Collapse Query Cause

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

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)

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

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:
1. Syncope (faint)
a. 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
b. 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)
2. Seizure (fit)
3. 'Psychiatric'; 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

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)

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
(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)

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)

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
[Ref]
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

[Ref]

OESIL, 2003: 1 = 0% mortality at 1y, 2-4 = 30%; 1 point for: age >65y, CV disease history, no prodrome, abn ECG (max 4). Consider admission: if ill, older, abn ECG, evidence heart disease, no prodrome, no previous syncope history

[Ref]

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

Don't forget

• History VITAL, preferably from witness
• TIA/stroke rarely presents as collapse
• DRUGS DRUGS DRUGS (esp BP tablets and bradycardic)
• 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