CollapseandSyncopeDR IAN TURNER FACEM

Definitions

▪ Transient LOC + loss of postural tone + full spontaneous recovery

▪ Loss of postural tone +/- LOC

Multiple causes

Toxicological

Conduction blocks

Aortic dissection

Addison’sSeizure

CVA

Psychogenic

Bradydysrhythmias

Tachydysrhythmias

Autonomic dysfunction

Aortic stenosis

HOCM

Vasovagal

Orthostatic hypotension

Pulmonary embolus

Hypoglycaemia

Subarachnoid haemorrhage

Iatrogenic

GI bleed

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

Case 1 – Important Questions

History▪ Previous episodes▪ Associated symptoms▪ Medications

Examination▪ Vitals (postural changes)▪ Murmurs▪ Neuro (posterior circulation)▪ PR for blood

Case 1 – Useful Tests

Bedside Tests▪ BSL▪ ECG▪ VBG▪ MSU

Other Investigations▪ As indicated

Case 1 – Now what?

▪ Admit?▪ Indications for PPM?

Case 2

▪ 82 female▪ Usually well▪ Nauseated, dizzy for last 2 hours▪ Afeb, HR 48, SBP 89/51, RR 20,

SaO2 100%

Case 2 - Interventions

Inferior STEMI▪ Definitive – reperfusion▪ Symptom control▪ Antiplatelet agents▪ Anticogaultion

Bradydysrhythmia▪ Atropine▪ Isoprenaline▪ Adrenaline▪ Pacing▪ Reperfusion

Case 3

▪ 54 female▪ At work, sudden onset headache

with collapse▪ Headache persisting, much less

severe, otherwise feels well

Case 3 – Important Questions

History▪ Headache details▪ Neurological symptoms▪ Family history

Exam▪ Vitals▪ Focal neurology▪ Meningism▪ Papilloedema

Case 3 – Important Questions

Bedside Tests▪ The usual

Other investigations▪ CT +/- A▪ MRI/A▪ LP – timing?

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

Case 3 – Should I do an LP? Complications

▪ CommonBack pain (25%)Headache (22%)Radicular pain (15%)▪ Unlikely

Paraparesis (1.5%)▪ Rare

Infection (<1%)Bleeding (<1%)

Case 4

▪ 74 male referred by GP with 2/7 dizziness and bradycardia▪ Normotensive but ambulance

officers concerned by rhythm strip

Case 4 – What interventions will you consider?

▪ Cardiac monitoring▪ IV access▪ Temporising medications▪ Electrolyte corrections▪ Pacing

Case 5

▪ 67 female collapse at home▪ 1/52 of dizziness, nausea, and

visual changes▪ PHx – AF, MVR (endocarditis)▪ Meds – aspirin, warfarin, digoxin

Case 5 – Choose two blood tests

▪ Digoxin = 3.7nmol/L (2.8ng/mL)▪ Potassium = 4.2mmol/L

Case 5 – What interventions are indicated?

▪ Cardiac monitoring▪ With-hold digoxin▪ Antidotes?▪ What if the potassium was 7.1mmol/L?

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

Case 6 – ED workup

History and exam▪ Dizzy, followed by

witnessed period of unresponsiveness, then return to normal GCS

Usual investigations▪ Normal

Case 6 – Discharge or Admit

▪ Gestalt▪ Decision rules▪ Social circumstances

Case 6 – Decision Rules

▪ San Francisco syncope rule (“CHESS)”▪ Boston syncope rule▪ Rose criteria▪ STePS criteria

▪ Generally good sensitivityAverage to poor specificity

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

Case 7 – Red flags?

▪ Young▪ Exertional syncope▪ Family history

Case 7 – Differentials?

▪ Conduction abnormalities▪ Structural heart disease▪ Channelopathies

Case 7

▪ Exertional syncope and abnormal ECG – admit!▪ Will need further cardiology workup▪ A lot end up with AICD

Case 8

▪ 47 male▪ Usually well▪ Palpitations since yesterday▪ Now dizzy and nauseated▪ Afeb, HR 195, BP 89/50

Case 8 – what are your actions?

▪ Cardiac monitor▪ Defib pads▪ IV access▪ Fluid bolus▪ Rate or rhythm control – why?

Case 8 – Rhythm control, how?

▪ Electrical▪ Synced▪ Sedation determined by urgency and cardiovascular

stability

Case 8 – Discharge or admit?

▪ Completely asymptomatic▪ Decision for anticoagulation▪ Need for ongoing rhythm control

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

Case 9 – Red flags?

▪ Sudden onset▪ Persistent symptoms▪ Headache▪ ESL▪ Multiple cardiovascular risk factors

Case 9 – Investigations

▪ Normal ECG▪ Normal bloods▪ CT…

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