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Just wait for a yes, just to make sure everything's actually just working and then we'll start. Awesome. Thank you. I'm Natasha and I'm currently in my f three year. Um We are gonna be talking about falls and silver trauma from an A&E perspective. Um As always, uh we're gonna try and keep this as interactive as possible. So if you are watching it on your laptop, just get your phones ready. I'd appreciate it because you might just want to take a little bit of notes or just take a picture of the case because we've got questions coming back after now. Um I've got my ipad beside me. So I'm just looking, if I'm looking to the right, I'm looking at your chat box. If, if you've got questions at all, just pop them through and we can get it through. But it's just to have an idea um for us to be more interactive in this session. So learning outcomes wise, what we're gonna do and what we're trying to achieve. The first thing is I want us to be able to approach a patient with a fall confidently to recognize that there are various pathophysiology behind this, be aware of management and treatment from an A&E setting. And always, always recognizing the importance of see of care or treatment escalation plans when it comes to the geriatric population, I want us to also be a little bit more conscious about limitations of management and treatment. And while you're doing all of this, maintaining a very holistic approach to your patient's care, so let's go very quickly and talk about facts about false. So this one's, well, this one's not exactly the most reliable reason, but, you know, for the sake of the Jif that I put out, what do you think the chances are being struck by lightning in the UK? It's a great brain tease at the start today. Yeah, we think it's, I mean, it is really rare. We think about it. It's actually apparently more common in the US. So it's actually one in a million chance. So I pity said grandma over there. But here there are just a few more poles that I wanna put up and we're just gonna think about them as well. So the first question is as a fraction. How many over 65 year olds have a fall? Do you think a quarter, a third, a half, three quarter of the population have a guest, don't worry. Go. And I know there's more of you, you can join into the polls. Yeah. So over 65 about a third of the population have a fall but as a fraction, my next question is how many over 80 have a fall? Good. So we think it's definitely more than 65 year olds. But how much more? Yeah. Spot on. We think half the population over 80 year olds have a fall, which is quite shocking. To be honest. My next question for you is what percentage of ambulance call outs are due to falls out of 100% of ambulance call out? 35% of that is due to the elderly population. But out of that, how many do you think are about falls in itself? And the these polls are not just only to get you to interact with me, but I think it's about us understanding how frequent someone can actually fall and actually just how high that percentage is about the geriatric population that fall in the UK. So yeah, 10 to 25% of ambulance calls are due to falls and it's a lot of numbers. But something that I read recently would make you realize actually how high the incidences and this is done by the UK Geriatrics Society. Um, an elderly person over 80 years old falls every 10 seconds. So that's six elderly people every minute in the UK. Now I've used the word fall already probably more than 10 times and I'm probably gonna use it another 50 more times in this presentation. So what is the definition of a fall? So nice has basically defined a fall as an either an unintentional or an ex unexpected loss of balance that has resulted in you basically resting on the floor or the ground or an object that's below knee level. And when people get a fall, you'd be surprised at the percentage of people that actually get hospital admissions or actually get treatment for it. So what's good and what's important to know is that when they actually do come into hospital, about 20% of falls can actually lead to very serious injuries like fractures and head injuries and bleeds, et cetera, et cetera. Very common incident is hip fractures and about 90% of hip fractures in over 65 year olds are due to falls. So falls lead to a lot of trauma. It leads to a lot of hospital admissions and it's something that comes in very commonly in Ed. So how we're gonna go about? This is number one thinking about the causes of fall. Um Yes, I know it's not the fairest of questions in the world, but it's a great question for you to pop down in the chat box for me. What do you think causes or falls? Are there are so many I know, but if we get at least five, I will move on. But I do need you guys to let me know and put down and drop chat like the chat box for me. What do you think common causes of a fall would be, yeah, mechanical or physiological. So you said physiological, what do you think infection, eyesight problem? Great. Someone's thinking outside of just, you know, medical issues, we're thinking about environmental issues. So like your, you know, eyesight problems, you're thinking about lighting, you're thinking about rugs, you think about just a different environment whatsoever. Low BP physiological brilliant was thinking more about cardiac. So a little bit like postural hypertension, anything else? So we've mentioned infection, we've mentioned cardiac, we've mentioned arrhythmias. Absolutely. Syncope, hyperglycemia. Extremely good thing to find out and invest an initial BM would tell you whether somebody's hypoglycemic. Um Can anybody else think of other reasons? So maybe things to do with your muscles. Yeah. Hyperglycemia. Brilliant, brilliant things to do with your muscles or maybe neurologically sarcopenia. Yeah. Yeah, 100% Parkinson's. Yeah. So we've got that different demographic of Parkinson's Alzheimer's and how it affects your balance, your proprioception and how it affects your neurological symptoms. So, thank you everyone. You've, you've done brilliantly and you've given me so many different causes. So we know that it's several causes. And the biggest thing to understand about fall is that it is all these causes, both intrinsic and extrinsic that work together to cause a fall. How do you want to go about trying to like differentiate them? And it's to think about these different categories like you've mentioned in your examples. So one is environmental factors. Two is cardiac factors. Three neurological factors like stroke, seizures, parkinson's and how it affects your balance, musculoskeletal arthritis. Um just weak muscles, common deconditioning after the infections. Like somebody has mentioned vision defects, like someone's mentioned just generic frailty and how someone will continuously have a poorer physiological reserve as they grow older. Mental health is another one. So it's very good to just understand the different types of causes of a fall. So, has anyone ever tried to talk to a well geriatric patient that's come in with a fall? Um Geriatric patient, that's just a bit all over the place. Any common challenges that you've ever faced with them, either talking to them or trying to examine them. Um Anything that you found difficult, anything that you have ever struggled with? Yeah, exactly. So, yeah, no memory of the fall. That's, that's annoying because that's what they've come in with and you're trying to find out