Collapse, Syncope, Mechanical Falls

Clinical Excellence Commission Post Fall Guide

https://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0003/258465/Post-Fall-Guide.pdf

• All of these are characterised by full and rapid neurological recovery
• Syncope is transient loss of consciousness and postural tone from reduced cerebral perfusion, followed by spontaneous and full recovery
• Presyncope refers to a reduction in cerebral perfusion resulting in a sensation of impending loss of consciousness, although the patient does not actually pass out

Phone Call/Presentation Questions

• Was the collapse witnessed?
• Was the patient lying, sitting or standing when the episode occurred?
  • If while lying down likely cardiac; cannot be postural hypotension
• Did the patient actually lose consciousness?
• Was any seizure like activity observed?
• What are the vital signs now, including GCS score?
• Did the patient sustain any injury?
• What is the blood glucose level?
• What was the reason for admission?

Instructions Over the Phone

• When no evidence of injury (head, neck or lower limb) and the vital signs are stable:
  • Ask the nurse to slowly raise the patient to a seated position, then standing position
  • Place the patient back into bed to remain there until you arrive
  • Request an ECG and attach non-invasive monitoring to the patient if syncope was the cause of collapse
  • Request a fingerprick BGL
  • Obtain a lying and standing HR and BP; ask the nurse to wait at least 2 minutes after standing the patient up before taking the observations, then repeat the vital signs every 15 minutes until you arrive at the bedside
  • Ask the nurse to call you back immediately if there is deterioration in the level of consciousness or any cardiorespiratory instability

Prioritisation

• Attend immediately if the patient remains unconscious and/or the HR or BP are abnormal
• If the patient is alert and conscious with normal vital signs, or following an uncomplicated fall with no injury, there is no immediate urgency to attend

Common Causes (Corridor Thoughts)

• Can remember using the mnemonic: HEAD, HEART, VESSELS
  • CNS (head)
    • Hypoxia (hypoglycemia does not cause syncope)
    • Epilepsy (not a true cause of syncope)
    • Anxiety and hyperventilation
    • Dysfunctional brain stem (basivertebral TIA)
  • Cardiac (heart)
    • Heart attack (ACS)
    • Embolism (PE)
    • Aortic obstruction (IHSS, AS or myxoma)
    • Rhythm disturbance, ventricular
    • Tachycardia
  • Vascular (vessels)
    • Vasovagal (emotional reactions) or Valsalva (micturition, cough, straining etc)
    • Ectopic (and other causes of hypovolemia)
    • Situational
    • Subclavian steal
    • ENT (glossopharyngeal neuralgia)
    • Low systemic vascular resistance
      • autononic dysfunction: Addison’s, diabetic vascular neuropathy
      • Drugs such as CCBs, beta-blockers, anti-hypertensives
    • Sensitive carotid sinus
• Otherwise categorise into causes of syncope and causes of mechanical fall:
  • Syncope
    • Cardiac central vascular
      • Bradyarrhythmias (Stokes-Adams attack): sinus arrest, second- and third- degree AV block, sick sinus syndrome, pacemaker malfunction
      • Tachyarrhythmias: VT, rapid AF or flutter (±WPW), rapid paroxysmal SVT (±WPW), Torsades de pointes (usually with prolonged QT)
      • Obstructive or low-flow conditions: HCM, aortic stenosis, pulmonary embolism
    • Peripheral vascular orthostatic (postural) hypotension
      • Durg induced: Nitrates, hydralazine, prazosin, ACE-i, antipsychotics, levodopa
      • Volume depletion: GI bleed, ruptured AAA, ectopic pregnancy, dehydration
      • Autonomic failure: Diabetes, Parkinson’s disease/plus/Lewy body
    • Vasovagal syncope
      • Excessive vagal tone assocaited with standing, emotion, fear, pain, stress, hunger
    • Situational syncope
      • ↑ intrathoracic pressure from coughing, micturition, swallowing, defecation, sneezing
    • Carotid sinus hypersensitivity causes syncope on turning head, tight neck collar etc
    • Cerebrovascular
      • Subarachnoid haemorrhage
      • Vertebrobasillar insufficiency
      • Subclavian artery steal: extremity exercise leads to vertebrobasilar insuffiency
    • Psychogenic
      • Hyperventilation
      • Psychogenic collapse: diagnosis of exclusion only; look for underlying organic basis first
  • Mechanical falls
    • Can be multifactorial especially in older people; combination of environmental hazards, poor vision, diminished muscular strength and impaired proprioception
    • Neurological
      • Dementia resulting in poor safety awareness
      • Confusion and cognitive impairment
      • Pre-existing weakness
      • Parkinson’s disease, or other movement disorders including normal pressure hydrocephalus
      • Cerebellar lesions with ataxia
    • Metabolic disorder
      • Electrolyte abnormality such as hyponatraemia, hypokalaemia, hypoglycaemia, hyperglycaemia
      • Dehydration, renal failure (multifactorial), hepatic failure
    • Drugs
      • Narcotics, sedatives, tranquilisers
    • Sensory impairment
      • Cataracts, age-related macular degeneration, glaucoma
      • Impaired balance and proprioception
    • Musculoskeletal
      • Arthritis, obesity and physical inactivity
    • Environmental
      • Wet floor
      • Unsafe clothing or inappropriate footwear
      • Physical
        • Bed rails, IV pole, bed height, edge of a carpet, poor lighting or no handrails

