Learning of the Week
This week has seen the first of my case-based discussion (CBD) clinics slowly filling up as everyone is coming to grips with their new jobs in the ED. As such, every doctor is required to do CBDs as part of their training to allow them to learn from the cases that they have seen.
Hopefully each week I’ll be summing up the key topics and guidelines we have been covering as part of these CBDs.
Topics this week: The Older Person Who Falls + Wheezy Children
The Older Person Who Falls
Falling in the over 75-year-old is one of the leading causes of mortality in that age group. It is estimated that 4 million visits secondary to falls occur each year in our EDs. The annual cost of falls is estimated at £1.7 Billion pounds in England every year. This is likely to rise with an ageing population.
The challenges of the older person who falls, who presents to the ED… where do you start?
Let’s start at the very beginning…
Take a good history… the how’s, the whys, the wherefores are crucial.
From this, consider – any recent symptoms of infection? Any cardiovascular signs or neurological symptoms leading up to the fall that precipitated it?
Can they remember the fall? Any head injury signs?
What is the problem today? Have they got any injuries? Have the family got any concerns?
Where are the injuries? What are the injuries?
Is this their first fall? Or their tenth?
Medications… What are they on? Anticoagulation? Blood pressure medications? Other medications?
Past Medical History… Are they swimming 10 miles a day, or do they have multiple co-morbidities?
Social History (is key)… Are they fully independent or walking with a frame?
Clinical Frailty Score (CFS)
The clinical frailty score can be used to help determine in a structured way how frail someone is. This becomes important with patients as it can help when thinking about ongoing health and social needs. It is also a way of describing the frailty of a person between the MDT so everyone understands what patients’ needs maybe.
Examination
Examination is crucial. Have a good look at everything. Older people are often very stoical, and this can let you get side tracked. I still remember the case of a missed neck of femur fracture in a patient who was in his 70s who had fallen from standing height. He had been just able to walk on it for 1 week having seen his GP twice, and when he finally came to use it was because it just wasn’t better we found it was broken.
Have a very, very low threshold for imaging especially for heads, spines and pelvis’.
Think about constipation? This is a common cause of confusion and thus falls in the elderly.
Futher Reading…
- #LeicGEM: Falls, Fractures & Trauma
- Geri-EM: Personalized E-Learning in Geriatric Medicine
- BMJ Best Practice: Assessment of Falls in the Elderly
- NICE Guidance: Falls in Older People – Assessing Risk and Prevention
Wheezy Children
A tricky topic where the management will fundamentally come down to what the cause is. Here's a list of some of the causes of wheeze, categorised by age…
Infants 👶
Oesophageal reflux; Congenital Anomalies of the lung, heart and airways (e.g. tracheomalacia, bronchomalacia, tracheoesophageal fistula, double aortic arch, anomalous left carotid artery); Cystic fibrosis; Infections (e.g. bronchiolitis, pneumonia); Ciliary dyskinesia and Immunodeficiency.
Preschool Age 👧
Viral induced wheeze; Foreign body ingestion; Cystic Fibrosis; Oesophageal Reflux; Infections/post infectious causes; Immunodeficiency and Congenital anomaly.
School Age 👱♀️
Asthma; Vocal cord dysfunction; Cystic fibrosis; Infections/post infectious causes; Immunodeficiency; Alpha-1-antitrypsin deficiency and Foreign body ingestion.
Futher Reading…
- Don't Forget The Bubbles: Steroids for Pre-school Wheeze & Easing the Wheeze
- RCEM Learning: W is for Winter… and Wheeze Paediatric Acute Asthma & The Unhappy Wheezer
