This document discusses various cases of collapse and syncope. It defines collapse as transient loss of consciousness with loss of postural tone and full recovery. Syncope is defined as loss of postural tone with or without loss of consciousness and full recovery. It then discusses the multiple potential causes of collapse and syncope including toxicological, cardiac conduction abnormalities, structural cardiac issues, autonomic dysfunction and more. It then goes through 9 case examples, discussing important questions to ask, potential tests and interventions for each case.

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