Falling Down And 'falling Out': Management And Outcome Analysis
Sam Zakhary MD, Laurel Omert MD, Richard Wilson MS Chris Dminno. RN, BSN
OBJECTIVES: Elderly patients reportedly experience syncopal episodes at the rate of 6% per year. A significant percentage of elderly patients who Fall will therefore require a syncope workup. This study focuses on patients who fail secondary to syncope to determine whether syncope workups are being appropriately performed and whether they contribute new information that results in a change in management.
METHODS: The charts of all patients who fell and were admitted to a Level 1 trauma center over a 14 month period were reviewed. Data collected included mechanism of injury, comorbidities, and severity scores in addition to details regarding a syncope workup in patients who had unclear reasons for falling, A complete syncope workup consisted of six components (EKG. enzymes, telemetry/Holter monitor, ECHO, EEG. carotid duplex). Outcome variables were mortality, hospital and ICU lengths of stay (LOS) as well as whether each test resulted in a change in management.
RESULTS: The data set included 387 patients. In general, they were not severely injured (mean ISS =11 .9, mean GCS=13.6). Falling down stairs or off ladders were the most frequent causes of falls in patients<65, while syncope was the leading cause in the elderly, Syncope workups were performed in 61 patients and included 14 patients <65 and 47> 65. There was no difference in ISS, GCS, presence of ETOH, mortality, ICU or hospital LOS in the younger vs older patients who had syncope workups. Patients who fell secondary to syncope had the following number of tests: 0 tests =4 (6.6%); 1 test =4 (6.6%); 2 tests = 9 (14.8%); 3 tests = 11(18.0%); 4 tests 19 (31.1%); 5 tests 10 (16.4%); 6 tests = 4 (6.6%). The table illustrates components of the syncope workup which were abnormal in the young vs elderly population.
|< 65 years(%)||> 65 years(%)||p value|
|Chronic EKG changes||38.4||72.1||0.027|
Excluding chronic EKG changes, there were 44 abnormal test results (27.1%). These resulted in a change in cardiac medications in 17 patients (27.9%) and seizure medications in 6 (9.8%). One patient underwent pacemaker placement and another cardioverted. Overall, 32.8% of patients who experienced syncope had an intervention performed as a result of their workup.
CONCLUSION: The majority of falls in elderly patients occur due to syncopal episodes. Mortality for falls secondary to syncope is low, even in the elderly (4.9%). Syncope workups were erratically performed in both young and older groups but frequently resulted in findings that required intervention. Protocols are currently being developed at our institution to assure complete assessment of trauma patients who fall for unknown reasons.