Falls + Syncope

Question 1

Questions to ask about a fall

Answer 1

BAD BALANCE

what happened Before, After and During

Banged their head? any injury?

Arrythmic symptoms recently/preceding the fall? - palpitations/chest pain

Loss of consciousness- do they remember the fall?

Alcohol- had they been drinking?

New medications started recently?

Collateral history may be needed or has been reported to them

Ever happened before? how many/where?

also important to ask about usual level mobility + home support

Question 2

what are the two categories of falls

Answer 2

syncopal

nonsyncopal

Question 3

what is syncope

Answer 3

transient loss of consciousness + postural tone due to global cerebral hypoperfusion

rapid onset, short duration and spontaneous recovery

(faint/blackout)

Question 4

causes of syncopal falls

Answer 4

cardiogenic syncope: arrythmia/ structural heart disease

reflex syncope: vasovagal - neurologically induced drop in BP

Orthostatic hypotension

Question 5

what is meant by a nonsyncopal fall

Answer 5

either a fall with loss of conscioussness without global cerebral hypoperfusion

or

fall without loss of consciousness

Question 6

causes of nonsyncopal falls where conscioussness is lose

Answer 6

epilepsy

metabolic disorders: hypoglycaemia, hypoxia, hypercapnia

drugs

Question 7

causes of nonsyncopal falls without loss of conscioussness

Answer 7

mechanical: extrinsic cause e.g. trip over step

gait/balance problem: stroke, parkinsons, arthritis

sensory deficits: site or hearing

drop attacks

cataplexy

pyschological: functional, panic attacks

Question 8

what is a drop attack

Answer 8

sudden leg weakness with quick recovery

more common in elderly women

may be due to leg weakness or vertebrobasilar insufficiency

Question 9

what is cataplexy

Answer 9

transient muscle weakness that occurs in narcolepsy

Question 10

typical features of cardiogenic syncope

Answer 10

no warning- may have had chest pain/palpitations at time

lasts seconds to minutes

may look pale during/after

quick recovery

Question 11

features of reflex syncope

Answer 11

can occur when standing or sitting (not when lying flat)

may have presyncope- nausea, pallor, sweating

can be triggered by emotional/physical stress

short duration

Question 12

what is orthostatic hypotension

Answer 12

dizziness when standing from sitting

Question 13

features of a fall due to epilsepsy

Answer 13

aura/trigger

tonic clonic seizure

incontinence may occur

slow recovery

Question 14

initial assessment of a fall

Answer 14

ECG

Bloods: FBC (anaemia), glucose

check CK if long lie after fall – rhabdomyolysis

brain imaging if head injury suspected

lying standing BP if orthostatic hypotension is suspected

Question 15

what is the most common cause of transient loss of consciousness

Answer 15

vasovagal syncope

• due to orthostatic stress e.g long period of standing, hot weather, reduced fluid intake

Question 16

what is carotid sinus syncope

Answer 16

altered HR and BP due to hypersensitive baroreceptors

• syncope on minimal stimulus of the neck e.g. shaving, tight collar

Question 17

what medications can cause orthostatic hypotension

Answer 17

anti-hypertensives e.g. ACEi, beta blockers

diuretics

anti-arrhythmics e.g. digoxin, flecainide

anti-anginals

TCAs

Question 18

criteria for orthostatic hypotension

Answer 18

fall in systolic BP >20mmHg or fall in diastolic BP >10mmHg after 3 mins of standing

Question 19

what is benign paroxsysmal positional vertigo (BPPV)

Answer 19

sudden onset dizziness + vertigo triggered by changes in head position

e.g. rolling over in bed, changing head position

Question 20

how is BPPV diagnosed

Answer 20

positive dix-hallpike manoeuvre

Question 21

how is BPPV treated

Answer 21

Epley manoeuvre

Question 22

how is a lying and standing BP measured

Answer 22

1st BP - taken after lying for 5 mins

2nd BP - taken after standing in first minute

3rd BP - taken after standing for 3 minutes