Assessment

End of Bed

• Pallor followed by flushing occurs in cardiac syncope, whereas persistent pallor may indicate occult bleeding or another cause of poor peripheral perfusion
• However, most patients who have had a simple mechanical fall or an episode of syncope regain normal consciousness and look perfectly well

A to E Assessment

• Heart rate?
  • Tachycardia, bradycardia or irregular rhythm may indicate an arrhythmia as the primary cause → perform ECG and attach cardiac monitoring
  • Cardiac cause of collapse have a increased mortality risk
• Blood pressure?
  • A postural fall in BP together with a postural rise in HR (>20 beats/min) suggests intravascular volume depletion
  • A drop in BP without a change in HR, or one that corrects on standing, suggests autonomic dysfunction
  • Hypertension may be associated with SAH or brainstem TIA

Immediate Management

• Recovery from syncope will be delayed if the patient is kept upright and not placed supine until symptoms resolve
  • Gradually sit the patient up over a few minutes as tolerated
• A cardiac arrhythmia should be confirmed with a 12-lead ECG and treated immediately
• Obtain IV access and give normal saline 10–20 mL/kg IV rapidly if BP <90 mmHg and does not quickly improve with recumbency
• Check for head or neck injury, as spinal immobilisation may be needed
• Move onto selective history and examination if the patient has fully recovered from the syncopal episode, has a normal ECG and normal vital signs

Selective History and Chart Review

• Can consider asking the 5P’s:
  • Precipitant
  • Prodrome
  • Position
  • Palpitations
  • Post-event phenomena
• Previous syncopal episode?
  • Ask if the patient has ever had a previous syncopal episode
  • Ask whether these previous episodes have been documented investigated or diagnosed
• What does the patient (or a witness) recall about the time immediately before the syncope?
  • Try to determine preceding symptoms or obvious precipitant to the collapse
  • Sudden collapse with no warning, syncope lying down, associated palpitations or syncope on exertion suggests a cardiac cause known as a Stokes-Adams attack (also consider syncope in individuals with a family history of sudden death or inherited cardiac condition)
  • Syncope on rising from a supine position suggests orthostatic or postural hypotension
  • Emotion or a noxious stimulus such as IV line insertion or painful wound dressing change may cause collapse secondary to a vasovagal episode
  • Preceding nausea, sweating, distant hearing and light-headedness are common with a vasovagal episode
  • Syncope during or immediately after coughing, micturition, straining at stool or sneezing suggests situational syncope
  • Syncope after turning the head to one side (especially if wearing a tight collar) or while shaving may indicate carotid sinus syncope, often in elderly men
  • Syncope occurring during arm exercise suggests subclavian steal syndrome
  • Numbness and tingling in the hands and feet are common just before presyncope or syncope caused by hyperventilation
• Confirm any presenting problem or past medical they may have caused the collapse; examples include:
  • Previous episodes of collapse or falls with or without known diagnosis
  • Evidence of LV failure or a documented reduced LV ejection fraction <30%
  • Known cerebrovascular disease
  • Autonomic neuropathy
  • Positive family history of collapse or sudden death may be due to underlying HCM, WPW syndrome, long QT syndrome or Brugada’s syndrome
• Charts
  • Observation charts
    • Check the vital signs to determine whether this is an acute change or if there were long-standing abnormalities in postural BP ⇒ autonomic neuropathy
    • Check the signs of hypovolaemia such as tachycardia, narrowing pulse pressure
    • Check for adequate fluid intake and look at the fluid balance chart
  • Medication charts
    • Nitrates, vasodilator antihypertensives, diuretics, antiarrhythmics, tricyclic antidepressants, antipsychotics, levodopa and sildenafil (Viagra) cause postural hypotension
    • Beta-blockers (including eye drops), calcium-channel blockers, digoxin and amiodarone may cause bradycardia
    • Any CNS depressant increases the risk of falls
    • Quinidine, procainamide, disopyramide, sotalol, amiodarone, tricyclic antidepressants, antipsychotics and some of the ‘non-sedating’ antihistamines prolong the QT interval