the reason for their fall, the hearing their understanding. I personally keep apologizing to them when I start yelling at them because I know that they can't hear me and maybe they might hear a fraction or you end up spending about 20 minutes trying to find this hearing aid, which is not there. Some are not good historians. Yes, that word poor, a poor historian is mentioned multiple, multiple times in all of our entries. Um And when we read that we all just have a little moment for ourselves, but with that said, like someone's already mentioned the history itself huge challenge because they've come in with this suspected fall. We don't really understand how, why, what's happened. So how do you go about doing it? Number two is actually I find a huge challenge is understanding their baseline. So it's really important to know somebody's mobility baseline and their cognitive baseline when you're looking at a new patient in front of you because you want to know, has it changed? Is this the same? Is this common for them? Delirium is a huge challenge because delirium patients present in so many different wonderful, very fascinating ways. And that goes hand in hand with not being cooperative. Sometimes they are challenging patients or they can be challenging patients with you. And these two kind of go hand in hand when you have a patient that's come to you in a and a and they're not very well coming in after a fall or a suspected collapse. And they've got a bit of a guarded prognosis and you need to consider and think about sea of care and their treatment escalation plan because like most things, unfortunately, most of the geriatric population that do come into the UK are all for full active management and it depends case to case. But this is something that when you're in the hospital with someone that is quite poorly, someone that's quite unwell, that has multiple comorbidities that has a very poor physiological reserve and you're hitting the ceilings of treatment for them. This is when you are concerned about their prognosis and you're concerned that actually nobody's actually spoken to them about different sees of care, their opinions or explained it to them before they got poorly. It's something that you have to take on as their clinician at three in the morning, unfortunately, but these are some of the challenges and we're just gonna talk through them as well with that said, these next few slides are going to be an approach to a fall or to a query collapse and how you're going to address these patients. So I like the common Ws and the hitch. And what that is is basically your w for where did it happen? When did it happen? What were you doing at the time? And who was around you at all of this? Why did you think you fell? And the reason why I asked them this is because you want to actually understand their understanding and their limitations of their own falls. Most of the time, you'll find that they are masking their own falls. They're just putting it down to, oh, just trip, don't worry about it. But what was concerning and what is concerning is actually trying to figure out whether they've had previous falls and it'll be very unsurprising to just find out that they've had multiple falls prior to this. And how did you fall? And I know like we've mentioned before, this is a huge challenge trying to find out the before the during and after because this actually helps us come true to a cause come true to a differential and not finding out these things is frustrating. But unfortunately, that is the dilemma that we're in. And ideally what would be super useful, extremely good to have is a collateral history. It's good to know that if your patient is from a care home, it's four in the morning or 230 in the morning, you're always allowed to call the care home and always get a collateral history from them about baselines, just about what they think happened or where they found them. Um, obviously, sometimes it's very difficult otherwise when there is no one there and then you just have to move on from that. But moving on from a history perspective, what more you would do past medical history? I know everyone knows we get a past medical history, we write it all down in a beautiful list. But what exactly are we doing with it in a geriatric case is I want you to start thinking about how complex their comorbidities are. How is it affecting their ADL s their washing, their walking? Are they still independent? Are they no longer independent? How does it affect their quality of life? The medication history? Great. We, you know, write it all down. That's great. Most over 65 year olds now have more than eight medications and that list is still growing as the population just grows. But I, what I want you to think about is polypharmacy. They're anticolonic burden. And two things that I'm not touching on very deeply on this presentation are the Beers criteria and the Stop Start program in the UK. And these are just both programs for the geriatric commu like community where you're thinking about deprescribing and stopping medications that are, you know, that are safe to be stopped in terms of the social history for them. What you want to know about is basically like what Carl is doing here is having a stair lift in his home. You want to know about their mobility. What is their current mobility before they came into hospital? How independent were they with the AD Ls? Where are they living? Are they living in a bungalow? Are they homebound? How many carers did they have? And who's their next of kin and who's their family? Who's their support around them when you actually need to call someone about them to update them, to talk to them, to discuss things with them if they lack capacity. And this is when systemic inquiry becomes so useful because when you have a very poor historian or basically what I like to just say is the patient just couldn't recall the events of the fall is you just throw a lot of questions systemically at them and you just get yeses or nos. Again, this comes with their own challenge that they might be confused comes with their own challenge of hearing like someone has mentioned, but it's the best that we can do to try and attack as many different, you know, uh systems as we can to get any more symptoms or any more relevant clinical history. So you go through your own systemic inquiry, ask them the relevant questions and try and gain something from that. So anything else that is fairly important that you'd want to know is one frailty? Anybody know what you know, a frailty scoring tool that we use. Um So there are two tools that we use commonly in the UK. Uh One is a frailty scale. So that is literally the clinical frailty scale or the Rockwood scale and the other one is the modified Rankin scale. So with that said, when we talk about frailty, anybody understands or does anybody know what makes up the frailty criteria? There are five things in total. Anybody want to give me a little guess about what makes somebody frail. So even a random guess. Yeah. Two com Yeah, you're on the right track. Santiago. Thank you. Thank you for answering. So, more than two comorbidities, it's part of the risk factor, but I think where you might be going with that is how it affects them. So in terms of the frailty criteria, there are five things and one of them would be low energy and would be low physical activity. So like you're mentioning how their comorbidities would affect them and that they have a