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
