Falls

Falls

Patient has fallen, please review. Vani talks to Geriatrician and fall expert Dr Cheryl Johnson about an approach to falls and when to order that head CT.

Fall causes

Common

  • Delirium
  • Visual impairment
  • Peripheral sensory neuropathy
  • Stroke/TIA
  • Joint buckling/instability
  • Deconditioning
  • Medication effect or polypharmacy
  • Enviromental hazards

Uncommon

  • Vestibular dysfunction
  • Gait disorder
  • Dementia
  • Depression
  • Seizure
  • Subdural haematoma
  • Syncope
  • Orthostatic hypotension
  • Mechanical mobility/gait disorder
  • Substance abuse
  • Carotid sinus hypersensitivity
  • Postprandial hypotension

Approach

  • Eyeball the patient / ABCs
  • History
    • Is this a collapse or a fall?
    • From patient and witness
      • What were they doing before the fall?
      • Do they remember it happening?
      • Do they remember hitting the ground?
      • What part of the body hit the ground first?
      • How did they get back up again?
      • “And then what happened?”
      • Any other falls?
      • Any near falls?
      • Using walking aid? On their own?
      • Preceding symptoms?
      • LOC?
      • Any injury or pain?
      • Head injury?
      • Review of symptoms
  • Red flags
    • Medications
    • Sleeping tabs, opiates
    • Head injury/alterered neurological status
    • Non-weight bearing
    • Don’t be reassured by a normal plain film
  • Factors that increase risk of fall in hospital
    • Poor lighting
    • Slippery floors
    • Equipment in rooms and hallways that gets in the way
    • Being weak from illness or surgery
    • Being in new surroundings
  • Vitals + Examination
    • General inspection
    • Top to bottom – squeeze everywhere and everything
    • Scalp
    • Joints
    • Ribs
    • Pelvis
    • Cardiorespiratory examination
    • Abdomen for signs of intraabdominal haemorrhage (peritonism)
    • Neurological exam/peripheral neuropathy
    • Lying and standing BP, can be deferred to next day
    • Check for injury, such as cuts, scrapes, and bruises. Always visualise and palpate the scalp (a significant injury can be easily obscured by hair).
  • Investigations
    • FBC, U&E, glucose, vitamin B12/folate, TFT, ECG, septic screen (if indicted)
    • Head CT (if head impact, neurological change, altered mental state/delirium, anticoagulant/antiplatelets, worried)
  • Management
    • Treat skin tears
    • Dressing/sutures
    • Analgesia
    • Hospital fall protocol
    • Review and withhold meds/flag for team review
    • Lying and standing BP
    • Infection/delirium management
    • ACC paperwork
    • Risk reduction
      • Bed height/remove rails
      • Hip protectors
      • Grippy socks
      • Hearing aid/glasses
      • Watch or increased frequency of observations
  • Document
    • Review past notes
    • Basics (date/time/name/reason for review)
    • Positives and pertinent negatives
    • Impression and differential with justification. Have you eliminated intracranial haemorrhage?
    • Clear and specific plan
    • Consider discussion with senior and escalation, especially if called back to patient again

 

Resources

Hypotension

Hypotension

Sam speaks to Intensivists Dr Jonathan Casement and Dr Rob Everitt about differentiating and managing hypotension.

Differential

  • Life threatening
    • Acute haemorrhage
      • On the floor and four more
    • Sepsis
    • Arrhythmia/cardiac
    • Drugs (including transfusion reaction)
    • Anaphylaxis
  • Dehydration (beware the accuracy of this diagnosis)
  • Epidural anaesthesia
  • Heart failure
  • Pregnancy
  • Syncope/postural
  • Neurological
    • Positional
    • PD
    • Diabetes

Approach

  • Eyeball the patient / ABCDEF
  • Calling a code
    • 777 (or your local hospital emergency number)
    • This is Sam, medical house officer I need the adult resus team to attend North Shore Hospital, ward 10, room E3.
  • History
    • Why are they in hospital?
    • Post-op?
    • Onset, timing & trend of hypotension
    • Postural
    • Medications
    • Associated symptoms
      • Pain is very concerning
    • ROS
  • Vitals + Examination
    • End-of-bed-o-gram is probably the most important
    • Peripheries for perfusion and pulse
    • Manual BP
      • Both arms
      • Cuff size
    • Urine output
    • Drain output
  • Consider investigations
    • Keep in mind these may be of limited value
    • ABG (lactate, glucose, Hb)
    • ECG
  • Management
    • Fluid challenge only if hypovolaemic
      • 250 – 500 mL stat
    • Rehydrate gradually
    • Transfusion
      • Target Hb >70
      • Use one unit then reassess
    • Avoid transfusion outside daylight hours
    • Catheterise and measure fluid balance
    • Fix the underlying cause
    • Have a low threshold to escalate to a senior
    • Clear observation and escalation plan if cause is unclear
  • Document
    • Review past notes
    • Basics (date/time/name/reason for review)
    • Positives and pertinent negatives
    • Impression and differential with justification.
    • Have you eliminated life threatening conditions?
    • Beware an impression of dehydration.
    • Are they actually hypovolaemic?
    • Why would they be dehydrated on the ward?
    • Clear and specific plan
    • Monitoring
    • Consider discussion with senior and escalation, especially if called back to patient again
Shortness of breath and oxygen

