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I completed my medical school and background EM training from India (Christian Medical College, Vellore and Apollo Hospitals, Hyderabad) where I worked for 4 years. Following this, I devoted (with all my heart) about 1.5 years to do US Medical Licensing Exams. My stint towards an EM Residency in States did not work but it took me to places and it has been quite a journey. I then relocated to London, England to work as a Registrar (Non-Trainee) in A&E. This gave me an opportunity to better understand NHS, EM training pathways and more importantly the EM Mindsets in the United Kingdom. 

Currently, I am pursuing Higher Specialist Training in Emergency Medicine at South East Scotland Deanery where I have the honour and privilege of training under some of the most innovative brains in the field of Emergency Medicine. Over the past few years, I have realised that LEARNING and UNLEARNING (which can be challenging!) is equally important to deliver cutting edge care to our patients.And through this blog, I aspire to disseminate knowledge, assist trainees with exams and stay up to date with contemporary EM literature. I have always been an avid FOAMed supporter because FOAMed has always played an indispensable role during my training. 


Lakshay Chanana
ST4 EM Trainee 
Edinburgh, Scotland
drlakshayem@gmail.com

Monday, June 26, 2017

Falls Assessment - Part 2

Several studies report that falls are the most common reason for geriatric trauma. Injuries in elderly tend to be more severe as compared to young even with similar mechanisms and severity. While evaluation an elderly with a fall, we also need watch for complications of prolonged immobility as well such as rhabdomyolysis, pressure sores, dehydration. 

What makes them fall?
  • CNS – slower nerve conduction, slower reflex response, poor co-ordination, decreased proprioception and vibration sense
  • MSK – arthritis, decreased muscle mass 
  • CVS - Arrythmias, Orthostatic drop
  • Visual impairment
  • Medications:  antihypertensives, sedatives, diuretics, autonomic meds, Anticoagulants complicate things further and lead to worse outcomes
  • Infections and related weakness
  • Environmental Hazards 


Here is a list of risk factors that can precipitate a fall:



Elderly are often poor historians
Ask next of kin, paramedics, neighbours, other informants and witnesses to get a better history. Do not rely 100% in a 90 year old with dementia. Follow this rule in cognitively impaired, 

IF IT WAS NOT WITNESSED, IT WAS NOT MECHANICAL 


Mechanical Fall v/s Syncope
Mechanical Fall (Simple Fall) is referred to a fall due to environmental reasons (tripped, slipped, loose rugs etc.) but not as a result of primary CNS, CVS. MSK etiology. 

Common causes of syncope elderly are:
1. Cardiac syncope (ECG every patient who comes with a fall esp if it was unwitnessed)
Advise or arrange follow up with Holter monitoring in unexplained falls. 

2. Orthostatic hypotension (Symptoms are more important than numbers)
In older people baroreceptor function and adrenergic sensitivity is less. Medication such as beta-blockers, calcium channel blockers complicate the picture further. 

3. Carotid sinus hypersensitivity  (neck massage and look for a drop in HR)

4. Micturition/defecation/cough syncope


Fall examination
  • Sensorium (Document Baseline)
  • GCS
  • Pallor, Pedal Edema, Calf Tenderness
  • Vitals: Fever, tachycardia, tachypnea, Low sats, Hypotension, postural drop
  • Massage carotid (if no bruit) to look for coated hypersensitivity 
  • RS/CVS/Abdo (suspect abdominal catastrophes, pneumonia)
  • Vision
  • CNS- Speech, Pupils, Joints ROM, Strength in limbs, gait assessment (if possible)
  • Skin - hidden abscesses, sores
  • AMT
  • Head to toe exam like secondary ATLS survey 
Delirium and tachypnea are two big signs of underlying infection



Assessing dependence and ADLs 
Assessment of ADLs (Activities of Daily Living) and IADLs (Instrumental Activities of Daily Living) – will help to determine how functionally independent the person was before the fall. This is helpful to plan discharge and assessing their functional abilities. 

Activities of Daily Living
  1. Transferring
  2. Toileting
  3. Bathing (first to be lost)
  4. Dressing
  5. Feeding (last to be lost)
  6. Continence
Instrumental Activities of Daily Living
  1. Meal preparation
  2. Housekeeping
  3. Medication management
  4. Finances
  5. Transportation/Driving
  6. Shopping
  7. Phone and use of technology

Assess function, need for carers and Mobility
At our shop, we are blessed in this regards as we have out super-efficient STARRS (Short -Term Assessment, Rehabilitation and Reablement Service) team to handle these issues for us. They often arrange home visits to double check if everything is okay. 


Falls Labs (with some clinical judgement) - Do not order everything for everyone
More testing leads to more false positives, unnecessary further work-ups and possible harm. 
  • CBC, CRP, Renal Function, Coags (if on Anti-Coagulants)
  • ECG
  • CT based on exam/suspicion of injury (Head, Spine, Chest, Abdo) 
  • Relevant X Rays (CXR, Pelvis, Others)
  • Urine dip
  • Cultures/Lactate if infectious ethology is suspected

DO NOT TREAT ASYMPTOMATIC BACTERIURIA (DON'T EVEN DO A URINE DIP IF THEY ARE ASYMPTOMATIC AND COGNITIVELY INTACT)


Imaging elderly
Have a low threshold for imaging (CT head/spine and CXR and Pelvis X ray) even in minor trauma. There are no long-term consequences of radiation exposure in this elderly. And remember, CT is just a snapshot, safety net them regarding the possibility of delayed subdural in future. 


Discharge Planning
New injuries may have a significant impact on the older person’s ability to function. Try and see things from their perspective or think - would you be happy to discharge your grandmother is she comes in with a similar problem?" For instance, they may not be able to climb two-floors with a knee injury, she may not be able to eat, cook with a sub on her dominant hand.

Preventing Falls
Small efforts towards prevention can make a huge difference. 
  • Document frequency and situation and look for a similar pattern
  • Request a thorough Geriatric Assessment (for Bone and Muscle weakness, Depression, Mobility, CNS) in case of frequent falls
  • Assess balance and gait as part of your physical exam (they might need walking sticks or frames for support)


Further Reading:
Aschkenasy MT, Rothenhaus TC. Trauma and falls in the elderly. Emergency Medicine Clinics. 2006 May 1;24(2):413-32.


Posted by:

              
     Lakshay Chanana
     
     Speciality Doctor
     Northwick Park Hospital
     Department of Emergency Medicine
     England

     @EMDidactic


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