Collapse Query Cause

Key facts:

Authors: Damian Mayo and Kris Ghosh
Top Tip: The history is vital, and helps distinguish cardiac and neurological causes. Check the BP

Key Causes (very wide)

• Syncope/cardiac (especially treatable conditions: arrthymia, aortic stenosis, HOCM, PE/MI)
• Seizure (neurological)
• pSychiatric

Key Investigations

• Glucose (BM), dipstick ± MSU
• O2 saturation ± ABG
• FBC, ESR, CRP ± BC
• U+E, LFT, Bone, Glucose ± CK, Troponin T
• ECG, CXR ± CT
  OESIL SCORE (1 for Age >65y, PMH heart disease, absence of prodromal symptoms and abn ECG; ≤ 1 = low risk collapse, consider discharge)

Key Treatment

• Depends on cause
  ± IV BENZYLPENICILLIN 1.2 g qds + IV GENTAMICIN 5 mg/kg od, if infected (and source unclear)
• Treat consequences of collapse (eg #, lacerations)

Key Management
Decisions

• CT head
• Pacemaker? (cardiologist will want evidence)
• Driving rules on discharge (see below)

Background

Tip-to-toe examination is required; especially cardiac and neurological. Only when nothing found, and all investigations (including ECG) normal, focus on simple causes (faint, mechanical fall etc)

Introduction

• This is one the commonest reasons for acute medical admission, though relatively little is known about it. Why don't you research into it?

• Note that TIA/CVA rarely presents as collapse; ie, if you are about to write 'Collapse ?Cause, ?TIA' .. rethink
• This is not a benign syndrome. 10% mortality at 1 year; 25% at 3 mths for missed cardiac cause; 6% med adm, 1-3% ED attendances. 30% another collapse in 1y

• A top-to-tail examination is also important, focussing on cardiac and neurological. All patients should have full bloods, CXR and ECG; and you should have a low threshold for CT head ± EEG

Definition

• Collapse, of uncertain significance

Epidemiology

• Elderly

• Polypharmacy (5-10% have drug cause

• In >30% of cases no cause is found. Collapse accounts for up to 6% of all ED attendances and up to 1-3% of all ED admissions. Epilepsy affects only 0.5% of the population; hence epilepsy may be overdiagnosed as a cause of collapse

Groups of Causes

The 3 'S' (or 'F's)

1. Syncope (faint, cardiac or non-cardiac)
2. Seizure (fit); 
3.  'pSychiatric' (feint)
   Note: seizures may be secondary to hypoxia, so not the primary cause

Causes

There are many causes, but the most important are:

Syncope (faint)

• Cardiac:
  • Commoner cardiac causes: Arrthymia (bradycardia in Stokes-Adam's attack; look for drug causes   bradycardia), valvular heart disease (especially aortic stenosis), congenital (HOCM
  • Rare cardiac causes: ACS, aortic dissection
    Note: cardiac more likely if no nausea or vomiting, and/or abn ECG
• Non-cardiac:
  • DRUGS DRUGS DRUGS: especially POSTURAL HYPOTENSION (secondary to autonomic dysfunction, diuretics or antihypertensive drugs, incuding betablockers; or combination), especially in elderly (there are guidelines regarding postural hypotension in the references); and bradycardia (digoxin, amiodarone, betablockers); 5-10% patients have a drug cause
  • Simple: vasovagal (true faint) OR mechanical fall; situational (cough, micturition surprisingly common)
  • Infection: UTI or pneumonia can cause collapse, especially in elderly
  • Metabolic: especially hypo/hyperglycaemia, hyponatraemia, failures (all)
  • Neurological: TIA/CVA are not common causes
  • Other: PE (rare)

Seizure (fit)

'Psychiatric' (feint)

• 25% have past history of depression or panic disorder
  Note: this last category covers a wide range of diagnoses: from patients in care of police, trying it on; to alcohol/recreational drug excess/withdrawal; to life problems; to true psychiatric disease

Symptoms

• History from witness essential (see below); eg observation of conscious level during cardiac cause

• Look at ambulanceman's notes (ECG, drugs given, patients normal drug list); ring him/her up, if necessary (contact via ambulance control)
  Note: <50% can make diagnosis, from history and examination

Distinguishing Cardiac and Neuro Causes

• Cardiac: No prewarning, sudden drop with reduced conscious level, quick recovery; some memory, not confused; may have flushing, dizziness, palpitations; N/V less likely; abnormal ECG

• Neurological: Warning (aura), variable drop, slow recovery; no memory ('I woke up in hospital') or confused; nausea/vomiting more likely; and normal ECG

Key questions

• "Have you ever collapsed before? (How many falls? When?)"

• "Has anyone changed your medication in the last 4-6 weeks?"

• "How did you feel just before the collapse?" (seizure may have a prodrome; no warning in cardiac; posture change in postural hypotension)

• "Do you rememebr seeing the floor before you dropped?" (if they do not, it is in favour of cardiac, ie sudden drop)

• "When you woke up, were you confused?" (if so, in favour of a fit)

Signs

• Full examination is required (don't forget to look for effects of collapse, not just cause; eg head injury, Colles #, #NOF, signs of epilepsy (incontinence, soft tissue injury)

• Focus on cardiac and neurological (proprioception? cerebellar?)

