Falls

Question 1

what does SOCRATES stand for

Answer 1

• Site
• Onset
• Character
• Radiation
• Associated symptoms
• Time course
• Exacerbating factors
• Severity

Question 2

What should you consider in the history of presenting complaint in a fall

Answer 2

• Who - did anyone witness the fall?
• What - what happened before, during and after the fall
• When - when did the fall happen, what time of day was it, what were they doing at the time
• Where - where did the fall happen, was it in the house or outside
• Why - what does the patient think the reason for the fall is
• How - consider how many times they have had a fall in the past 6 months

Question 3

what should you consider in the before, during and after phase of the fall

Answer 3

Before
- any preceding symptoms

During

• loss of consciousness s
• any incontinence or tongue biting
• any injuries - head injuries my warrant imaging
• what was the mechanism of the fall

After

• how did the patient get up after the fall
• how did they fall
• any confusion, weakness, speech difficulty or injuries

Question 4

Name some differentials for chest pain and syncope

Answer 4

• MI
• pulmonary embolism
• aortic stenosis
• aortic dissection
• aneurysm rupture

Question 5

what do you do when someone falls

Answer 5

• Initial ABC
• NICE guidelines: older people who fall during hospital stay are checked for fractures and potential spinal injury before they are moved

Post fall protocol

• check for fractures or potential for spinal injury before moved
• safe manual handling methods for those with signs of fracture or spinal injury
• neurological observations with head
• medical examination after a fall within 12 hours (or 30 minutes if serious injury, vulnerable to injury, immobilised)

Question 6

When should you consider sepsis

Answer 6

• temperature can be high or low
• signs of symptoms suggesting infection
• consider non-specific and non localised features or behaviour change
• factors that increase risk such as immunity, age, invasive risks

Question 7

When are you at risk of severe illness/death from sepsis

Answer 7

• new altered cognition
• RR>25/ need 40% oxygen
• HR >130
• SBP < 90mmHg
• anuric in previous 18h (<0.5ml/kg/h catheterised)
• mottled or cyanosis or non blanching rash
• risk factors for sepsis

Question 8

What do you give and measure during sepsis

Answer 8

Measure

• urine output/fluid balance
• lactate and bloods
• blood cultures/samples to identify source

Give

• oxygen
• fluid bolus/resusctiation
• broad spectrum antibiotics within 1 hour

Question 9

When do you do a CT head scan within 1 hour

Answer 9

• GCS < 13 at initial assessment
• GCS < 15 at 2 hours after initial head injury
• suspected open/depressed skull fracture
• basal skull fracture signs - CSF leak, panda eyes, battles sign, harm-tympanum, post traumatic seizure
• focal neurological deficit
• more than 1 episode of vomiting
• if on anticoagulants - within 8 hours unless other urgent indication

Question 10

when do you do a CT cervical spine within 1 hour

Answer 10

• GCS <13 at initial assessment
• intubated
• plain X ray inadequate or suspicious
• definitive diagnosis of C spine injury needed e.g. pre surgery
• scans for multi-trauma or head injury

Clinical suspicion in alert patient plus any:

• age > 65
• dangerous mechanism such as height, collision, diving, ejection
• focal neurological deficit
• upper or lower limb paraesthesia

Question 11

What is the NEWS score

Answer 11

National early warning score

• tracks changes and triggers responses
• define parameters to be measured
• define frequency of observation
• includes: HR, RR, oxygen sats, BP, Temp, GCS

Question 12

Name some drugs that contribute to falls and confusion

Answer 12

• anti hypertensives
• opiates
• diuretics
• antidepressants
• steroids
• levodopa
• insulin

Question 13

How do you do the confusion assessment method test

Answer 13

1. Acute onset and fluctuating course
2. inattention, distractibility
   3, disorganised thinking, illogical or unclear ideas
3. alteration in consciousness

the diagnosis of delirium requires the presence of both features 1 and 2 and plus either feature 3 or 4

Question 14

What are the causes of a long QT interval

Answer 14

• congenital
• hypokalaemia
• hypomagnasaemia
• hypocalcaemia
• hypothermia
• raised intracranial pressure

Question 15

name the factors that can cause falls

Answer 15

• mental health
• cardiovascular
• respiratory
• gastrointestinal/metabolic
• musculoskeletal
• loss of muscle bulk
• peripheral nervous system
• central nervous system
• medications
• physical home environment
• eye sight
• lack of social support