Shortness of breath and oxygen

Sam discusses shortness of breath and oxygen use with Respiratory and General Medicine advanced trainee Dr Cam Sullivan. We also delve into more advanced pneumonia management and investigation as well general expectations of house officers on ward calls.

Differential (acute dyspnoea)

  • Life threatening
    • PE
    • Infection
    • Asthma
    • Anaphylaxis
    • Pneumothorax
    • Pulmonary oedema
    • Pulmonary haemorrhage (TB or anti-coagulated)
    • Anaemia
    • Narcosis
  • Obstruction
    • Chronic/COPD
    • Foreign body
  • Atelectasis – especially post-op
  • Pleural effusion
  • Cardiac
    • Heart failure
    • Arrhythmia
    • ACS
  • Mechanical
    • Obesity
    • Sleep apnoea
    • Flail chest
    • Blocked chest drain
    • Ascites
  • Drugs
  • Pregnancy

Approach

  • Eyeball the patient
  • ABCs – respiratory arrest code if the patient is having difficulty talking to you
  • History
    • Onset
    • Previous shortness of breath
    • Cough/sputum
    • Inhaler use
    • Foreign body
    • Recent new medications
    • Rash/oedema
    • Pain
    • Review of systems
  • Identify risk factors/respiratory background
  • Vitals + Examination
    • General inspection
    • Current oxygen flow rate/FiO2
    • Talking in sentences, broken sentences, single words
    • Peripheries/fluid review
    • Chest wall movements and auscultation
    • Listen to the posterior chest!
    • Listen to the entire breath cycle
    • Heart sounds
    • Abdomen
    • Calf tenderness and swelling
      • Not sensitive or specific. No negative predictive value
    • Chest drain – is it swinging?
  • Investigations
    • ABG
    • ECG
    • CXR – consider urgent/portable
    • Consider FBC, U&E, CRP
    • Pneumonia microbiology
      • Sputum sample
        • Consider adding on atypical panel
      • Urinary antigens
      • Respiratory panel
    • Consider D-dimer
  • Management
    • Posture!!!
    • Chest physio if not clearing secretions (mucous plugging or neuromuscular disease)
    • Analgesia (if splinting)
    • Fluid restriction
    • Frusemide
    • Prednisone
    • Antibiotics
    • Consider discussion with senior and escalation, especially if called back to patient again
    • Consider transfer to respiratory ward
  • Document
    • Review past notes
    • Basics (date/time/name/reason for review)
    • Positives and pertinent negatives
    • Impression and differential with justification. Have you eliminated life threatening conditions?
    • Clear and specific plan
    • Specify target SpO2 range and prescribe oxygen including delivery method.

Oxygen delivery

  • Target SpO2
    • 92 to 96
    • 88 to 92 for CO2 retainer
  • Oxygen delivery methods
    • Nasal canulae
      • 0.5 – 4 L/min
    • Hudson mask
      • 4 – 10 L/min
    • Venturi mask
      • Fixed FiO2 0.21 – ~0.6 (flow rate determined by attachment)
      • Varies from Blue: 24%, White: 28%, Yellow: 35%, Red: 40%, Green: 60%
    • Airvo
      • Fixed FiO2 with PEEP
    • Non-rebreather/reservoir mask
      • High FiO2 >0.9, set to 15 L/min, near 100% as long as reservoir bag does not empty
    • Bag mask
      • Approximate FiO2 1.0
    • BiPAP
    • Invasive ventilation in ICU
Verifying and certifying death

Verifying and certifying death

Update March 2018

Since recording, a pilot electronic death certification project has launched. See these resources:

The MOH has also released some new guidance to completion of the death certificates and including cause of death. See the resources section at the bottom of this post.


Despite its significance, the verification and certification of death are tasks few RMOs excel at. Sam talks to Dr Garry Clearwater, FACEM and Medical Referee, about the practical aspects of verifying death, and completing the paperwork.

Verifying death

  • Must be done “immediately after a doctor learns of the death” (within reason).
  • Body clearly in a state incompatible with life (rigor mortis, decomposition, major injury) or;
  • Absence of:
    • Heart sounds, ideally a minute
    • Breath sounds
    • Pupil reactivity
    • Muscle tone
  • Recheck if in doubt, or do a rhythm strip
  • It’s okay to backdate the time of death to when you think it actually occurred.

