Syncope presents a challenge in the ED, in part because by definition the patient has usually fully recovered by the time you see them. It remains a common presentation with an estimated incidence of 6.2 per 1000 population in the Framingham Study.
Roughly 3-5% of Emergency Department attendances and 1-6% of urgent hospital admissions are with syncope. It also becomes more common with over the age of 70 years with a further rise over the age of 80 in women. In older patients in long term care, the incidence can be as high as 6%.
The Framingham Study found that around 30% of patients with syncope had more than one episode. For a single episode of syncope is related to the underlying cause and can vary greatly. A diagnosis is only made in approximately 50% of cases. Our role is to risk stratify serious and non-serious causes of syncope and ensuring appropriate intervention when required.
- Neurocardiogenic syncope – Vasovagal
- Orthostatic – Drug effects, Volume depletion, Autonomic failure
- Cardiac arrhythmias
- Structural cardiac disease – Ventricular failure, Aortic stenosis, HOCM
- Neurological/cerebrovascular – Vascular steal
Falls in Older person
Falls cost the NHS billions of pounds, therefore preventing falls is a national priority.
People who have fallen should have a basic assessment. A multi-factorial assessment is required if the patient has an abnormal gait and balance, or if they have fallen more than once in the last 12 months.
- 650,000 older people attending emergency departments for fall-related injuries
- 82,000 hip fractures
Acute Confusion in the older person
Delirium (acute confusional state) is common in hospital medicine. In the older person the prevalence of delirium ranges from 11%-42% (Siddiqui et al., 2006).
It is estimated that one-third of cases are preventable (Inouye et al., 1999). However, the detection and documentation of delirium by emergency physicians is poor, with reported sensitivity rates as low as 35% (Hustey and Meldon, 2002).
It is vital that we identify patients with delirium in the ED, because if we miss it then often it is not identified.
- Increased length of hospital stay
- Higher risk of complications in both medical and surgical settings
- Higher mortality, both in hospital and up to 6 months following discharge (APA, 1999)
LEARNING OUTCOMES FROM COMPLETING THE TASKS
Differentiate between syncope and other cause of collapse.
Formulate a differential diagnosis for syncope.
Apply decision making tools to risk stratify syncope and assess when to investigate further.
Describe the reasons why older people fall.
Evaluate a patient who has presented after a fall, using a focussed history and examination.
Formulate a management plan to prevent future falls.
Differentiate between delirium and dementia in the Emergency Department.
Construct a structured, pragmatic approach to the investigation of the acutely-confused elderly patient.
Explain the options for sedating patients with delirium if required.
Complete the following before the face-to-face session:
Task 1: Syncope
Duration: 50 mins
This is a very useful module for the Emergency Department and covers many of the available decision making rules and tools for ED.
Task 2: The Older Person and the ED
Duration: 10 mins
Listen to this podcast on the older patients and the ED. It is a brief interview conducted with Dr Jay Banerjee from the Leicester Royal Infirmary ED.
Task 3: MDTea Podcast - Falls
Duration: 40 mins
This episode of the excellent MDTea Podcast focuses on the acute management of falls. What causes them, how to approach managing them, and why they are important.
Click on their infographic to go to the main page where you can access the audio and the show notes.
Remember the bottom of the page also has the specific curriculum links as well.
Task 4: #EM3: Delirium
Duration: 30 mins
This is summary from the IPE session held in the department serves as a good introduction to the subject and how we can identify patients with delirium. It also covers why it is important that we identify patients with delirium in the ED. You can listen to the audio from the session as well as review the slides, don't forget to also check out the infographic.
For another quick summary we also have a Lightning Learning.
Inter-Professional Education (IPE) Summaries
Designing an Older Person Friendly ED (Presented at RCEM15)
Leicester held a conference dedicated to Geriatric Emergency Medicine and we were on hand with a camera and microphone, this youtube playlist covers the highlights of the day.
It includes all the main talks as well as some shorter summary videos. There is more #GEMcon16 content on the website including posters and some resources from our workshop.
We have written a series of interactive cases (wikis) with short answer questions to be answered by trainees prior to the face to face teaching sessions. Currently this is only available to East Midlands Trainees.
Answer one or two questions before attending the face-to-face teaching session. Add comments to answers already given if you think it's appropriate. We will also provide tutor comments. If you find good resources that answer a question why not include links in your comment.
Part of the face-to-face teaching will be spent discussing the case(s) below:
Here are some extra resources to review if you want more information:
Emergency Medicine Cases:
Part of their "Best Case Ever" Series
- This short podcast covers the Mental Capacity Act (2005)
BMJ Learning (subscription Required):
Once you have worked through the exercises, discussed the example cases and attended the face-to-face teaching, please complete the following form: