Case 4: Collapse

66 year old gentleman was out having dinner with his family. He describes the pub as very hot, half way through eating his main course, he became very hot and a sweaty and then everything went blank. When he woke, his family were all gathered round him, fanning him. He had not bitten his oral mucosa and had not been incontinent. He felt a bit out of sorts, but knew where he was. An ambulance was called and he was brought to hospital.

His wife attended hospital with him, and reports that half way through the meal, he became very quiet and visibly sweaty and fell unconscious for approximately one minute. She reports he was breathing throughout. When he came round, he was a little ‘dazed’ but quickly recovered. The family were a bit concerned because when he was unconscious he had some twitching of his arms and legs.

The patient reported no preceding chest pain, palpitations, shortness of breath, he felt suddenly lightheaded just before he collapsed. No head injury. He has never lost consciousness before.

Past medical history: Hypertension, osteoarthritis, hiatus hernia

Drug history: Ramipril, amlodipine, paracetamol, lansoprazole, NKDA

Social History:, Retired caretaker, lives with wife, independent, never smoked, alcohol 2 pints three days a week

Examination

Appears well

Talking in full sentences, not confused

RR 16, SpO2 98% on air, chest clear

HR 86 reg, lying BP 133/59, standing 136/62, HS I+II +0

ECG – normal sinus rhythm

GCS 15/15

Cranial nerves in tact

Normal neuro exam

 

Differential diagnosis

Differential Rationale
Vasovagal syncope Likely, hot pub, eating large meal, felt sweaty and lightheaded beforehand, recovered on lying flat, re-orientated quickly.
Postural hypotension No change in position, although is on anti-hypertensives that can cause this, no change in lying/standing BP
Seizure Unlikely, some twitching of the limbs –but this can be normal for a faint. No tongue biting/incontinence, no history of seizures, no post-ictal period.
Cardiac arrhythmia No evidence for this – no palpitations, normal ECG, no history
Acute blood loss No history of acute blood loss, recovered within minutes
Aortic dissection No pain and good recovery

 

Investigations

Arguably this patient only needs an ECG and no other investigations

Diagnosis: Vasovagal syncope

Management: discharge with safety net advice

Vasovagal syncope
Intermittent loss of autonomic control of heart rate and blood pressure.
Increased parasympathetic nervous system tone and reduced sympathetic nervous system tone.
Essentially results in vasodilation and bradycardia and reduced cerebral perfusion.

Useful links

NICE guidance – transient loss of consciousness

Canadian Syncope Risk Score