Collapse query cause

From WardWiki - Foundation Doctor Helper

Collapse query cause is an extremely common reason to be bleeped to the wards and has various presentations, from a fall in the night to a life threatening ventricular arrhythmia. It is an extremely important acute medical admission that takes much time and care in finding the true cause. Each case must be carefully assessed on its merits and no quick conclusions should be drawn.

The role of a foundation doctor is to ensure any serious causes are treated quickly and appropriate investigations are arranged. It is not essential to know every single cause and it is futile to attempt to do so in the first few months. Collapse query cause should be limited to mean syncope rather than any cause for falling. Any sudden event in medicine is very often caused by a drop in neuronal output or interruption to neural blood supply.

Causes of syncope

These are causes that are common, easy to exclude or frankly dangerous. These must be appraised before any rarer cause is found.

• Vasovagal syncope - a transient drop in cardiac output caused by vagal overdrive, causing a bradycardia
• Cardiogenic syncope - arrhythmias, cardiogenic shock, cardiomyopathy and aortic valve stenosis
• Epilepsy
• Postural hypotension
• Drug induced - don't ever forget glucose in diabetic patients
• Any cause of vasodilatation when the patient cannot compensate - UTI or pneumonia are common

History

A witnessed history is invaluable but the following factors must be carefully searched for:

• Was there a presyncope or aura?
• Does the patient fell warm or cold on regaining consciousness?
• Has it happened before?
• Have multiple syncopes been investigated and remain undiagnosed?
• Is there associated chest pain or palpitations?
• Is there any focal neurology or headache?
• Does the patient remember the event?
• Have new medications been started?
• Was there loss of bowel and bladder control?
• Was it relating to coughing or other forms of strain?

Examination

Airway and breathing must be assessed and any abnormality acted upon before further examination. A sudden collapse is either circulatory or neurogenic and these must form the focus of the examination. Examination of the pulse is extremely important yet so many foundation doctors focus more on the inaccurate heart rate as given on automated blood pressure machines.

Listen carefully to the chest and carotid arteries. Valve lesions are common in the elderly, especially aortic stenosis.

Carotid bruits are not always audible and although there is an argument not to listen to them, it is a part of the taught circulatory examination so should be performed at foundation level.

Performing an ECG is an integral part of the examination and must not be left until a HCA is free to perform it.