Managing Falls Flashcards
What key factors should you consider when assessing a patient who has had a fall? (4 W + 1 H)
- Who?
- When?
- Where?
- What? - before during and after
- How?
What factors should you consider about when a fall occured?
- Time of day
- Night- could be a vision issue
- Morning- arthritis makes you stiff in the morning
- What where they doing at the time?
- Were they looking up
- Getting up from a chair/ bed?
- Been to the toilet?
What does the ‘where’ of the fall tell you?
- In the house/ at the shops. If at home:
- which room?
- any trip hazards?
- flashing lights from tv?
What should you ask the patient about before they fell?
- Any symptoms prior to the fall (light headedness/ dizziness)
- Chest pain
- Did they trip or slip?
What should you ask the patient about during the fell?
- Was there loss of conciousness?
- Any incontinence, tongue biting, shaking
- Any injuries?
What should you ask the patient about after they fell?
- Did they regain conciousness quickly
- Were they able to get up without help?
- Any confusion or neurological symptoms?
What should you ask in the ‘how’ of assessing falls?
- How long where they on the floor?
- How many times have they fallen
- How many in the last 6 months?
- Any serious injuries?
What is syncope?
The transient loss of conciousness characterised by fast onset and spontaneous recovery
Caused by reduced perfusion pressure to the brain
Usually self limiting - being horizontal will fix low blood pressure
What symptoms might you experience preceding a syncopal episode?
- Light headedness
- Sweating
- Pallow
- Blurred vision/ wavy lines
Explain what happens in reflex syncope?
- Disorder of the autonomic regulation of postural tone
- Activation of part of the medulla leads to a decreased sympathetic output and an increased parasympathetic
- Leads to a fall in CO and BP leading to reduced cerebral perfusion
Give some examples of reflex syncope
- Vasovagal- simple faint from prolonged standing, stress, sight of blood, pain
- Situational syncope e.g. coughing, straining, weight lifting
- Carotid sinus massage
What is orthostatic hypotension?
- Hypotension tht occurs after standing from a sitting, or lying postion
- Can cause syncope of drop in blood pressure is severe enough
- Normally a drop of 20mmHg of systolic BP, with pre-syncopal symptoms on standing
Explain how standing can cause syncope
- Standing causes 500-800ml of blood to pool in the legs
- Reduces end diastolic volume
- Reduces cardiac stretch → reduces SV and CO
- This is normally manahges by baroreceptor reflex
- If this fails → syncope
Explain the baroreceptor reflex to a drop in arterial blood pressure
- Baroreceptors located in the aortic arch and carotid bodies detect reduced CO and signal to medulla
- Causes increased HR, SV and vasoconstriction to maintain cerebral perfusion
Why does the baroreceptor response fail with age?
- Baroreceptors become less sensitive with age
- Becomes less sensitive with hypertension
- Medication (anti-hypertensives) can impair response
- Altered by dehyrdration - many elderly dehydrated
What is cardiac syncope?
Syncope caused by cardiac disease or abnormality, either electrical (rhythm) or structural)
Electrical:
- Bradycardia
- Tachycardia
Structural:
- Aortic stenosis
- Hypertrophic Obstructive Cardiomyopathy
Coronary:
- MI/ IHD
Explain how aortic stenosis can cause syncope
- Narrowing of the aortic valve
- Harder to push blood through the valve
- Heart has to work harder e.g. exercise can fail to adequately perfuse the brain
- If patient has aortic stenosis with syncope - mean survival is 2-5 years untreated
- Heart as an ejection systolic murmor
What are some of the red flag features of cardiac syncope?
- Exertional syncope
- Family history of cardiac disease or sudden cardiac death
- Preceding chest pain or palpitations
- Past medical history of heart disease
- Abnormal ECG
What social history should you ask when assessing whether a patient whos had a fall is fit for discharge?
- Who do they live with
- Do they have any felp at home?
- Any family close by?
- Any stairs?
- Any walking aids?
- Do they drink alcohol?
- Do they smoke cigarettes?
What type of walker/walking aid is not reccomended by occupational? health
A wheeled walker
A zimmer frame or something with sturdier base is much better
How do you assess a patient who has a had a fall?
- Don’t just examine where it hurts
- Palpate all bony prominences
- Do a full neurovascular, cranial nerve, CVS and respiratory examination
What investigations can you do on someone who has had a fall?
- Long standing blood pressure
- ECG
- FBC and U&Es
- CK if they’ve had a long lie on floor
Guided on symptoms:
- X-ray
- Echo
- 24 hr tape
- CT
What is one of the dangerous side effects of having a fall and being on the floor for a long time
Rhabdomyolysis
What is rhabdomyolysis?
- Any traumatic or medical injury to the sarcolemma
- Releases of intracellular ions, myoglobing, CK and urates into the circulation
- Can lead to electrolyte disturbance, (DIC) disseminated intravascular coagulation, renal failure, multi organ failure
How do you diagnose rhabdomyolysis?
Creatinine Kinase is x5 upper limit of normal
What risk factors after a fall would prompt you do perform a CT scan?
- Age >65 years
- History of bleeding or clotting disorder
- Dangerous mechanism of injury
- More than 30 minutes retrograde amnesia of events immediately before the head injury
