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Collapse and syncope
- 1. Collapse and Syncope DR IAN TURNER FACEM
- 2. Definitions ▪ Transient LOC + loss of postural tone + full spontaneous recovery ▪ Loss of postural tone +/- LOC
- 3. Multiple causes Toxicological Conduction blocks Aortic dissection Addison’s Seizure CVA Psychogenic Bradydysrhythmias Tachydysrhythmias Autonomic dysfunction Aortic stenosis HOCM Vasovagal Orthostatic hypotension Pulmonary embolus Hypoglycaemia Subarachnoid haemorrhage Iatrogenic GI bleed
- 4. Case 1 ▪ 80 male ▪ PHx – T2DM, HPT, hypercholesterolaemia ▪ Witnessed collapse with LOC when walking down the street after having got up to leave the hairdressers ▪ Now well
- 5. Case 1 – Important Questions History ▪ Previous episodes ▪ Associated symptoms ▪ Medications Examination ▪ Vitals (postural changes) ▪ Murmurs ▪ Neuro (posterior circulation) ▪ PR for blood
- 6. Case 1 – Useful Tests Bedside Tests ▪ BSL ▪ ECG ▪ VBG ▪ MSU Other Investigations ▪ As indicated
- 8. Case 1 – Now what? ▪ Admit? ▪ Indications for PPM?
- 9. Case 2 ▪ 82 female ▪ Usually well ▪ Nauseated, dizzy for last 2 hours ▪ Afeb, HR 48, SBP 89/51, RR 20, SaO2 100%
- 11. Case 2 - Interventions Inferior STEMI ▪ Definitive – reperfusion ▪ Symptom control ▪ Antiplatelet agents ▪ Anticogaultion Bradydysrhythmia ▪ Atropine ▪ Isoprenaline ▪ Adrenaline ▪ Pacing ▪ Reperfusion
- 12. Case 3 ▪ 54 female ▪ At work, sudden onset headache with collapse ▪ Headache persisting, much less severe, otherwise feels well
- 13. Case 3 – Important Questions History ▪ Headache details ▪ Neurological symptoms ▪ Family history Exam ▪ Vitals ▪ Focal neurology ▪ Meningism ▪ Papilloedema
- 14. Case 3 – Important Questions Bedside Tests ▪ The usual Other investigations ▪ CT +/- A ▪ MRI/A ▪ LP – timing?
- 17. Case 3 – Should I do an LP? ▪ http://www.thennt.com/risk/high-risk-headache-in-the- emergency-department/ ▪ We probably do more than we need ▪ Often subspecialty driven ▪ Can find other diagnoses
- 18. Case 3 – Should I do an LP? Complications ▪ Common Back pain (25%) Headache (22%) Radicular pain (15%) ▪ Unlikely Paraparesis (1.5%) ▪ Rare Infection (<1%) Bleeding (<1%)
- 19. Case 4 ▪ 74 male referred by GP with 2/7 dizziness and bradycardia ▪ Normotensive but ambulance officers concerned by rhythm strip
- 21. Case 4 – What interventions will you consider? ▪ Cardiac monitoring ▪ IV access ▪ Temporising medications ▪ Electrolyte corrections ▪ Pacing
- 22. Case 5 ▪ 67 female collapse at home ▪ 1/52 of dizziness, nausea, and visual changes ▪ PHx – AF, MVR (endocarditis) ▪ Meds – aspirin, warfarin, digoxin
- 24. Case 5 – Choose two blood tests ▪ Digoxin = 3.7nmol/L (2.8ng/mL) ▪ Potassium = 4.2mmol/L
- 25. Case 5 – What interventions are indicated? ▪ Cardiac monitoring ▪ With-hold digoxin ▪ Antidotes? ▪ What if the potassium was 7.1mmol/L?
- 26. Case 6 ▪ 71 male BIBA following witnessed loss of consciousness at lunch whilst sitting ▪ Now feels fine and determined to go home ▪ PHx – HPT, CCF ▪ Meds – prazosin, irbesartan, frusemide, metoprolol ▪ SHx – lives alone
- 27. Case 6 – ED workup History and exam ▪ Dizzy, followed by witnessed period of unresponsiveness, then return to normal GCS Usual investigations ▪ Normal
- 28. Case 6 – Discharge or Admit ▪ Gestalt ▪ Decision rules ▪ Social circumstances
- 29. Case 6 – Decision Rules ▪ San Francisco syncope rule (“CHESS)” ▪ Boston syncope rule ▪ Rose criteria ▪ STePS criteria ▪ Generally good sensitivity Average to poor specificity
- 30. Case 7 ▪ 19 male collapse and LOC whilst running ▪ Usually fit and well ▪ Brief CPR by bystanders with swift return of consciousness ▪ FHx – unexplained deaths in father and uncle ▪ Now well ▪ Normal examination
- 31. Case 7 – Red flags? ▪ Young ▪ Exertional syncope ▪ Family history
- 32. Case 7 – Differentials? ▪ Conduction abnormalities ▪ Structural heart disease ▪ Channelopathies
- 36. Case 7 ▪ Exertional syncope and abnormal ECG – admit! ▪ Will need further cardiology workup ▪ A lot end up with AICD
- 37. Case 8 ▪ 47 male ▪ Usually well ▪ Palpitations since yesterday ▪ Now dizzy and nauseated ▪ Afeb, HR 195, BP 89/50
- 39. Case 8 – what are your actions? ▪ Cardiac monitor ▪ Defib pads ▪ IV access ▪ Fluid bolus ▪ Rate or rhythm control – why?
- 41. Case 8 – Rhythm control, how? ▪ Electrical ▪ Synced ▪ Sedation determined by urgency and cardiovascular stability
- 43. Case 8 – Discharge or admit? ▪ Completely asymptomatic ▪ Decision for anticoagulation ▪ Need for ongoing rhythm control
- 45. Case 9 ▪ 72 F ▪ Witnessed collapse at the Italian Club ▪ Headache and persistent nausea ▪ “Doctor, doctor, dizzy, dizzy” ▪ PHx – AF, HPT, T2DM ▪ Meds – aspirin, perindopril, metformin, gliclazide ▪ SHx – home with husband, ESL ▪ O/E – Hypertensive, nystagmus, left sided weakness
- 46. Case 9 – Red flags? ▪ Sudden onset ▪ Persistent symptoms ▪ Headache ▪ ESL ▪ Multiple cardiovascular risk factors
- 47. Case 9 – Investigations ▪ Normal ECG ▪ Normal bloods ▪ CT…
- 50. Case 9 - Management ▪ Analgesia and antiemetics ▪ Neuro obs – risk of raised ICP with larger posterior fossa strokes ▪ Blood pressure control ▪ Neurology opinion and consideration of thrombolysis ▪ Stroke unit