slower physical activity, how they are, you know, they've got reduced weakness and they've got unintentional weight loss. So these five aspects can make up a frailty criteria. And that scoring tool that I was talking to you about is known as the clinical frailty scale. And we are going to get very used with this clinical frailty scale at the minute. So if you can and if it's doable at the minute, um just take a picture of your on your phone or just Google it very quickly and have it with you as well while we're talking about the next cases that are coming up. Now, a clinical frailty scale was invented as a way to summarize an overall level of fitness or frailty of your patients. How it's developed is with our clinical acumen there. It's been used as a tool to stratify degrees of fitness and frailty. Now, when you're documenting someone's clinical frailty scale, when you're actually larking someone in, I want you to remember when you use ACF S score, you're documenting what their frailty level was. Two weeks before admission, it is not what they are when you're looking at them face to face. It's what they were two weeks before. What I want you to understand is that four is being at the cusp of being well jumping into the frailty criteria. So that is understanding that at four, they're not dependent on others for their AD LS, but their symptoms will limit their activities. They're starting to slow down. Whereas while they're frail, they're showing that they need help in or with their AD LS with that said the next criteria that I like talking about that's important is delirium. Uh We know delirium. Delirium is an acute fluctuating confusional state that is multifactorial. Now, you guys will know the answer to this. What is a scoring tool that we use to assess someone with delirium? And I will not, I will refuse to move on until I get the answer. So it's a very common, very rapid screening questions that we can ask people. Yeah. Brilliant 480 someone's mentioned cas ICU. Yeah. So I think in terms of rapid efficient like initial assessment of a cognitive impairment, what we tend to use here is, is the 480 for delirium screening. Um It helps you basically just test for delirium and whether or not there's any underlying cognitive impairment behind that. What I want you to just be aware of the pinch me. Uh Pneumonic is basically the potential causes of delirium. Again, very multifactorial. Any element of this can exacerbate your delirium. Next thing I want you to think about is your treatment escalation plan and your feeling of care in our geriatric population. It's something good to always have at the back of your mind and it's always good to start that conversation with someone and while they are in an inpatient with you, they are not going to be very mobile and it's good to think about VT if they're not suitable for Enoxaparin or Tinzaparin, whatever your trusts want to prescribe, um, think about your Ted Stockings. Just consider this because it's obviously a very high chance for them to develop VT S while they're an inpatient with you. Now, when we come to an approach to examination and investigation, we're doing an A&E series. I want you to keep telling me that we're gonna do an at E. So in brackets, what I've done is we'll just talk through it. You want observations, you want to check their airway while you're checking for the air breathing. You can do an ABG or a chest X ray looking at their heart. You are, you want to get some cannulas, you want to get some blood E CG urine dips. Um Does anyone want to know why I and the geriatric, the geriatricians are not a fan of urine dips in those over 65. Um And we've got catheters and doing line standing blood pressures. We've got BMS, which can be easily done and everything else. So you can think about your swabs. If anything is discharging, you've got sores, medical photography. If you need tissue viability nurses, if you need dermatology, any neuro observations, when it comes to imaging, you just depends on your pathology and also their compliance with you. Uh Many a time were stuck. Yeah, many a time were stuck in terms of compliance trying to get this very delirious, very agitated, very excited patient through a scanner for a CT head or an MRI head and it just does not happen. Um Even x-rays sometimes and we have to think about things like sedation and things so like like Jessica's beautifully mentioned. Yeah, the elderly usually have some protein in their urine. Normally, a urine depth in people over 65 most commonly come back with at least two or three of the elements positive. Anyway, um and we'll talk a little bit more about that. So urine dip is not the is not the girls standard way to diagnose someone with a uti it's symptomatic and if you want, if you want to show you anything, it's probably just gonna need your MC NS. So different examinations that we're gonna cover it through is number one, your Silver Trauma therapy. So what exactly is the Silver Trauma survey? It was initially started for your major traumas in people that you know, have had like a road traffic accident. It was very atl s kind of lead. But what we've noticed over the last couple of years is that your trauma patient has changed from the 30 year old that has had a huge trauma to actually a huge population of over 65 year olds that have had falls and they have actually we've actually delayed intervention, delayed management, delayed them moving into a major trauma center because of missed things. So, the Silver Trauma survey has actually been adapted to accommodate this population. Um, sorry to recognize major trauma in over 65 year olds. So how does it start? And it basically starts with examining a person's head and examining for bruises, examining for bumps or bleeding. And then you go down to your neck, your cervical spine. And you're looking for, you know, range of movement. You're looking for any tenderness on palpation and then you go down your spine. So as you just go down your vertebral column, again, you're looking for any tenderness, you're looking for any per uh spinal spine, you're looking for your thoracic rotation. You're looking for any, you know, red reduction in range of movement there. And then you're just going through basically all the bony bits in someone's body. So you're looking at your shoulders, elbows and wrists, you're doing a very quick um look, feel, move and a range of movement to see whether there are any bruises, whether there are any, you know, reduced in range of movement or tenderness. Basically, anything that can indicate that there is a pathology or a fracture or anything causing this pelvic girdle, extremely important. You're trying to see whether there's any signs of any pubic rami fractures. Um And then we're going to our hips, hips are huge, hugely important. So you're trying to look at your range of movement. You're trying to see whether they're able to straight leg raise at all and if they're able to flex and your knee and ankle. So this is what a silver trauma serving looks like in my, um, in my department here in MD. So again, it's basically like what I've mentioned to you and it just tells you basically, it's not an exhaustive list, but it gets you through making sure that every bony bit of your body you've actually had a check. And if there's anything that you are worried about, you would do an X ray first. And if that's not the case, then you would think about Act. This is a very good poster. And what it basically