Clinical notes

  • If death verified using a standard approach, simply note absence of vitals on examination.
  • Otherwise, document details that lead you confirm death.

Cause of death

  • Part 1 may be a clear underlying fatal condition e.g. metastatic colon carcinoma, severe dementia.
  • In part 2, list conditions that would modify your approach to further treatment of the primary cause of death e.g. dementia, cancer, severe cardiac or pulmonary disease.
  • List enough information for the medical referee to understand why the patient died and further treatment or intensive care was withheld.
  • If the cause was idiopathic, say so, otherwise list the underlying cause.
  • Remember to state the obvious, and don’t agonise about making a final diagnosis if it remains uncertain.
  • Importance of cause of death:
    • Used to make resource and funding decisions based on death statistics.
    • May have implications on surviving family members (genetic predisposition).
    • Clarifies whether or not it should be a coroners case.

Referral to the coroner

  • Detailed list available at cremation.org.nz
  • Essentially anyone who dies:
    • An unnatural death (violent, suicide),
    • Or is in custody, or pregnant, at the time,
    • Or as a result of injury,
    • Or unexpectedly as a result of medical treatment or anaesthetic.
  • An exception applies for death by accident in the frail elderly. Patients over 70 years of age who die due of an injury that was primarily a result of their significant underlying medical condition e.g. Dementia -> NOF# -> death. But you must be certain there was no element of neglect or abuse that contributed, and no other indication for referral to the coroner. More detail on the exception here.

Sighting patients

  • It is reasonable to ask (or be asked) to sight a patient expected to die after hours.
  • This is primarily to benefit the family, as it will allow the body to be removed from the hospital. This is probably the most useful thing you can do, while on call, for the patient and their family.
  • If asked to sight a patient, you should be familiar with their condition, current treatment and sight them such that you can verify they are alive, and will then be able to identify them once they have died.
  • If you do not sight a patient alive, and are asked to complete the paperwork.
    • You must still verify the death and document this in the notes.
    • You should not do the paperwork if you have not seen the patient alive and the team (attending doctors) will be back within 24 hours of the death.
    • You should complete the paperwork if:
      • The team will not be back within 24 hours of the death, and
      • You are satisfied that referral to the coroner is not required.

Burial & Cremation Act 1964. Section 46B (3):
A doctor other than a doctor who attended the person during the illness may give a doctor’s certificate for the death if (and only if) satisfied that the person’s death was a natural consequence of the illness and that—
(a) the doctor who last attended the person during the illness is unavailable; or
(b) less than 24 hours has passed since the death, and the doctor who last attended the person during the illness is unlikely to be able to give a doctor’s certificate for the death within 24 hours after the death; or
(c) 24 hours or a longer period has passed since the death, and the doctor who last attended the person during the illness has not given a doctor’s certificate for the death.

Form B (cremation form)

  • Pecuniary interest
    • Might you receive anything in the will?
  • Ordinary medical attendant
    • This is generally the GP, and is very unlikely to be you!
  • Biomechanics aids
    • Is there something in this person that might blow up in a cremator and damage or people around it?
    • Also, if the patient has a communicable disease, have you written it on the death certificate? e.g. TB or hepatitis C.
  • Mode of death – layman’s explanation of how the death occurred.
    • Syncope (sudden event) e.g. collapse
    • Exhaustion e.g. respiratory compromise
    • Died in their sleep
    • Note there are 4 parts to this question on the form.
    • The rationale for this question to record how the patient died and who it was according to. If you didn’t witness the patient collapse and die, write down who did.

Resources

Introduction to the podcast

Introduction to the podcast

The Ward Calls podcast dissects common ward calls you will need to confidently manage as a PGY1 doctor and beyond. We discuss practical, safe and comprehensive approaches that are achievable in the limited time available when working on the ward.

The podcast is co-hosted by Dr Vani Chandran and Dr Sam Holford, based in Auckland, New Zealand.

We hope to provide guidance applicable to hospitals throughout New Zealand, and expect most of the content to apply to Australia and further abroad. Thanks to the NZRDA Education Trust for making this podcast possible.

Feedback

Please send feedback, questions and suggestions of what you’d like discussed on the show to [email protected], or find @wardcalls on Twitter, Facebook or Instagram. And remember to leave us a review on iTunes, to help others find the show.

Disclaimer

Practicing medicine is to make black and white decisions based on grey information. We can’t cover every possible scenario on this podcast and cannot guarantee accuracy. We’ve done our best to bring you useful and reliable advice, from guests volunteering their time to give expert opinion. Our advice does not replace your local hospital policy or guidelines, nor good clinical judgement.