Loss of Consciousness Colin Dibble

Emergency Physician

Objectives

Approach to the

unconscious patient

Approach to differential

diagnosis

Syncope

Management

Approach

Airway

Breathing

Circulation

Disability

Exposure/Environment

Fever?

GLUCOSE

Differentials

1. Vasovagal syncope

2. Cardiac

3. Neurological – intracerebral

4. Neurological – extracerebral toxins

Differentials

Trauma Subdural

Extradural

Parenchymal

DAI

hypoxia/hge

Infective Sepsis

Meningitis

Encephalitis

Fungal: crypto/

Malaria

rabies

Endocrine Hypoglycaemia

DKA/HONK

Thyroid storm

Addisons

Alcoholic

ketoacidosis

Toxic overdose

alcohol

sedatives

cyanide

carbon monoxide

opioids

Environmt hypo/hyperthermia

radiation

snake bite

electrocution

lightning

Carbon monoxide

CNS fitting

post ictal

SAH

AVM

Stroke

Tumours CVS

hypovolaemia

arrythmia

cardiac arrest

dissection

vasovagal

cardiogenic shock

Misc hypoxia

hypercapnia

anaphylaxis

encephalopathy

narcolepsy

Eclampsia

Amniotic fluid embolism

History

Onset/duration/ any asso’d movements

Preceding position, activity, predisposing factors/ events

Previous episodes and medical history/cardiac

Medications/drugs/exposure

Fevers/rashes

Headaches/fitting/vision/behaviour

Trauma

Examination

ABC+DEFG

C – rate/rhythm/postural BP

E - temperature/rashes/smell

full neuro ?focal signs, neck stiffness

toxidromes

Any injuries after collapse?

• Always check ECG

Syncope

Was LOC complete?

Was LOC transient, rapid onset

and short duration?

Did patient lose postural tone?

Did patient recover spontaneously, make full

recovery without sequelae?

Pietro Longhi (1702–1785)

Fainting 1744

“Syncope” red flags

• Over 65 years of age and young Paeds

• No prodrome; during exertion

• Prolonged LOC

• Associated with pain – chest, abdo or back; headache

• Family history of sudden cardiac death

• History of structural heart disease

• Fevers

• Clinical findings suggestive of heart failure

• Persistently low blood pressure (systolic <90 mmHg)

• Shortness of breath with event or during evaluation

Investigations

ECG, Glucose

Gas, EUC, CMP

(Trops, D-dimers as indicated)

Specific tests, eg paracetamol,

alcohol level?

LP?

MRI/MRA etc?

CT? • Altered neurological state

– confusion, focal deficit

• After first seizure

• If sudden onset headache

• If on anticoagulants

• (If over 65 years of age)

• If incurred secondary

head trauma

ECGs

Can Quick BRAD walk home?

• Conduction defects

• QT – long or short

• Brugada

• RV ischaemia

• Arrhythmogenic RV dysplasia

• Dilated cardiomyopathy

• WPW

• Hypertrophy – either LVH or HCM

55 year old man collapsed whilst standing

18 year old collapsed whilst playing rugby

67 year old, collapse, SOB and ankle

oedema

33 year old lady, collapsed whilst

jogging

Syncope summary

• Vasovagal syncope

• 4 questions

• Importance of ECG

• Cardiac – Can Quick BRAD Walk Home

• Neuro

• When to CT