wants us to do is recognize any major trauma. It starts with an at E and then it goes through your secondary survey like your silver trauma would and then you think about your imaging, for example, Act head Act neck or what's very common is CT pan scanned where you've got tenderness everywhere, you're not sure what's going on. And that's basically a ct head neck, thorax, abdel vs. So you're scanning them everywhere with that said, what's very important next is a neurological examination again, because sometimes your patients aren't really telling you anything. So what you got to do is you got to examine them to find out if there are any symptoms starts out very simply with inspection. Um common pneumonic is you're swift, your scars, you wasting your intention, tremors, any fasciculations and any, um I said tremors already didn't I? Yeah. Um, and then we've got a tone power reflex and we've got a sensation, cranial nerve examination, cerebellar examination. Danish is a very common mnemonic that we can use. And these two go hand in hand because what they're non compliant with your examination, they're not really exactly letting you examine them. It's just if you can't do a proper G CS with them, not following your command, just do an A V pu what I tend to do or try to do, let's say when they are those excited agitated patients is just try to shake their hands to just see their grip strength just to see whether they will. That gives you a fairly, fairly, fairly rough in the middle gray idea about what's going on. And if not, what I'm trying to do is just lift up their hands and just see what they do with it. If it's completely floppy, if they actually send it out or if they're actually waving it all about and they're trying to hit you or something, you at least know that their limbs are working. So, I mean, it's not the most ideal case, but it is what happens. And the third one which you will see very commonly in the geriatric ward are for a geriatric, a geriatrician as apr examination. Why? Because we're talking about constipation, exciting stuff. But it's actually so important because in the geriatric community, you'd find that constipation is actually very significant to almost all pathologies. Because number one, it can cause infection or obstruction, pseudo obstruction, like Ogilvy's, it can then cause urinary retention which causes their discomfort, their pain, they come in with abdominal pain, just generalized and then most importantly, it just exacerbates everything, their confusion and their delirium. And what exactly can cause constipation or numerous of things. Immobility, having complex multiple conditions, polypharmacy, frailty, dehydration and nutrition. But it is a very important element when we talk about examining in somebody that's coming in with a fall in terms of the geriatric community. So that is a very quick stop idea of how we're gonna get through a few things in terms of an approach, what we're gonna go through next is a series of cases and we're not gonna go through everything as systematically as I said, I know very hypocritical, but we'll go through it so that we can just cover a variety of pathophysiologic. So we've got an 85 year old female that's come in with a fall. It was witnessed lucky for you. She fell on her side. She's unable to mobilize because of pain. So they couldn't get her up until the paramedics came to get her. She's got type two diabetes. Previous history of endy hypertension cataracts. She's on some insulin clopidogrel, ramipril, amLODIPine and she mobilizes with her Zimmer frame independently. So my first question for you is what do you think her clinical frailty score is? So, just take a second, have a look at what that case is or take a picture of it if you don't mind. And this is your clinical frailty scale, what would you guess it would be? So, she's got a few comorbidities. Um She immobilizes a little bit with a Zimmer frame just getting a bit slow go on guys. I think we can do better. No, we've got a variety of answers. That's what I like to see. There is no wrong. I will be very honest with you because at the end of the day, this is all very subjective and you will see that most of the time in a frailty team assessor come to assess them and it changes almost instantly after one of us have clocked them in. So, yeah, I would agree with um with the majority here, it is between four and five. So I would assume she's a four. She's at the cusp of being a little bit frail. She's otherwise quite well in herself and not having mentioned to you, but she's fairly independent with the Ad Ls. So you've done a silver trauma and her excellent well done. You were paying attention to me. She's very tender in her right shoulder, her left wrist and her left femoral head is very tender cos it's shortened, it's externally rotated. She can't move it because of pain. So we've done a series of x-rays. So this is her shoulder. Now, all I would like and all I would appreciate from you guys is, can you tell me in the chat box? Is it normal or abnormal? And then we will discuss, so just say normal or abnormal, have a look. She was very, just tender around the um head of the right humerus, abnormal normal. Oh, very interesting. Any idea why it has? You think it's an abnormal x-ray? Was there anything in particular? I've got two normals abnormal. Ok. So what was abnormal to you guys fracture? Ok. Well, if I just show you guys, so this is actually a normal shoulder x-ray. So if you are looking at anything, you would just look at the lines of the bones and look for any, you know, well, different lucency or different factors. You're actually just seeing a normal shoulder x-ray with a normal humerus head and normal contours. Actually, that, that, that's just um really just how the position is, but it's good to be mindful of it. Number one, you'd always relate it anywhere where, where they're tender. But um that is just a normal, good space in between. Ok. So next one, we've got a wrist. I particularly hate hand x-rays. What do we think normal or abnormal? She was complaining of tenderness around the radius. So let's say she was complaining of tenderness around this bony head if you can see my cursor normal or abnormal. Oh, someone's not sure. That's all right. Normal. Yeah. Yeah. So this is a perfectly normal wrist x-ray again where she's pointing, you're looking for the lucency of the bone. You're looking for the good contours of the bone and they are all within normal range. Yeah. Brilliant guys. Normal. Yes. Oh, we've got a hip X ray here. So, take a minute. Have a look normal or abnormal. And if you want extra stars, we can, if you wanna just tell me what you think you see. If you see something you can just go for it. Abnormal. Yes, Jessica, I agree with you. This is abnormal. Does anybody wanna agree with Jessica? What do they think it is strep L of Shenton fractured neck of femur. Yeah. Brilliant. It is a left sided fractured neck of femur, neck of femur. So first question for you in terms of this. Yeah, neck fracture. Absolutely brilliant. You guys are on it. Do you think it's intracapsular or extracapsular? Do is a 5050 guess intracapsular? Very interesting. So just for, well, to remind ourselves basically what it is. So we're looking in between our femoral head and our intertrochanteric space where our great tranter is this area here is intracapsular and everything below that is your abs extracapsular space. So yes, it is an intracapsular Neco feur fracture. Ok. So we have some clinical concerns about case one, about 85 year old female. What would be the management for her neck of feur fracture? Anybody, anybody wanna wild a guest? Would it be conservative or would it be theater TN O referral? 