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Next Lesson - Sepsis in Paediatrics
Contents
- Understanding Falls
- History of the Fall
- Syncope
- Non-syncopal Fall
- Complications
- Rhabdomyolysis
- Head Trauma
- Safe to go Home?
- Walking Aids
- Basic Advice
- Quiz
Abstract
- Falls make up a large proportion of A&E attendances throughout the country.
- They can happen at any age, often crescendoing in frequency with increasing age and comorbidities, and are known to reduce quality of life, independence, and lead to isolation through loss of confidence.
- It is the job of medical professionals to determine why the fall happened, to treat the consequences of the fall and reduce the risk of any further falls from occurring.
Core
When trying to understand falls, it is necessary to ask a lot of questions to establish everything possible about the fall. Common question themes include: who, when, where, what and how. Using all of this information we can paint a picture of the event and work out what the true cause was.
Who else was there and did anyone see the fall occur? If so then take a collateral history from them. Patients can be unreliable historians after a fall, especially if they have underlying health conditions like dementia or lost consciousness.
What time of day did the fall happen? What were they doing at the time? Patients can often fall if they have a visual impairment, if standing up suddenly, or if pushing themselves, for example with exercise.
Where did the fall happen? It is important to identify any hazards present that need addressing, such as trip hazards or flashing lights, a possible trigger of epilepsy.
To determine what happened during the fall, it is important to understand what happened before, during, and after the fall.
- Before falling were there any prior symptoms such as light-headedness or dizziness? Did the patient see any lights? Did the patient experience any chest pain? Or headaches? Did the patient trip over an obstacle/slip on the ground?
- During the fall did the patient lose consciousness? This is particularly important to determine in unwitnessed falls but can be difficult as patients may be unable to remember. It is important to ask about incontinence, tongue biting, or shaking, as these features can suggest a seizure but are not diagnostic on their own. It is vital to identify any injuries that may have occurred as a result of the fall, particularly if they have hit their head or sustained any bone fractures.
- Discuss what happened after the fall. How long did it take them to regain consciousness (seconds, minutes or hours)? Was the patient able to get up without help? Did the patient demonstrate any confusion or neurological signs following the fall, or have any resulting weakness or numbness?
How long was the patient on the floor for? Unfortunately, it is not uncommon for patients to be on the floor for more than 12 hours, which is associated with a higher incidence of complications such as rhabdomyolysis (the breakdown of muscle due to prolonged pressure), potentially leading to an acute kidney injury.
Patients who have remained on the floor for a long time should have discussions about social issues and vulnerability, leading to discussions about the increased need for care.
Another indicator of the need for more support is frequent falling. If the patient is falling regularly, this indicates they need more support.
Alongside understanding the fall itself, it is important to investigate the patient. In order to do this, the past medical history, drug history, and social history all need to be considered, and any risk factors from these histories considered and managed.
Cardiac conditions can often precipitate falls. The heart can either beat too fast or too slow; in both cases, this can reduce effective cardiac output, meaning not enough blood is pumped to the brain and syncope may occur. This is discussed more later on.
Patients with severe diabetic neuropathy are prone to falls as they lose sensation in their feet, increasing the likelihood of them tripping.
Vertigo sufferers can lose their balance when they feel dizzy.
These are a few of many examples, but it is important to understand how a patient’s long-term conditions could lead them to fall.
Drugs alter the function of the body’s processes, meaning all actions of medications, both desirable and less so, have the potential to increase the risk of patients falling. This effect is compounded with the more medications that a patient is on, called polypharmacy. This comes with an increased number of drug-drug interactions and side effects with each medication added and so an increased potential for a fall.
It is vital to find out what medications any patient is on, both prescribed and over the counter. It is also important to double-check that patients are taking all medications as prescribed, and crucially if there was any recent change in any medication so it is possible to understand the effects these may have.
If patients are on blood thinners such as warfarin there is a significantly increased risk of intracranial bleeds with any head trauma.
Many patients take medications to manage hypertension or cardiac arrhythmias, both of which can make them more prone to developing orthostatic hypotension as they age, meaning they are more likely to experience a drop in blood pressure when they stand up suddenly. It is important that these medications are assessed regularly because the need or the side effect profile can change as the body ages.
Drugs that can induce drowsiness, such as analgesics, benzodiazepines, antidepressants, antipsychotics, and antihistamines, can decrease a patient’s awareness levels and increase the likelihood of them falling over. Again, with these patients, it is necessary to determine when was their last medication review to see if they still need to be on the medications.
As much as clinicians search for any medical cause for a fall, exploring the patient’s social history can give a far better understanding of the person’s background and the circumstances leading up to a fall.
Important pointers relating to this are whether the patient consumes alcohol, takes any recreational drugs or smokes?
Alcohol decreases both awareness of surroundings and control of any motor function, meaning it is important to identify patients who are alcohol dependent, as they will have a high rate of recurring falls without any intervention.
Some recreational drugs such as LSD or magic mushrooms can alter the perception of the world or cause hallucinations. This can lead to either dangerous behaviours or a complete lack of awareness of surroundings, both of which increase the risk of falls. This is far more commonly seen in younger people than the elderly.
