Vasovagal Syncope by Paolo Alboni & Raffaello Furlan

Author:Paolo Alboni & Raffaello Furlan
Language: eng
Format: epub
Publisher: Springer International Publishing, Cham

Differential Diagnosis with Unexplained Falls

Falls may be accidental or unexplained. A fall is defined as accidental when there is a clear cause such as slip, trip, or an accidental collision, and as unexplained when there is no evident explanation for the event. If syncope occurs in the upright position, TLoC may lead to a fall; therefore, the clinical presentation of syncope and fall are potentially very similar. In the international guidelines, syncope and falls seem to travel along two different tracks. Indeed, the European guidelines on the management of syncope [1] refer to falling as a nonsyncopal event and provide no discussion on the differential diagnosis. Similarly, the recent international guidelines on the management of falls [31] only mention that unexplained falls could be a manifestation of syncope in patients without prodromal symptoms or with retrograde amnesia. Syncope is due to transient cerebral hypoperfusion, which is responsible for prodromal symptoms, such as dizziness, lightheadedness, and blurred vision. Symptoms caused by activation of the autonomic nervous system may be present. When a patient seeks assistance after a fall of uncertain origin, the first question to answer is whether he or she had symptoms due to cerebral hypoperfusion or activation of the autonomic nervous system. If these symptoms were present, this indicates syncope. If the patient does not remember any prodromal symptoms, a fall should be considered. The patient should be asked to describe every part of the entire incident (Fig. 13.1). If the patient clearly remembers a slip, a trip, or an accidental collision, an accidental fall is indicated. If no such obvious cause is identifiable, the fall can be regarded as unexplained. In such cases, some patients remember the mechanism of the fall, how they lost their balance, and the moment when they hit the ground; thus, a fall can be diagnosed. In the literature, there are no clear data on the percentage of patients suffering from unexplained falls who are able to remember every part of the event. Often, the description of the event is incomplete or confused. Thus, the question arises as to whether we are dealing with an unexplained fall or with syncope leading to a fall with retrograde amnesia. This diagnostic problem is crucial in older persons, although young and middle-aged subjects are sometimes involved. In such situations, it is not useful to ask patients “Did you lose consciousness?”, as they may be suffering from retrograde amnesia. Often the patient states that he or she had a fall, but, in light of the aforestated reasons, this statement should be taken with caution and a thorough history should be taken. Witnesses should be asked whether the patient was unresponsive to external stimuli, particularly acoustic stimuli, during part of the incident, and how this unresponsiveness was established. In the presence of reliable witnesses, the differential diagnosis between syncope and fall can be made. Unfortunately, in 40–60 % of cases, the patients fall in the absence of any witnesses, thus making the differential diagnosis more difficult [32].

Fig. 13.1Investigative pathway in patients with falls of uncertain origin.

Download

Copyright Disclaimer:
This site does not store any files on its server. We only index and link to content provided by other sites. Please contact the content providers to delete copyright contents if any and email us, we'll remove relevant links or contents immediately.