100%? I agree with that. Yeah. Oh, someone's got 100% for this. Yes, I agree with all of you guys. TN O referral. 100%. Uh, they're the specialists but somebody's been extra great. They've said hemi arthroplasty. So let's take it step by step. We'd want her bloods and a coag on her done to make sure that I nr is all fine. Um We would do a fascia iliaca block on her while we're in A&E just for pain control. And that's literally just where the femoral nerve is. What we would do, give her a very stronger anesthetic agent like bup of the canine and just make sure that she's comfortable in that sense. And then yes, orthopedic management 100%. Let's just load it off on them. But the question is, are they fit enough? So for someone that has had an intracapsular fracture, you want to first your first question is, is it displaced or is it undisplaced in her instance? It is a displaced intracapsular fracture for ladies or for not ladies, for people that are over 70 years old. The I think the most common thing is what they would do is a total hip arthroplasty where they change the femoral head and the acetabulum. If they are not fit enough. They normally go or they opt for a hemi arthroplasty. This changes, per trust, this changes per team. So, my question to you is, is this lady fifth enough to go through surgery? The orthopedic reg is speaking to you. So I'll let you have a look again at her entire case. Do you think she's fit? Someone says yes, she is fit. Yeah. And I'll just go back to the case. So what do you think? Yes or no, I'll wait for one more person. Oh, that's brilliant. Yeah, we've got two people that agree 100%. I think this 85 year old is, you know, fit enough for surgery. So next is they've gone for surgery. This is way past A&E but like we've got an Oreo Geriatrician point of view where, what they will do is have a look at her in terms of what, what's the mechanism of the fall. Um, in terms of her frax score, which basically evaluates the risk, the fracture risk of patients. It gives you a 10 year probability of fractures. And according to that score, according to the mechanism of the fall, was it low injury, high injury? They can start her on treatment like Vitamin D calcium bisphosphonates if she needs a dexa scan, thinking about osteoporosis and her bone density. Um just for later reading if you ever want, uh we've got the Frax guidelines and we've got the NOG guidelines to help us. Now, my next question for you very quickly is are there any other reasons that could be contributing to a fall? So you guys told me this beautifully earlier, different causes. So we obviously know that she's got enough anything in her past medical history or her medications that you would think could contribute to her fall? The cataracts? 100% well done. Jessica. I agree with that. Anything else? I'll just wait for one more person to just give me a potential cardiac meds. Visual issues. Yeah. Brilliant. Yes. So we've got, we got a plethora of things going on there. Um, amLODIPine. Yes. Medication. I want you guys to look at it. Diabetes. Yes. So on things. And what I want you to do is I just basically wanted you guys to look at it and think about these things. Ok. So we're going on to our second case. We have got a 73 year old guy that's come in with an unwitnessed fall. He's been found the next morning by the carriers on the floor. He's confused. He's got some neck pain. Um, and his past medical history, he's got af he's had a previous stroke, previous M I, he's type two diabetes. He's got his real vascular path basically. At the end of the day, he's on a DOAC, he's on quite a bit of pregabalin gabapentin. He takes the medication for his diabetes and he is housebound. He's got carers t Ds. So take a second read all of that. What do you think his clinical frailty score is? I'll just give you an extra minute of just reading that. We've got the clinical realty scale. Oh, we've got a very quick person to say eight, very severely frail. We've got a six, we've got a seven. So we've got in betweens, we've got a 6 to 8 and I like that. So to me, this would be around a six to a seven. I would agree with you as well. Just because of obviously the car. Yes and how he's house bound. No, on examination with him. He's got a G CS of 14 out of 15, which is new for him. Um for confusion, his power, he's got this reduced power. So on the right side, upper limb and lower limb is four out of five. And on your silver trauma, he's got a right sided head wound. He's got c spine tenderness and um he's got c spine tenderness at C three or C four. Can ap span, increase the risk of frailty. I think for a doac it increases your risk of complications. That's why you always have a risk of benefit discussion with them, but it doesn't necessarily increase the risk of someone becoming frailer if that helps. Now, coming back to our 73 year old chap, we've got clinical concerns. Number one. What are your current differentials? So let you go back to him right now this scenario that you have, I know limited information. But what do you think is a differential for this fall or what do you think is going on with him? With all of those examination findings? A reduced G CS, reduced power? Anybody wanna think about anything else at this point in time? Someone with neurological findings, someone with New G CS. Yes. You wanna think about a stroke 100%. Can someone think of another differential hemorrhagic stroke? Yeah. Yeah. 100%. Yeah. Can someone think? Can you guys think of another one apart from a stroke that you would be just a little bit worried about? Just from maybe his uh past medical history? Hypo? Yeah. Yeah, 100%. He's on a Gliclazide. Hold on. Sorry, sorry. Tas I'm just trying to give you guys a thumbs up. I really appreciate it when you guys developing neuropathy leading to false. I like how you think? Yes, I agree. Yeah. So we've got different ways of thinking here so we think could be a stroke. That's brilliant. So, what initial investigation would you like to perform for him? What would you like to do? I'll wait for you. You're leading me head ct. Oh, bloods. Yes, you're right on it. Great. Blood glucose. Yeah, I agree. First thing BM. 100%. Yeah. You'd wanna do that. Anybody want to do anything about the c spine tenderness that he has in the C three and C four CK. Yeah. 100%. You want to do a CK on him. He's been left on the floor for quite a while. We don't know how long he's been on that. You're concerned about rhabdo. Anybody want to do, anybody know what they're gonna do about this c spine tenderness. Stabilize the neck. Yeah. Beautiful. Yeah, you do want to stabilize this neck. What are some of the signs that will make you concerned about his c spine tenderness? This could just be like neurological findings. So it could just be things like um pins and needles down his hands, reduced sensation, paraesthesia. So like Taz has beautifully said, you want to stabilize his neck. This is a collar and cuff. Oh brilliant Jessica, you've just reiterated what I've said, collar and cuff. What they're doing in the middle, there is a lug and roll and this is how you would examine a patient very, very carefully for c spine tenderness. Does he fit the criteria for act head as the