Examination

Examination	Notes
Vitals	Repeat now, then take the BP in both arms. A difference >20 mmHg may indicate aortic dissection or subclavian steal syndrome
HEENT	Bitten tongue or cheek ⇒ seizure disorder
	Neck stiffness ⇒ meningitis causing a seizure, SAH
	Haemotympanum ⇒ fractured base of skull
Eyes	Check for visual fields
Resp	Crackles, wheezes ⇒ LVF, or aspiration during syncope
CVS	Pacemaker ⇒ pacemaker syncope
	Flat JVP ⇒ volume depletion
	Focal features of right heart failure ⇐ ↑ JVP and parasternal heave with dyspnoea suggesting PE
	Atrial fibrillation ⇒ verebrobasilar embolism
	Systolic murmur ⇒ aortic stenosis, HCM, pulmonary stenosis
	Supra- or subclavicular bruit ⇒ subclavian steal syndrome
Abdo	Abdominal mass ⇒ ruptured AAA
	Rectal blood or melaena ⇒ GI bleed
	Pelvic tenderness, vaginal bleeding ⇒ ectopic pregnancy
GU	Urinary incontinence ⇒ seizure disorder
Neuro	Residual localising signs such as unsteadiness or cranial nerve abnormalities such as diplopia, nystagmus, facial paralysis, vertigo, dysphagia and dysarthria occur in brainstem (vertebrobasilar) TIA
	Can consider gait and balance
	4AT
	Other testing: mental status, muscle strength (power), lower extremity peripheral nerves (can use blunt needle (red in colour) to test pin prick sensation), proprioception, reflexes, cerebellar function
MSS	Check passive ROM of the limbs and for evidence of a fracture if the patient fell
	Gently externally or internally rotate the leg
	Get the patient to take a deep breath in (assessing for rib fracture)
Skin	Contusions, abrasions and laceration from injury

Investigations

• Check a fingerprick glucose for hypo/hyperglycaemia
• ECG in all patients
  • Bradyarrhythmia, tachyarrhythmia, evidence of ACS or previous MI
  • Conduction defects, WPW, prolonged QT, LVH in HCM, or Brugada’s syndrome
• Urinary beta-hCG in women of reproductive years
• Other tests as indicated:
  • FBC (bleeding, anaemia)
  • UEC, troponin if AMI is suspected
  • CXR re. cardiomegaly, heart failure
  • Echocardiography, Holter monitoring and exercise testing to investigate for cardiac cause
  • CT if possible neurological cause (e.g. SAH, vertebrobasilar insufficiency) - usually quite rate <2% of syncope

Specific Management

Cardiac Causes

• Arrange continuous ECG monitoring if you suspect a cardiac cause for syncope such as an arrhythmia, valvular or a pacemaker problem
• Exclude MI with resultant AV block, VT or VF as the cause by ECG analysis and troponin
• Arrange for an echocardiogram in the morning to document a suspected cardiac lesion
• Organise a cardiology consultation if aortic stenosis, hypertrophic cardiomyopathy or an arrhythmia is suspected
• Pacemaker syncope requires a cardiology consultation for reprogramming of the pacing rate, output or mode, or for an upgrade to AV sequential pacing
• Otherwise, arrange an outpatient 24-hour Holter ECG in younger patients with no overt evidence of heart disease

Orthostatic Hypotension

• Volume depletion → IV fluid replacement
• Drug-induced orthostatic hypotension and autonomic failure → leave to the medical team to manage
• Instruct patients that if they need to get out of bed during the night, they must ask the nurse for assistance and should move slowly from supine to sitting, dangle their legs for 2 minutes and then move slowly again from sitting to standing

Neurological Causes

• Arrange a CT head for suspected TIA (with contrast) or SAH (non-contrast) and consult with senior

Vasovagal Syncope

• Nausea and malaise persist for longer in these patients
• Exclude pregnancy in females

Situational Syncope

• Usually no specific therapy other than explanation (e.g. tell men to micturate sitting down)
• Refer a patient with suspected carotid sinus syncope to a cardiologist for investigation

Hyperventilation

• Presyncopal patient due to hyperventilation or anxiety:
  • Instruct to breathe into a paper bag when the anxiety presyncopal feeling begins (corrects hypocapnia from hyperventilation)
  • Administer a benzodiazepine if resistant but remember to explore the underlying precipitating trigger

Falls

• Correct the reversible factors
  • Postural hypotension from volume depletion and unnecessary drug therapy in elderly
  • Make sure nocturia is not iatrogenic (e.g. cancel evening diuretic order or unecessary IV infusion) and limit evening fluid intake
  • Disorientation: ensure the call bell is easily accessible and a nightlight is left on
    • Lower the bed height
• Check for complications (e.g. shoulder dislocation, hip fracture on paralysed side of a stroke patient)
  • Anticoagulated patient may develop a serious delayed traumatic intracranial haemorrhage (leave a note for the medical team to re-examine these patients frequently)
  • Common fractures: Colles’, femoral neck, pubic rami, spinal crush, rib and humeral neck
  • Fear, loss of confidence and independence, loss of mobility → arrange physiotherapy and occupational therapy consultation
• Consider referring to other teams such as falls clinic and ASET
• Always organise a CT brain for all unwitnessed falls

Resources

• My notes from medical school: https://mango-cellar-b90.notion.site/Approach-to-a-pre-syncope-syncope-308c2fce084d467e9b2ebb7cc3afb6a5