“Patients who have fallen should be assessed for injury, but why they have fallen is also a question that needs answering – this may not be answered in the ED.”

One of the presenting complaints that gives every Emergency Physician a sense of dread is “Collapse ?Cause”. 

Syncope is a common presentation, accounting for an estimated  3-5% of Emergency Department (ED) attendances, and each year in the UK there are approximately 650,000 older people attending emergency departments for fall-related injuries and 82,000 hip fractures. Falls cost the NHS billions of pounds, therefore preventing falls is a national priority.

Patients who have fallen should be assessed for injury, but why they have fallen needs to be considered. The first decision is to decide if the patient has had a syncopal episode. Using the philosophy of “Rule Out the Worst Case Scenario” it's recommended you consider syncope as a possible cause for all patients who have had a fall and that the latter is a diagnosis of exclusion. 

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.

For patients presenting with a “fit” remember to think, could this be a syncopal episode? A really good history – especially from a witness who can give a description of what happened – and examination is vital.

All patients with collapse should have an ECG recorded and remember to seek out a paramedic ECG if one was recorded on scene for patients who come to the department by ambulance.

A postural blood pressure measurement (lying and standing) may show a drop in blood pressure on standing which is abnormal – but don’t be reassured if the numbers don’t show a drop. If the patient is symptomatic on standing that should be considered to be significant.

Female patients who could possibly be pregnant (child-bearing age with a uterus and an ovary!) should have a pregnancy test to exclude ectopic pregnancy.

Consider abdominal aortic aneurysm in older patients – male and female – and whether these patients need aortic imaging. Be wary of common conditions presenting for the first time in elderly patients – in particular “migraine” (could this headache be a cerebral bleeding event?), “renal colic” (think AAA!) and “fainting”.

Tasks

1. Listen to the podcast and watch the associated slides from the Emergency Medicine Ireland team.

2. Read the RCEM Learning summary on syncope

3. Review the DVLA Guidelines

4. During your next shop floor shift try to see a patient presenting with "collapse ? cause" and complete a case based discussion with a senior.

This video is a summary taken from the excellent Emergency Medicine Ireland website and is a teaching session delivered to a group of registrars. It covers a range causes to look out for, including features in history and examination.

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.

This RCEM Learning summary gives a good overview.

Read this summary document from RCEM - it is worth knowing the specifics for some common conditions, however it is also important to know this document exists and be able to refer to it if you are unsure after seeing a patient. Click on the image to see the full document.