Collapse

Acute Cardiac Arrest

  • Check response and signs of life
    • Pinch shoulders and loudly ask for a response (in case the patient is sleeping)
    • If the patient is unresponsive, check airway (A) briefly to look for obstruction; feel carotid and breath exhalation, look for chest movements and listen for breath sounds for 10 secs (best done with your ear by their mouth and looking down their chest for rising/falling)
    • If absent:

Shout for help (crash team) and/or call 2222 for the crash team.  Commence CPR until crash team arrive.

  • Begin with 30 chest compressions followed by two breaths
    • If there is no-one else there, this may be done mouth-mouth
    • If there is someone to help, a resus mask may be used to administer the breaths
  • ContinueCPR once crash team has arrived as they are setting up the monitor/defibrillator
    • White lead (one pad)- right mid clavicle
    • Red lead (the other pad)- left axillary line (V6- position)
    • Assess rhythm and confirm if shockable
      • VF or pulseless VT

    • Charge the Defibrillator to 150J/s biphasic shock
    • Once charged, stop CPR and CLEAR the area of persons and oxygen
    • Administer the shock
  • CONTINUE CPR straight away for 2 mins while rhythm is being detected (10 breaths)
  • Reshock if necessary (i.e. if still unconscious, and in shockable rhythm) and repeat again
  • If, VT/VF persists after 3rd shock, continue CPR and administer 1mg adrenaline IV and 300mg Amiodarone IV
    • NB while all this is going on, you want to get someone else to get IV access and take bloods etc

If the patient comes in unconscious (GCS 3-8), always consider hypoglycaemia, particularly if alcohol is involved or if a ‘seizure’ has been reported (hypoglycaemia can often cause collapse and fits- and is much more readily treatable than epilepsy).

Assessment of Falls

History

  • What do they mean by ‘fall’?
    • Did they trip? (Neuropathy/Cerebellar/Alcohol etc)
    • Did they lose consciousness?
      • If so, do they know how long? (Long may be epilepsy? Shorter may be vasovagal/autonomic cause/Post hypotension)
      • If so, were they confused afterwards?  Do they need time to get back to normal? (Again thinking epilepsy)
  • Ask about timing-
    • What happened leading up to the collapse?  Were they exercising (cardiac cause)?  Were they in a hot/crowded space?  Were they drinking/drunk? Sleep-deprived?
      • Did they feel light-headed/nauseous?
      • Do they remember the preceding time?
      • Do the witnesses describe any abnormal behaviours (either personality or physical e.g. lip-smacking/swallowing/chewing etc)
    • What happened during the collapse?
      • Any injury?
      • Any jerks/involuntary movements? (a good description of the movements can help with the diagnosis e.g. sudden rigidity followed by rhythmic jerking movements is classic of tonic-clonic seizure)
        • How long did these last? (seconds- syncopal jerks; minutes- epilepsy; hours- dissociative seizures)
    • What happened after?
      • Confusion? Personality change?
      • Muscle ache/fatigue/weakness?
  • How long has it being going on for?
    • One-off (accident- trauma/injury concern)
    • Becoming slowly more regular (consider age-related causes and chronic disease causes e.g. diabetes)
    • Acutely regular (consider head injury causes e.g. haematoma)
  • Under what circumstances does it occur?
    • Time of day?
    • History of head injury/chronic disease?
    • Standing (postural hypo)
    • Do they occur only when the patient is panicking? (Anxiety)
    • ? Random ? (Possibly vasovagal)
    • Do they happen at home? (thinking about home environment)
  • How long were they down? / How were they found?
    • IMPORTANT: A COLATERAL HISTORY IS OFTEN MORE USEFUL, NOT JUST FOR THIS QUESTION BUT IN GENERAL TOO
  • How are they in general?
    • Cognitively? (neurodegenerative)
    • Any other motor symptoms (Parkinsons)
    • MEDICATIONS and PMHx
      • BP meds/CVS meds/Warfarin etc
      • Diabetes (hypo)

The rest of the history should include social, family histories etc as well.

Examination

  • Intro
    • Wash hands, introduce yourself, check name and dob, gain consent etc
  • General
    • Hands: look for evidence of muscle wasting/fasciculations; look for clubbing (confusion secondary to lung cancer for example); peripheral cyanosis (heart causes)
    • Pulse (AF)
    • BP (standing and sitting/ right and left arm/ collapsing)
  • Head
    • Check Cranial nerves II, III, IV, VI
      • Pupillary reflexes (haematoma)
      • Peripheral fields (brain lesion)
      • Central field (age related macular degeneration)
      • Sensory inattention
      • Visual acuity (is it they need their glasses checked?
      • Eye movements (other cranial causes)
  • Neck
    • Check carotid pulse and bruit (carotid disease/stroke)
  • Chest
    • Check CVS (Only do in-depth examination e.g. positioning for murmurs, if you suspect cardiac cause)
    • Check RS (Again, all that is really necessary is percussion/auscultation over the three zones, unless you are worried about the respiratory cause e.g. lung cancer, vasovagal secondary to breathlessness from COPD etc)
  • Neuro/MSK
    • Motor
      • Check Tone, Reflexes and Power, particularly of the lower limbs
      • Check coordination of all four limbs
      • Check and observe gait +/- Romberg’s test
    • Sensation
      • Check sensation of the lower limbs (and upper limbs) IF you have need to e.g. in diabetic neuropathy; radiculopathy related falls; relapse of MS etc
      • Proprioception may be particularly important
    • Cognitive function
      • MMSE may be of use if you are concerned about dementia/stroke

Investigations

  • ECG
  • FBC, U&Es, Blood glucose, LFTs (if alcohol involved)
  • CT head is only indicated if
    • persisting significant focal neurological deficit or confusion/decreased consciousness
    • head injury/recent head injury (especially if anticoagulated)
    • recent diagnosis of malignancy that could metastasise to the brain

Differential Diagnosis

  • Epilepsy
  • Non-epileptic seizures/epilepsy mimics
  • Syncope
  • Stroke/TIA
  • Head injury (subdural haematoma/subarachnoid haemorrhage/extradural haematoma etc)
  • Vertigo
  • Hypoglycaemia
  • Postural hypotension
  • Alcohol excess/illicit drug use
  • Anaphylaxis
  • Brain tumour
  • CNS infection e.g. meningitis, encephalitis

Paediatric BLS

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