Managing Falls Flashcards
Differential diagnosis for falls
Trip UTIs Stroke Sub-arachnoid haemorrhage Heart failure Cataracts Parkinson’s Hip osteoarthritis Etc Page 5
What factors to consider around a fall
Who -was there history
When - night vision/ arthritis morning
Where - trip hazards, set goals
What - (2 mins before/ during/ after) set goals, just got up (syncope), dizziness/ symptoms, trip hazards, lose consciousness when regain, incontinent, bite tongue, shaking, pale, eyes roll, hurt, help getting up, ongoing symptoms
How - how long on floor, how many times, how many last 6 months, seriousness injuries
2 main causes for loss consciousness and describe each
Syncope - transient loss consciousness, fast onset and sudden onset, reduced perfusion pressure in brain, self limiting usually
Seizures - tonic clonic seizures, can be subtle, much higher in elderly
Pre-syncope symptoms
Light headed
Sweating
Pallor
Blurred vision
Types of syncope
Orthostatic hypotension -
Reflex syncope
Cardiac/ cardiopulmonary disease
Describe reflex syncope
Orthostatic hypotension -
Reflex syncope - disorder autonomic regulation of postural tone (activation of part of medulla leads to decrease in sympathetic output & increase parasympathetic, fall in CO and BP leads to reduced cerebral perfusion e.g. vasovagal (simple faint), situational (coughing), carotid sinus massage
Describe orthostatic hypotension
Symptoms occurring after standing from sitting/ lying position
If drop in BP severe enough (drop of 20mmHg or more with pre-syncope symptoms on standing)
Pathophysiology: standing causes 500-800ml of blood to pool in legs, reduction diastolic volume, reduced cardiac stretch -> reduced stroke volume and cardiac output, managed by barorecptors, if fails cerebral perfusion will drop
Describe baroreceptor reflex
Low BP detected by baroreceptors in aortic and carotid body
Signals sent down CN9
Medulla
Signals sent down CN10
SAN activation -> increased HR
Medulla
Signals along sympathetic chain Increased ventricular contractility
Why does the barorecptor reflex fail?
Barorecptors become less sensitive with age
Less sensitive with hypertension
Medications e.g. anti-hypertensives can impair response or venous return
Dehydration
Describe cardiac syncope
Syncope caused by cardiac disease or abnormality
Can be electrical/ rhythm (bradycardia, tachycardia) structural (aortic stenosis 2-5yrs survival untreated, hypertrophic obstructive cardiomyopathy) coronary cause (MI/ IHD)
Features of cardiac syncope
Exertion also syncope
Family history cardiac disease/ sudden death cardiac death
Preceding chest pain/ palpation
Past medical history of heart disease
Abnormal ECG
Describe non-syncopal falls
Fall in which cause is not a syncope
Fall with loss of consciousness post head trauma still non-syncopal
Trips and slips
often fall can be end result of intercurrent illness e.g. infection
Many multifactorial
Walking aids
Wheeled walker - get occupational assessment, less sturdy then Zimmer frame and land worse, shouldn’t actively lean on
Zimmer frame
Walking stick
Wheelchair
Investigations to consider after fall
- LSBP ECG FBC U&Es CK if long lie - rhabdomyolysis (5X upper limit normal) can lead DIC/ renal failure/ multi-organ failure
X-ray
Echo
24hr tape
CT
When to perform a CT head scan within 1 hr of risk factor being identified
Sign basal skull fracture
Focal neurological deficits
Post traumatic seizure
More than one episode vomiting since
GCS <13 initial assessment
GCS <15 2hrs after injury
Suspected open or depressed skull fracture
(If none of above but on warfarin Ct within 8hrs, if loss of consciousness or amnesia and over 65yrs/ dangerous mechanism injury/ clotting disorder CT within 8hrs)