next big thing? And what does it show? So we'll go through it so, very quickly. Nice guidance has created a beautiful flow chat for you. So yes, for a cervical spine very quickly, you would immediately go for a scan of A G CS under 12. And if they are, you know, if there's a suspicion of cervical spine injury, any dangerous mechanism of injury, any paresthesia that we've talked about. Now, we're talking about a CT head scan here. A G CS of 12 or less or G CS of less than 15 at two hours after the injury, which this person has immediate. Yes. Now I'm not gonna go through the rest of the flow chat with you, but you're gonna have the slides soon. So you can definitely go through yourself too. So, very quickly, guys. What do you think the CT head shows? I'll be a little bit cheeky and I'll show you where I think it is where my cusses. So we've got a convex side that's under the dura subdural hemorrhage. Oh, absolutely. Well done. Yes. So who are you gonna discuss a subdural with? You're gonna discuss it with your neurosurgery? Yeah. They're gonna ask you, is your patient fit for surgery and based on what we've discussed on this clinical frailty score, they're gonna say that it's more likely than not, please monitor his BP aimed for under 100 and 50 systolic and rescan. If his G CS drops and deteriorates would likely not be a candidate for neurosurgical intervention. What do you do? Two things? You talk to your patient about it, talk to his family and his next of kin about it and you discuss what the limitations of his management is going to be at the minute. And if he's confused and if he lacks capacity, you know, dolls have to be in place and he needs to speak to the next of kin next case, 69 year old has had a fall and had a collapse brought in by ambulance from supermarket following a sudden collapse. So we've done the before during and after and she's great. So she got some warning signs. She's had palpitations, she was sweaty, she was dizzy but she was not sure how long she was lost conscious for and there was no postictal period. She's a fairly fit and well lady, she's still working at 69. Um She's only on one tablet, amLODIPine for 5 mg. And to me, she's a fairly, fairly fit um physically well lady, she's a clinical for score free. What investigation would you want first for her? Something that's easy. Something that's like more like bedside wise that you can do for this person D dimer and Troponin. Yeah, I hope you came for my D dimer lecture last week. We can definitely consider that you're worried about it. What if her observations were stable? She's not hypoxic with you. Yes. Brilliant Santiago. Brilliant Jessica. I'd want you to think about an E CG. So this is her E CG. What do you think her ECG shows? I've just put up a little poll for you guys. Take a proper look to look at the L rhythm strip right at the bottom. What do you think? It could be my first question that I always ask myself when I look at CG. Is, is it regular or is it irregular? And to me that looks, that looks irregular. Yeah, we've got 100% success rate. We think that this is af so clinical concerns start all over again. You know that this E CG shows us af So what is your first most important question? I want you to think about whether this patient is stable or unstable. That is your first question in arrhythmia, any arrhythmia? And this is what A LS guidelines tell us if they have any signs of shock syncope M I or failure, heart failure, they are unstable and you go down the unstable pathway. Now, if she is stable and you can go through the pause where she, you know, has an irregular narrow complex tachycardia, you won't control them with beta blockers or dilTIAZem and you'll just basically stabilize her in that sense. Now, things that could trigger your af anybody know, things could just make you go a bit awry. Things that can just cause it to flare up. You would say common things are common. Um When somebody's a bit poorly, if they are poorly with, you know, different types of, I'm hoping someone will complete my sentence for me. What do you think can trigger af viral? So we're thinking in the lines of infections. Yes. Yeah. So we're thinking of lines of infections, electrolytes, we're dehydrated medication, caffeine. What scoring tool do you use prior to initiating anticoagulation? We've got two tools that we use. Now, I know you guys know the answer. We all know the answer. Come on, one is a stroke risk for af don't worry about how you type it or how you spell it. I'm not going to judge and the other one yet. Chad vsc. Absolutely great. And the other one is a bleeding risk tool. So it's calculating the bleeding risk in a patient for an anticoagulation. Yeah. Orbit orbits basically replaced. Has blood. How do you manage this lady? So as an inpatient is what we were talking about earlier, is she stable or is she unstable, unstable? You're going down your A LS pathway and you're stabilizing her with shocks stable. You're thinking about rate controlling her, controlling what this trigger was for her af and getting her cardiology review and making sure that she is safe outpatient. If she's completely safe, it is rate controlled. You want to send her off with a 24 hour tape for 24 hour echo and you would monitor her. Now, can she drive the famous question? Now, now it's depending on how she collapsed. So she had a bit of early warning symptoms, um which is good, but she needs some more investigations to find out. So you'd ask her to notify to the D VLA and yeah, also if the AF is new or existing. Brilliant. Yeah, but um can she drive? So you'd notify to the D VLA and wait for the clinical work up if she has collapsed while sitting and she has no warning signs. She will not be allowed to drive for at least six months and then it would persist based on investigations but always look up D VLA guidelines. These are just your med calc um, uh, calculators for your chad vas score and your or a bit. And this is just basically a bigger slide to show you the e less guidelines for the tachycardia case four. We've got just, we've got two more cases to get through. Um, so I will uh I will try, I do apologize. It might become a bit over time. So if you have to leave, thank you very much. The feedback is just right at the top of the chat box. So if you don't mind filling that up, I'd really appreciate it. We've got an 87 year old that was found at the bottom of the stairs. He's unresponsive. He's garbled. He's been discharged from another hospital for a cap that needed some O2 requirement. So when he was discharged, he refused 24 hour care. He said he'd go home with carers once a day and family support. Yeah, he's that patient that can't remember how he ended up at the bottom of the stairs. He's got a plethora of things. He's got af he's type two diabetes. CO PD, he's got arthritis hypertension and he's out of area. So you don't really have his medication records. But his, um, carer tells you that he used to immobilize with a stick but needed a Zimmer frame and discharge. He's not safe on stairs. I think his prior to is about a five at the minute with you. Examination wise, these are his examinations. So I want you to be mindful of his BP, his oxygen rate and obviously his tachycardia, his airway is patent. He's got right sided crackles and his heart rate is strong. It's irregular. He has known af his G CS is 11 out of 15. His abdomen is soft but he's groaning on palpation. His tone is really reduced. He's really unable