Understanding Collapse and Syncope: A Guide for Junior Doctors

Introduction

Collapse and syncope are common presentations in the emergency department (ED), often causing anxiety for both patients and healthcare providers. As a junior doctor, you’ll frequently encounter patients who present after a sudden loss of consciousness. The challenge lies in differentiating between benign causes and those requiring immediate intervention. This guide will help you navigate the critical steps in history-taking, examination, investigation, and management, ensuring that you approach each case with confidence and competence.

History Taking: The Foundation of Diagnosis

Effective history-taking is the cornerstone of diagnosing collapse and syncope. A thorough and systematic approach can often reveal the cause without needing extensive investigations.

Key Questions to Ask:

·       Event Description:

·       What exactly happened?

·       Was there a prodrome (e.g., dizziness, palpitations, nausea)?

·       How long did the episode last?

·       Was there any warning before the event?

·       Witness Accounts:

·       Was the patient observed to have any seizure-like activity (jerking, tongue biting, incontinence)?

·       Was the patient unresponsive or confused afterward (post-ictal state)?

·       Precipitating Factors:

·       Was the collapse related to any specific activity (e.g., standing up, emotional stress, pain)?

·       Were there any triggers such as dehydration, fasting, or exertion?

·       Past Medical History:

·       Does the patient have a history of cardiovascular disease, diabetes, or neurological disorders?

·       Is there a history of previous similar episodes?

·       Medication History:

·       Is the patient on any medications, particularly those that could lower blood pressure or alter cardiac rhythm (e.g., antihypertensive, diuretics, antiarrhythmic)?

·       Social and Family History:

·       Is there a family history of sudden death, cardiac conditions, or epilepsy?

·       Red Flags:

·       Sudden onset without warning.

·       Chest pain, palpitations, or shortness of breath preceding the event.

·       History of cardiac disease or family history of sudden cardiac death.

·       Persistent neurological symptoms post-event.

Examination: Targeted and Thorough

A comprehensive physical examination can provide vital clues to the underlying cause of collapse or syncope.

Vital Signs:

·       Assess blood pressure (including postural changes), pulse rate, and rhythm.

·       Measure oxygen saturation and temperature.

Cardiovascular Examination:

·       Listen for murmurs, especially aortic stenosis (ejection systolic murmur) or hypertrophic cardiomyopathy (harsh systolic murmur).

·       Check for signs of heart failure (e.g., raised JVP, peripheral edema, basal crackles).

·       Palpate pulses for irregularity (e.g., atrial fibrillation).

Neurological Examination:

·       Assess cranial nerves, motor and sensory function, and reflexes.

·       Check for any focal neurological deficits that might suggest a cerebrovascular event.

Orthostatic Hypotension:

·       Measure blood pressure lying down, then after standing for 1 and 3 minutes. A drop in systolic BP >20 mmHg or diastolic BP >10 mmHg suggests orthostatic hypotension.

Additional Examinations:

·       Check for signs of dehydration or anemia.

·       Look for stigmata of chronic liver disease, thyroid disease, or any other systemic condition that might contribute to syncope.

Investigations: What’s Essential?

Investigations should be guided by clinical findings and history, aimed at ruling out life-threatening causes and confirming the diagnosis.

Initial Investigations:

·       ECG:

·       Look for arrhythmias, heart block, signs of ischemia, long QT syndrome, or Brugada syndrome.

·       Blood Tests:

·       Full blood count (for anemia or infection), electrolytes (for imbalances), glucose (for hypoglycemia), cardiac enzymes (if suspecting ischemia), and renal function.

·       Imaging:

·       Chest X-ray if there’s a suspicion of heart failure or lung pathology.

·       CT head if neurological symptoms are present or if there’s concern for intracranial pathology.

Further Investigations:

·       Echocardiogram:

·       To assess for structural heart disease if a murmur is detected or there’s suspicion of heart failure.

·       24-hour Holter Monitor or Event Recorder:

·       For patients with intermittent symptoms or suspected arrhythmias.

·       Tilt Table Testing:

·       In cases of unexplained syncope, particularly if vasovagal or orthostatic causes are suspected.

Specialist Referrals:

·       Consider referral to cardiology for patients with suspected arrhythmias or structural heart disease.

·       Neurology referral may be necessary for those with suspected seizure activity or unexplained neurological symptoms.

Management Plan: Tailoring to the Cause

Management of collapse and syncope is highly dependent on the underlying cause. However, some general principles apply.

Immediate Management:

·       If Cardiovascular Cause:

·       Administer oxygen if hypoxic.

·       Start IV fluids if the patient is hypotensive or dehydrated.

·       For arrhythmias, initiate appropriate antiarrhythmic therapy or consider cardioversion if indicated.

·       If Neurological Cause:

·       For seizures, administer benzodiazepines if actively convulsing.

·       Protect the airway if the patient is post-ictal or unresponsive.

·       If Orthostatic Hypotension:

·       Advise the patient to rise slowly from a sitting or lying position.

·       Increase fluid and salt intake unless contraindicated.

·       Review medications and adjust those contributing to hypotension.

Long-term Management:

·       Cardiac Monitoring:

·       Patients with suspected arrhythmias may need prolonged monitoring and possibly an implantable loop recorder.

·       In cases of confirmed structural heart disease, follow-up with cardiology for potential interventions (e.g., valve surgery, pacemaker insertion).

·       Lifestyle Modifications:

·       Advise patients prone to vasovagal syncope on triggers and how to avoid them (e.g., avoiding prolonged standing, staying hydrated).

·       Encourage regular follow-up for those with chronic conditions like diabetes or hypertension.

Patient Education:

·       Ensure the patient and their family understand the nature of the condition, the importance of follow-up, and when to seek urgent care (e.g., recurrence of symptoms, chest pain, or neurological signs).