Collapse

History

HPC:
– Onset – when did collapse occur? What were you doing at the time?
– Previous episodes – has this ever happened before?
– Do you remember falling? Did you lose your consciousness? For how long?
– Was the episode witnessed? Did they mention on specific jerky movements during fall in limbs or face how
did these spread? Mention of particular colour before or during fall?
Pre
– Any sweating, nausea, lightheadedness, dizziness, tunnelling of vision before fall? – vasovagal
– Any chest pain, palpitations, feeling breathless before fall? – cardiogenic – dysrhythmia
– Any head injuries, severe headaches, weakness in legs or arms, slurred speech, facial droop? – stroke
– Prodromes:

o Dehydration
o Last meal
o Alcohol/ caffeine – arrhythmias
o Hot weather
o Fear/stress
o Flashing lights

– Any sudden neck movements, neck injuries or head injuries?
During
– Do you remember hitting the ground? LOC for how long?
– Tongue biting side of tongue? Urinary incontinence? Jerky movements spreading?
– Any injuries to head?
– Eyes closed or open?
After
– How fast did you come around? How did you feel after regaining consciousness? Any drowsiness,
confusion, headache, weakness in arms or legs (Todds paresis) ?
PMH:
– Diabetes
– Heart problems – previous heart scans or heart tracings
– Seizures
– Recent viral infection? Cough? Coughing up blood?
– Angina – chest pain on exertion – AORTIC STENOSIS
MH – Compmliance with medications? Any recent changes?
– Anticholinergics
– Antihypertensives
– Anti-gylcaemics/ insulin
– Benzodiazepines
– Ilicit drugs e.g. cocaine, amphetamine, ecstasy
– Drugs which prolong QT
– OTC medications or herbal medicines

FH
– Sudden deaths at young age < 60
– Cardiac problems
– Epilepsy
– Diabetes
SH:
– Hobbies – swimming, cycling
– Driving
– Alcohol
– Recreational drugs
– Smoking
– Occupation – any heavy machinery
Red Flags
– Transient loss of consciousness without warning without precipitant
– History of event during exertion
– Previous history of structural heart disease, congenital cardiac abnormality
– Family history of sudden death or strucutural heart disease or arrhythmias (Hypertrophic Obstructive
Cardiomyopathy, Arrythmogenic Cardiomyopathy, Brugada Syndrome, Cousin had collapse now has device
in)
– Hemoptysis – PE cause of syncope

Examination
– Cardiovascular

o VSD louder with Valsava Manoeuvre
o Pulse – AF
o Systolic murmur – ESM or HCOM

– Neurological

o Cranial Nerves

Differentials:
– Neurally mediated vasovagal syncope
– Situational syncope – cough, micturition, post-exercise
– Carotid sinus syncope
– Orthostatic Hypotension (primary or secondary autonomic failure, drug-induced, volume depletion)
– Cardiac Syncope
– Arrhythmias

o Bradycardia, tachycardia
o Brugada syndrome
o Long QT Syndrome
o AV Node Block

– Structural

o HCOM
o Arrythmogenic right ventricular hypertrophy
o Aortic Stenosis – bicuspid valve in young

– Pulmonary Embolism
– Aortic Dissection
– Pulmonary hypertension

To complete assessment I would take full collateral history
Lying Standing blood pressure
12-lead ECG (exclude long QT, LVH, Q waves, conduction defects)
Bloods: blood glucose at time of incident
ECHO – exclude structural heart disease – asymmetric septal hypertrophy, systolic anterior motion of mitral
leaflets, assess LV function and LV outflow obstruction
Special tests:
Tilt table testing
Exercise tests