to follow commands but very dense weakness on the left side. Silver trauma, palpation wise, you're not getting very much. So I hope that all makes sense. Just take a second. Yeah, your clinical concerns. What are your differentials for this gentleman that has basically landed at the bottom of the stairs is more likely than not on a doac for his AF and has a G CS of 11 out of 15 has dense weakness, sepsis. Yeah. Yeah. Yeah, definitely as well because yeah, 100% because of um his BP. He's hypertensive, he's a bit pyrexial, he's tachycardic. He's got CO PD, he's recently treated stroke, heart failure. Yeah, you guys are thinking about the different things. That's what I want you to be doing. So, what investigations do you want to do? So step by step from your A to e so if we go to your breathing, what are two things that I'd, you'd want to do is things like your gas and your chest X ray and, and you see, you'd want to do some bloods and some EC GS and here is his ABG for you. So you can see it. My first question always is, is he acidotic or is he not acidotic via acidotic? Where is it coming from? Um Obviously sorry, just to mention the rangers are all here. The normal ranges. Yeah. So we think he is, we agree that he is a type two respiratory failure, but we're a bit 5050 in terms of is he respiratory or is he metabolic? So have a look at the bicap. The bicap is only 22. So it's within normal. So, but his CO2 from a respiratory point of view is 8.3 and the normal goes up to six. So this is a respiratory acidosis, a type two respiratory failure with respiratory acidosis. So we see this as his chest X ray. What do you see on his chest X ray? And what scoring tool would you use for him? Anybody have any rough idea what they see in that right lower zone over there? Do we think it is maybe, maybe a pneumonia? And if so what scoring tool would you use for pneumonia? Yeah, we think it's a consolidation or pneumonia. Brilliant pacification consolidation with thinking that Yeah, on the same lines. And what else? The aim in that which I know you guys will get is we're thinking about Curb 65. And now we need to just think about his escalation of care because the reason I'm asking you this is because he's acidotic. Does he need an IV noninvasive ventilation? That's something that we just need to think about. We've got his bloods over here and it's basically in bold. So he's quite hyponatremic. He's got an infection CRP is three fifties, white cells and neutrophils are elevated and his ECG is just a regular trace of rate controlled af so nothing too concerning an ECG perspective and because you've followed nice guidance. You have done a CT head on him. Anybody have any idea what that shows to be honest with you first, I'll just tell you it is an infarct. If you think about it, it's not bleed in that sense. Ischemia. Yeah. Well done. RAA Yeah, we think it's an in ischemia stroke in his left MCA territory. So who do you discuss this with? You discuss it with your stroke coordinator? Who else should you inform somebody's this gentleman who's G CS 11 out of 15 only with his carer is here in front of you who has a stroke has a G CS of 11 out of 15. It's quite unconscious with you. Who else should you try to get, you know, in touch with next of kin? Yeah. 100%. I want you to try and reach them as soon as you can. Why? Because you need to discuss his resuscitation status. Really? And you need to think about your problem list and how unwell this gentleman is stroke. What complication is he at risk for? So, if you were here, yeah, you would need to talk about the neurosurgery. 100%. You need to talk to anesthetics as well. Yeah, from a medical point of view in terms of his stroke where the territory is his MCA. I want you to be thinking about malignant MCA infarct and he's quite severely hypernatremic and he's also got a cat. So he's got a lot of things going on for him. So that's why you need to get in touch with all the relevant specialties like you guys have said, inform his next of kin and just start treating him. Obviously, you start treating him with aspirin 200 mg. We discuss with stroke and see whether he's a candidate. If anything, depending on what hour we're on now as well. You would give him start him on some antibiotics and some fluids. Um, try and see where his hyponatremia is coming from. Is he just, you know, if he's euvolemic? Is this all coming from somewhere else? Are you thinking about si A DH if he's hypovolemic? Is he just dehydrated? Um, a lot more investigations can be done. Risk of low sodium. Oh, this could just be honestly just be a few things just because of um just how unwell, how poorly dehydrated that he could be as well. I was just trying to get us to just think about the different scenarios that he could be at going and treating. He didn't have um an absolute risk factor in this case for low sodium. But very quickly, we've got two final cases. Case five is a 90 year old that's come in with a fall, no head injury. He has dementia increased confusion and he's struggling to pass urine and he's got a list of medications. So we're gonna go through that. He immobilizes with a frame with assistance and he's dependent with most of his ADL S. His clinical frailty score is about a seven. Ok. So 91 year old come in with a fall. No head injury. It was witnessed and struggling to pass urine. He's got a new AK I one which is based on our AKI I criterias. Yeah, which we'll talk about. His observations are completely stable. His inflammatory markers completely stable and his G CS is 14 out of 15 for being confused, but that is his baseline. Oh, sorry. Is the noise better now, hopefully, um he's got a new ati and his infection markers are all fine and he's confused but he's normally confused. So that's fine. So when we talk about an API what are we talking about? Three different criterias? I want you to. Well, basically kind of remember, I don't expect you to remember numbers, it is an increase in your serum creatinine level. So it can be about 25 micromoles per liter or an increase in serum creatinine levels over 50% over the last seven days or above your baseline. And if they've had no urine output, so the urine output is under naught 0.5 mils per kilogram per hour in the last six hours. These three things will help you define what an AK I is. And this gentleman at the minute has a stage one AKI I with that said, look at his medication list. Anything you change here for his medications at all? Anything that you'd say? Absolutely not. Let's see that. NSAID. Yeah. Diuretic 100% naproxen. Yep. Anybody else see anything else that you don't like Metformin? Stop? 100% agree with you, Ramipril. We've got Ramipril, we've got Metformin, we've got furosemide. We've got naproxen. I think so. Someone hasn't said one more. It's Poten. It's something that we would like to stop as well. Yeah, the codeine is not gonna be great in terms of managing him as well, but it's actually the do Doxazosin as well in an AKI. I, you'd like to have uphold on that. Oh, I couldn't get my words there. You'd like to suspend his Doxazosin as well. All done guys. So when we think of AKI is again, very simple, categorize it to yourself. Are we thinking prerenal renal or postrenal. Do we think it's prerenal due to dehydration? Do we think it is, you know, any signs of hypoalonemia? Do we think it's medication related in his case as well? Intrarenal. Do we think it is uti S nephrotic syndromes, interstitial disease or