Tag: collapse

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