Patients who smoke are generally less well than those who don’t, and are more at risk of conditions like vascular disease, which can decrease mobility and sensation in the legs.
A patient’s living situation can alter the likelihood of falls occurring and the recovery after one. It is particularly important to establish who they live with, and if they are able to be cared for by members of their household or by friends and family nearby? An important factor to consider is if there is anyone depending on the patient, for example a child or vulnerable adult? If a patient is the sole earner for a family then they may need some additional support throughout recovery.
Where does the patient live? Identifying if they are homeless, live in a flat, care home, house with stairs or bungalow is important in the prevention of further falls. Identifying hazardous areas and fitting appropriate handrails or stair lifts can be done by the occupational therapists. Patients are known to rearrange furniture in such a way that they can furniture walk around the home. this is a sign of decreasing function and more support is needed.
Patients may have some help at home in the form of carers. These can either be provided by the government or private companies. If a patient appears malnourished then an assessment about whether or not they can look after themselves at home is needed.
Does the patient use any walking aids for mobility assistance? Technique and type of aids should be assessed before the patients are discharged. Wheeled walkers can be unstable, so traditional Zimmer frames are often recommended.
Extensive examinations of the patient are required after a thorough history is taken. It is easy to be guided by the patient to where it hurts, but full neurological, cranial nerve, cardiovascular, and respiratory examinations should be undertaken with any abnormalities noted. Any pain that the patient reports should also be investigated, especially bony or joint-related tenderness.
There is a standard set of investigations that should be performed for everyone presenting to the emergency department with a fall. These include a lying and standing blood pressure, a 12 lead ECG, baseline blood tests looking for any severe anaemia or electrolyte imbalances.
A raised creatine kinase can indicate the severity of muscle breakdown related to rhabdomyolysis, and the length of time a patient was on the floor.
Other more specific investigations should be guided by the presentation. These include x-rays of any painful areas, a chest x-ray if pneumonia is a differential, echocardiograms if suspecting valve disease, or 24-hour ECG tapes are ordered if suspecting any arrhythmias.
A CT head scan should be considered if the history suggests a neurological cause for the fall or if the patient meets recognised head injury risk criteria, such as concerning symptoms or anticoagulant use.
Throughout all of the history taking, examinations, and investigations performed, the main question that needs to be answered is whether there was any loss of consciousness prior to the fall. That is, was this fall syncopal or non-syncopal?
Syncope is defined as a transient loss of consciousness due to reduced perfusion pressure in the brain. This causes the brain to shut down, meaning the muscles holding the body upright give out and the body falls.
The key characteristics of a syncopal fall are a fast onset and spontaneous recovery, as lying a patient horizontally will encourage blood back to the brain.
Pre-syncopal symptoms are those which occur before the loss of consciousness. They can include light-headedness, sweating, blurred vision, and pallor. These symptoms should be inquired about for any fall, even if there was no syncope.
There are multiple different types and causes of syncope, in this article we will explore reflex, orthostatic hypotension, cardiac, and pulmonary causes. The principal syncope mechanism stated above applies to all types of syncope.
Reflex syncope is a disorder of the autonomic regulation of postural tone, with an unexpected increase in parasympathetic output. This causes a fall in cardiac output, as both the heart rate and blood pressure have reduced, causing a reduction in cerebral perfusion.
Causes of reflex syncope can be divided into vasovagal, situational, and specific causes such as with a carotid sinus massage.
Vasovagal syncope is the most common cause of syncope known better as a simple faint. This is often brought about by prolonged standing, stress, the sight of blood, or significant pain.
Situational syncope is caused by coughing, straining, or lifting heavy weights. This can often occur if the patient has just been to the toilet.
A rare cause of reflex syncope is from a carotid sinus massage where the baroreceptors in the carotid arteries are stimulated causing increased parasympathetic output to the heart.
Orthostatic hypotension is where there are symptoms of syncope or presyncope when moving from a lying or sitting position to standing. It is defined as a drop in systolic blood pressure of at least 20 mmHg, or a drop in diastolic blood pressure of at least 10 mmHg, with pre-syncopal symptoms within 3 minutes after standing up.
Upon standing between 500 to 800ml of blood pools in the veins in the legs. This leads to a reduction in end-diastolic volume as there is less venous return to the heart. As the heart fills less, there is reduced cardiac stretch occurring and so, according to the Frank Starling law, there is a reduced stroke volume and corresponding cardiac output. For more information, see here.
The baroreceptor reflex fails as the receptors become less sensitive with increasing age and hypertension. Some antihypertensive medications (e.g. beta-blockers) can also impair the response.
Dehydration is an alternative cause of orthostatic hypotension, this time due to low blood volume, meaning the pooling has a larger impact.
Cardiac disease is a common cause of syncope, and can be classified into electrical abnormalities, structural abnormalities, and coronary abnormalities. Features of cardiac syncope include exertional syncope (syncope brought on by increased activity), a family history of sudden cardiac death syndrome, syncope associated with chest pain or palpitations, a past medical history of heart disease or an abnormal ECG.