postrenal stones? B ph cancers. So, in terms of management for this 91 year old, what management would you want to do a urine dip versus a urine M CS, which we've already discussed, prefer an M CS over a dip. You do a bladder scan on him post void and he's got 650 retention. So you have catheterized him well done and you know that he's got a blood, his blood stuff out and he's got an AK I one. So he's fairly well on himself, completely comfortable. Now that you've categorized him, he's got a slight AK I one. Do you admit or do you discharge him from? Ed? Admit? Yeah. Admit. Yeah, I will be honest with you pragmatically. Yes. According to the numbers and what we've discussed, you will admit him. But realistically what does happen a lot of the time that can happen as well based on these little criterias that were set is that you can discharge him if he's at baseline functional status. He, you, he's going home with this catheter in place. You have suspended these medications that you think are likely causing all of this. And you ask your GP to follow up with bloods and review these medications to make sure that it's not getting any worse. Again, these are all just dependent on a few different factors. The reason why you discharge him in this criteria is because he's not complaining of any pain. His observations are completely stable with you. His bloods are otherwise all right. It is a very, very slight achy I one which you think it's obviously got to do with retention. You think it might be due to his medications, he looks a bit dry and you have a safety net in cl like process in place. So you can make sure that obviously if it gets any worse or his bloods are repeated next week and it's much worse or he presents his c you worse. He will come back in. Also. He's a dementia patient and it's just a risk and benefit when you talk to, you know, the care home and the sex of kin as to what they want to do in a pragmatic world. So again, nothing wrong. You can admit him. I would as well depending on the criteria, but he's also safe for discharge our last case. Again. I do apologize. We won't take any much further. 74 year old male come in with a fall. His carers have found him on the floor near the commode and he's been covered in black fecal matter. He's been vomiting and he's really confused. Um He's, he's just had a recent um exacerbation of AC O PD and he completed a rescue pack. He's got previous Anstey heart failure, previous stroke, iron deficiency anemia and CO PD. So he's on these lovely things. Clopidogrel Furosemide. He's on iron and his recent rescue pack included doxy and pred, he immobilizes with a frame. He's homebound. He's got carers four times a day. This man is quite frail and examination wise. He's a little bit tachycardic, a little bit hypertensive. And when you do an A to e in him, his pulse is a little bit faint which is not great. He's got new confusion and you've done apr examination on him. And there is Melina, what are your differentials for this Chappy over here that has come in covered in black fecal matter um has had steroids is on a blood thinner. You've done APR on him. Is that Melina? Yeah, 100%. I made it very classical. So upper gi bleed. How do you want to start to manage this gentleman? He's actively having Melena with you. He's actively vomiting with you. He's a bit hypertensive at the minute. His pulse is a bit faint. Anything that you would initiate in an A&E setting that I'm trying to get you to get at trans exam acid. Yeah. Can help. Guidance is a little bit 5050 about trans exam acid in terms of an upper gi bleed. But yes, you're on the right tracks with fluid recess but if not for fluid, you would give blood. Yes, you'd start a major hemorrhage protocol. So that's absolutely something that you can initiate in this scenario. And I want you to be thinking of based on how unwell and how unstable he is. So what scoring tool would you use for an upper gi bleed? You will need it when you are referring to your gastroenterologist on call Rockel. Yeah. Rock's one of them but there's another one, Rle is will also be dependent a little bit on your endoscopic findings. Glasgow Blatchford. Yeah. Brilliant. Rodrigo. Yeah. Yeah. So you're Glasgow Blatchford and I've done it for you. You're scoring 14 at the minute. So you were discussed with your gastro on call. So your consultant on call and their responses. I do not think they are fit enough to tolerate a scope. Let's treat conservatively with some IVP P. So 40 mg IV twice a day, blood transfusions, major hemorrhage protocol. Let's stabilize him first and they ask you, do you think they are fit enough for a scope? This gentleman has gone through the works. He has got um he's got a plethora of things about previous stroke. Previous Antemi he's currently house found. He's currently carers Q DS. Do you think they'll fit enough for a scope? And don't be afraid to say yes as well if that's what you think? No. You think it's a no. Yeah. You think it's a no? Yeah, that is fair. That is fair. And that is also why the gastroenterologist has agreed with you at the minute. They want to stabilize him first and see how he gets on at the minute. So as they went, please discuss with family update your treatment escalation plan because unfortunately, this is a real life case actually. And um what happened with this gentleman? The 14 is that we treated conservatively, started giving him few units of blood. Um started him on IV PPI fluid resuscitation and we updated his family and let him know that he's not a candidate right now to stop the bleeding. And even if the gastroenterologist changed her mind and wanted to do it, there is a good chance that he could die on the table and you have to be confident enough and brave enough to use the word die, especially when you're speaking to people. And we discussed the reasons why we thought he was not fit based on his comorbidities, based on the fact that he is no longer de you know, no longer independent with his AD LS, which means that his physiological reserve is quite low in himself. And actually the most dignified things is to make sure that if he were to die and if his heart were to stop is that we would put in a DNA R in for him because it wouldn't be in the best to actually prolong this because the quality of life he would get back if we got Ros would be poorer than the one that he has. Now. They agreed with all of this. We put it in place and this man eventually went on to being palliated and died comfortably four days later. So take home messages is that we're getting so old. So you want to treat us well a little bit. But um falls are very likely multifactorial functional baselines are key factors in your management. Don't always trust your patient, try and get a collateral if you can try and talk to someone else. Always think of your tap on your feeling of care and stay as holistic as you possibly can in the geriatric community. Thank you very much. I'm very, very sorry that I was over time, but I hope that was OK. I would greatly, greatly appreciate if you guys could do the feedback for him for us. Thank you. Um Thank you so much for staying back. Oh, yeah, you do get the slides. So um give us a couple of days and then I'll put it on the catch up content and then you can see it from there. Thank you for everyone for being so interactive. I wouldn't have been able to do this entire presentation if you guys weren't interactive with me. So, thank you. I really appreciate it.