance and extreme caution
Inotropes and vasopressors:
treatment of anemia
IV access
IV fluid resuscitation if the patient if hypotensive or tachycardic
Type and screen with crossmatching of 6 units of blood
FBC, UE , LFT, CLOTTING PANNEL
Consent patient for blood transfusion.
Consider indications for transfusion
Obtain blood for further diagnostic workup of anemia before initiating transfusion = iron studies haementics - b12, folate , ferritin celiac serology urie dipstick FOB OGD colonoscopy blood film
treatment of urinary tract infections
antibiotics of symptomatic
paracetamol or nsaods or symptom relief
remove any catheter if present
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lower UTI and women
NITROFURANTOIN or trimethoprim PO 3 days
if complicated uti eg (abnormal renal tract . immunosuppressed , uncontrolled diabetes , catheter associated : same but for 7 DAYS
FOR MEN
NITROFURANTOIN or trimethoprim PO = 7 days if cystitis
ciprofloxacillin po 2-4 weeks if prostatitis
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UPPER UTI
most upper UTI are uncomplicated
managed with PO - ciprofloxcacillin - 7 -10 days
no response within 24 hours or complicated UTI - hospitalisation and consider IV antibiotics with 2-3 gen cephalosporins AND ciprofloxacillin
causes of orthostatic hypotension
Common underlying causes
Hypovolemia (e.g., dehydration, hemorrhage, use of diuretics such as thiazides)
Medications that cause vasodilation or limit tachycardia (e.g., beta blockers, alpha blockers, calcium channel blockers)
Prolonged bed rest