Electrical abnormalities in the heart, also known as arrhythmias, can cause syncope. Tachycardia (heart struggles to fill between beats) or bradycardia (heart not pumping fast enough) can both lead to a decrease in cardiac output. This decrease in blood pressure leads to syncope.
Structural abnormalities of the heart can lead to syncope. For example, aortic stenosis is the narrowing of the aortic valve. This makes it harder for the heart to push blood through the aortic valve and into the aorta, meaning the heart cannot eject enough blood with each beat, leading to a reduced cardiac output. Both of these lower the cardiac output and so can lead to syncope. If patients with aortic stenosis are experiencing syncope symptoms, then it is a sign that their cardiac function is getting worse and these patients require reassessment with echocardiography.
Other conditions such as hypertrophic obstructive cardiomyopathy can be a cause of falls and premature cardiac death cause in younger people.
Coronary events such as myocardial infarction can also lead to syncope as they impair the heart's normal function very suddenly, meaning it cannot maintain an adequate blood pressure.
A non-syncopal is a fall in which the cause is not syncopal, i.e. the patient did not lose consciousness before the fall.
Generalised trips and slips are good examples of these, however, what caused the trip must still be investigated to help prevent them in the future. Falls are still non-syncopal if the patient passed out from the impact of the fall such as if they hit their head.
Seizures are classified as separate causes of falls. A generalised tonic-clonic seizure can cause the patient to lose consciousness and fall, but they often take hours to recover fully so do not fit the classic picture of a syncopal fall. Seizures can be subtle and easy to miss and so preceding symptoms of aura, or any tongue biting and incontinence must be asked about. New epilepsy in older adults can occur and is often only diagnosed in patients in their eighties.
Multifactorial falls occur when there is a culmination of many different patient factors coming together and acting with a mass effect causing the patient to fall. A very common example of this is an elderly patient who is being chronically managed for osteoarthritis, diabetic neuropathy, atrial fibrillation and has just obtained a new community-acquired pneumonia. Everything together becomes too much for the patient’s body to handle and so they fall.
The majority of severe complications from falls are derived from either the impact of the fall itself or how long the patient was left on the ground for.
Any head trauma sustained in a fall has the potential to cause skull fractures and intracranial bleeds. Any patient who is acutely deteriorating with a diminished Glasgow Coma Score, who is on anticoagulant medication, or who has a new neurological deficit, repeated vomiting, or post-traumatic seizures requires urgent head CT. Other risk factors that indicate head CT include age 65 or over with loss of consciousness or amnesia, a dangerous mechanism of injury, or more than 30 minutes of retrograde amnesia for events before the head injury. Note that this can be difficult to identify with dementia patients. This information has been summarised from guidance found here.
Bony fractures, such as neck of femur or wrist fractures, can also be sustained in the fall, especially if the patient suffers from osteoporosis.
Rhabdomyolysis is the condition in which skeletal muscle breaks down due to constant pressure, for example if the patient has been on the floor for a long time. Cell lysis occurs after any tissue damage from the impact of trauma and the subsequent lack of blood flow to the muscles as they are not being used whilst the patient is on the floor.
The toxic contents of the muscle cells such as myoglobin, intracellular ions, creatine kinase, and urates are released into the extra-cellular fluid where they then spread round the body.
Rhabdomyolysis is defined as a serum creatine kinase over 5 times the upper limit of normal.
Myoglobin molecules are relatively small and are filtered at the glomerulus, where they contribute to tubular toxicity and cast formation in the nephron, leading to acute tubular necrosis of the kidneys. This process consequently leads to acute kidney injury (AKI).
The combination of renal failure and toxic intracellular contents has catastrophic effects such as electrolyte disturbances, disseminated intravascular coagulation, and even multi-organ failure. Rhabdomyolysis can also be complicated by dehydration; if a patient has been on the floor for a long time and has become dehydrated, this can worsen the AKI and organ damage.
When discharging a patient who presented with a fall, the top priority is to ensure that it is safe for this patient to go home and that they won’t fall again. This can be done by:
- Ensuring that the patient has appropriate walking aids if needed and that they know how to use them properly.
- Advising the patient on behaviours and actions that will reduce the chance of another fall. This includes that the patient should drink plenty of water, stand up slowly, have arm chairs with high arms that provide adequate support, remove any loose carpets or wires that are trip hazards, wear sensible slippers, and have adequate lighting in the house.
An assessment by an occupational therapist may need to be arranged to identify if a patient requires any railings or stair-lifts in their house.
A social worker or primary care coordinator assessment should be organised if patients need increased help at home.
It is always advisable for patients to go to their opticians after a fall to check their prescription. Patients are far less likely to trip over hazards if they can see them clearly.
When discharging a falls patient from A&E, a complete GP letter should always be written to assist in any follow-up care. This should include any details of injuries found, information about the history of the fall, and any management implemented. A medication review should occur in primary care after any fall.
It is important to remember that not all risk factors can be completely removed when considering a patient’s discharge. The key consideration is for the minimisation of risk factors that can be changed, and then a thorough assessment of the risks that remain.
Edited by: Dr. Maddie Swannack
Reviewed by: Dr. Thomas Burnell
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