• Check it's not 'simple' (eg eyesight, faint, mechanical fall)

• LYING/STANDING BP (very important in the elderly)

Investigation

At 48 hrs, if no diagnosis has been made, do a CT head; before if clinically indicated

Blood

• Glucose (BM)
• FBC, CRP
• U+E (Na↓?), LFT, Bone, Glucose
• (If chest pain) Troponin T, D-Dimer (only do, if low-risk; don't do latter if infected)
  Note: both are poor screening tests in collapse, in terms of positive predictive value; some use as 'going home' tests (eg good negative predictive value) 
•  O2 saturation ± ABG
• CK (to assess length of time on floor, rather than diagnosis; interpret knowing renal function)

Other

• Urinalysis: UTI can cause collapse, especially in elderly
• CXR
• ECG (?arrythmia; ?ACS; ?effects of cardiac lesion, eg LVH in aortic stenosis)
• If suspect secondary injury, XR hips (?#NOF) and/or wrists (?#Colles)
• MSU

Key investigation

• Glucose (BM)
• ECG

Specialist investigations

• CT head, if no diagnosis obvious after 48 hrs
• ± ECHO (valvular heart disease - eg aortic stenosis, HOCM etc)
• ± 24h or 72h ECG (if think missed arrthymia); 7 day event monitor
• ± EEG, if diagnosis of seizure possible

Treatment

Treatment (first line)

Drugs

• If bradycardic, ?atropine/isoprenaline
• If tachycardic, ?beta-blocker/digoxin/amiodarone
• rt-PA for STEMI, massive PE (both rare causes of collapse)
• If infected (and source unclear), IV BENZYLPENICILLIN 1.2 g qds + IV GENTAMICIN 5 mg/kg od; Penicillin Allergy: IV VANCOMYCIN 1 g bd + IV GENTAMICIN 5 mg/kg od

Procedures            

• IV (+ fluids, if dry)
• ECG monitoring
• O2 saturation monitoring
• OXYGEN, if hypoxic

Stop

• If BP low, or orthostatic hypotension: diuretics (especially if hyponatraemic), and antihypertensive agents
• If bradycardic, beta-blockers, digoxin or amiodarone
  Note: these three groups of drugs can be cause of a collapse, or its treatment       

Treatment (second line)

Drugs

• PO FLUDROCORTISONE 50-300 mcg od

Procedures

• ?Pacemaker, if bradycardia severe and not improving with first line Rx (cardiologist will want evidence of temporal link between arrthymia and collapse)

Prescribing issues

• If no other cause identified, consider stopping most drugs, except essential ones - and inform GP when they go home

Admit?

• Usually

Bed plan

• Observation Ward, if suspect admission <24 hrs
• Medical admission ward, if >24 hrs

Referrals

Medical:   

• ?Cardiology
• ?Neurology

Other

• Rapid discharge team (physiotherapist, occupational therapist, social worker)

The Rest

You are legally bound to advise a patient on driving post-discharge. If you have advised them not to drive, they must inform the DVLA. Record all of this advice

Complications

• Secondary injury

Prognosis

• This is not a benign syndrome
• (From Framingham Study) Patients with cardiac syncope are at increased risk for death from any cause and cardiovascular events, and patients with syncope of unknown cause are at increased risk for death from any cause. Vasovagal syncope appears to have a benign prognosis 
• Mortality = 10% at 1y; 25% in three months, for missed cardiac diagnosis
  Increased mortality:
  >45 yrs, heart disease, CCF, arrthymias, creatinine > 180 μmol/L, abnormal ECG
• Recurrence (common):
  • 30% have another collapse in a year (in one study, a mean of 7 over 2.5 yrs); especially if has psychiatric history; and if young (ie <45 yrs)
  • Implications for job, driving etc

Risk stratification, and who to admit

• The OESIL (Osservatorio Epidemiologico sulla Sincope nel Lazio) score is calculated by the arithmetic sum of a number of predictors. Score = 1 point for: age >65y, CV disease history, no prodrome, abn ECG (max 4). In the original study, mortality increased significantly as the score increased (0% for a score of 0, 0.8% for 1 point; 19.6% for 2 points; 34.7% for 3 points; 57.1% for 4 point.  Ie, consider discharge if score 0 or 1 (Colivicchi F, 2002)
• The San Francisco Rule is an alternative risk stratification method (Saccilotto RT, 2011). It suggests that five risk factors, indicated by the mnemonic “CHESS,” predict patients at high risk of a serious outcome:
    - C – History of congestive heart failure
    - H – Hematocrit < 30%
    - E – Abnormal findings on 12-lead ECG or cardiac monitoring17 (new changes or nonsinus    rhythm)
    - S – History of shortness of breath
    - S – Systolic blood pressure < 90 mm Hg at triage
• [Ref]

2° Prevention + Health promotion (driving and collapse rules/law)

• If mechanical fall, ask GP to arrange home visit by social team
• Ring GP, if thought to be a drug cause
• If recurrent, refer to falls clinic
• If discharging, driving rules are:
• Simple loss of consciousness with low risk of recurrence = 4/52 no driving. High risk recurrence/no cause found = 4/52-6/12 no driving (+ ask patient to consult DVLA, and record this request in notes). Also record the length of time you have asked them not to drive

Don't forget

• History VITAL, preferably from witness
• TIA/stroke rarely presents as collapse
• DRUGS DRUGS DRUGS (esp BP tablets and bradycardic). Ring GP if drug cause suspected
• Aortic stenosis
• Look at ECG. Little diagnostic yield for ECHO in absence of cardiac signs, CT in absence neurological signs, or from CXR or EEG
• Consider cause and effect of collapse
• CT head at 48h, if no cause obvious; or at start, if no obvious cause and unwell
• Consider admission: if ill, older, abn ECG, evidence heart disease, no prodrome, no previous syncope history
• Driving rules

Red flags

• Cardiac cause, take very seriously

References