Session 2 Flashcards
Factors that are important when taking a history about a fall
- Who?
- Did anyone else witness the fall? - If yes - take a collateral history
- When?
- When did the fall occur? If at night, is vision an issue?
- What were they doing at the time?
- Were they looking up?
- Just got up from a chair/bed?
- Just been to the toilet ?
- Where?
- In the house?
- At the shops?
- If at home,
- Which room?
- Any trip hazards?
- Flashing lights from TV?
• What? – Before, During, After
- Before
- Any symptoms prior to the fall (light headedness/dizziness)
- Chest pain
- Did they trip or slip?
- During
- Loss of consciousness (beware of this in unwitnessed falls as the patient probably won’t know)
- Incontinence, tongue biting, shaking
- Any injuries?
- After
- What happened after?
- Did they regain consciousness quickly?
- Were they able to get up without help? If not then they may be unsafe to return home.
- Any confusion or neurological symptoms?
- How?
- How long where they on the floor for?
- How many times has the patient fallen over before?
- How many in the last 6 months?
- Any serious injuries?
Most Important part of any fall historyis to establish the presence or absence of loss of conciousness leading to the fall
Define syncope
- A transient loss of consciousness characterised by fast onset and spontaneous recovery
- Caused by a reduced perfusion pressure in the brain
- Syncope is usually self limiting- being horizontal will fix low blood pressure
- Beware of people who have been held in an upright position
What can cause a fall?
Many different causes so thorough history is important.
What is pre-syncope?
- Symptoms preceding a syncopal episode, includes:
- Light-headedness
- Sweating
- Pallor
- Blurred vision
Not everyone who has these will have a fall but if someone is experiencing these regularly, then they are at much higher risk of having a fall
Seizure as a cause of falls and how it’s different to syncope
- A generalised tonic-clonic seizure is a cause of loss of consciousness and will cause a fall however it is not a syncope. Both will have a loss of conciousness and cause a fall put a seizure spontaneous recovery.
- Be aware of new epilepsy in the elderly as incidence increases in old age
- Seizures can often be subtle
Categories of syncope
- A few broad categories:
- Reflex Syncope
- Orthostatic Hypotension
- Cardiac/Cardiopulmonary Disease
What is reflex syncope?
- Disorder of the autonomic regulation of postural tone
- Activation of part of medulla leads to decrease in sympathetic output and increase in parasympathetic
- Fall in CO (reduced HR) and BP leads to reduced cerebral perfusion
- Examples:
- Vasovagal- ‘simple faint’- from prolonged standing, stress, sight of blood, pain
- Situational syncope e.g coughing, straining, lifting heavy weight
- Carotid sinus massage
What is orthostatic hypotension?
- Symptoms occur after standing from a sitting or lying position
- Can cause syncope if drop in blood pressure is severe enough
- Normally defined as a drop of 20mmHg or more, with pre-syncopal symptoms on standing
- Standing up causes 500-800ml of blood to pool in the legs
- Reduction in end diastolic volume
- Reduced cardiac stretch, therefore reduced stroke volume and cardiac output
- Normally managed by the baroreceptor reflex
- If this fails then cerebral perfusion will drop and syncope occurs
Describe the baroreceptor reflex
Baroreceptors present in the arch of the aorta and carotid body, undergo a slight stretch under higher pressure causing a decrease in baroreceptor activity and this signal is taken by the glossopharyngeal nerve (CN IX) to the brain and causes deactivation of our sympathetic chain and activation of the vagus nerve (CN X) which goes to the sinoatrial node and causes heart rate to fall so cardiac output falls and then blood pressure falls. The oppsoite occurs during low blood pressure. The symapthetic chain causes an increase in heart rate and an incresed force of contraction.
Why can the baroreceptor reflex fail?
- Baroreceptors become less sensitive with age
- Also become less sensitive with prolonged hypertension
- Medications, such as anti-hypertensives can impair this response, or venous return
- Dehydration - causes lower blood volume
Cardiac Syncope
- Syncope caused by a cardiac disease or abnormality
- Can be an electrical (rhythm), structural or coronary cause
Electrical
- Bradycardias
- Tachycardias
Structural
- Aortic Stenosis
- Hypertrophic Obstructive Cardiomyopathy
Coronary
• MI/IHD
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
How can aortic stenosis cause syncope?
- Narrowing of the aortic valve
- Harder to push blood through the aortic valve
- If heart has to work harder, e.g during exercise, it can fail to adequately perfuse brain
- If AS with syncope then patients have a mean survival of 2-5 years untreated
What are non-syncopal falls?
- A fall in which the cause is not a syncope
- A fall with a loss of conciousness following a head trauma is still a non-syncopal fall
- Trips and slips fall in this category
- Often the fall can be the end result of an intercurrent illness, such as an infection
Are falls normallydue to one cause
• Many falls will be as a result of more than one thing
E.g. A patient with osteoarthritis and diabetic neuropathy. Add in an infection on top of this.
Risk factors pile up and act together.
When is it okay to send a patient home after a fall?
- Main question: Is this patient safe to be at home?
- As with any patient, you take a complete history:
- Presenting Complaint
- History of Presenting Complaint
- Past Medical History
- Family History
- Drug History:
- Polypharmacy
- Any new medications?
- Anti-hypertensives/anti-arrythmials - Long-term?
- Any drug which may induce drowsiness? - E.g. new analgesia, benzodiazepines, antidepressants, antipsychotics etc
- Have they had a recent medication review?
• Social History:
- Who does she live with?
- Does she have any help at home?
- Family close by?
- Any stairs?
- Any walking aids - Or other helpful household aids?
- Does she drink alcohol?
- Does she smoke cigarettes?
Depending on the patient’s history and the type of fall they’ve had you can use this to piece together the likelihood of them falling again upon returning home. Social and rug history will be more important here.