How To Assess A Patient Presenting With Collapse / Unresponsive Episode

Patients presenting with collapse are tricky to the clinicians due to variety of possible causes and uncertainty, here is our guide yo assess a patient presenting with collapse or unresponsive episode:

Step 1: Initial Assessment and Triage
A. Rapid Assessment and Stabilization

1. Airway: Ensure the airway is patent. If obstructed, employ maneuvers like head tilt-chin lift or jaw thrust. Consider advanced airway management if necessary.
   
   
2. Breathing: Assess breathing rate, depth, and effort. Administer oxygen if hypoxia is present or suspected.
   
   
3. Circulation: Check for pulse, blood pressure, capillary refill, and signs of shock. Initiate intravenous access and fluid resuscitation if needed.
   
   
4. Disability: Perform a quick neurological assessment using the AVPU (Alert, Voice, Pain, Unresponsive) scale to determine the patient's level of consciousness.
   
   
5. Exposure: Conduct a rapid but thorough examination to identify any immediate threats such as hemorrhage, injuries, or environmental hazards.

B. Triage

Prioritize patients based on the severity of their condition. Use triage systems like the Manchester Triage System or the Emergency Severity Index to categorize patients into appropriate urgency levels.

Step 2: History Taking
A. History of Presenting Complaint

1. Onset: Ask about the time and nature of the collapse. Sudden onset might indicate a cardiac cause, while gradual onset could suggest other etiologies.
   
   
2. Duration: Determine how long the patient was collapsed. Prolonged unconsciousness requires a different approach compared to transient episodes.
   
   
3. Associated Symptoms: Inquire about symptoms before, during, and after the collapse, such as chest pain, palpitations, shortness of breath, dizziness, or seizures.

B. Past Medical History

1. Cardiovascular: History of heart disease, arrhythmias, or syncope episodes.
   
   
2. Neurological: Any history of seizures, strokes, or transient ischemic attacks.
   
   
3. Metabolic and Endocrine: Diabetes, thyroid disorders, or electrolyte imbalances.
   
   
4. Medications: Review current medications, including over-the-counter drugs and supplements, to identify potential drug interactions or side effects.

C. Social History

1. Alcohol and Substance Use: Excessive alcohol intake or drug use can contribute to collapse.
   
   
2. Recent Activities: Physical exertion, recent trauma, or stressors may provide clues to the underlying cause.

D. Family History

Ask about any family history of sudden death, cardiac conditions, or epilepsy, as these can indicate genetic predispositions.

Step 3: Physical Examination
A. General Examination

1. Vital Signs: Measure and monitor blood pressure, heart rate, respiratory rate, oxygen saturation, and temperature.
   
   
2. General Appearance: Observe the patient’s level of distress, pallor, cyanosis, or signs of trauma.

B. Cardiovascular Examination

1. Inspection: Look for signs of heart failure such as jugular venous distension or peripheral edema.
   
   
2. Palpation: Check for the presence of peripheral pulses and any abnormal cardiac impulses.
   
   
3. Auscultation: Listen for heart sounds, murmurs, or abnormal rhythms. A new murmur might indicate valvular disease or structural heart changes.

C. Respiratory Examination

1. Inspection: Observe the chest for symmetry and any use of accessory muscles.
   
   
2. Palpation and Percussion: Assess for any abnormalities in the chest wall or lung fields.
   
   
3. Auscultation: Listen for breath sounds and any abnormal noises like wheezes, crackles, or absent breath sounds.

D. Neurological Examination

1. Mental Status: Assess orientation to person, place, and time.
   
   
2. Cranial Nerves: Evaluate the function of cranial nerves to rule out central causes.
   
   
3. Motor and Sensory Function: Check muscle strength, tone, and sensory responses in all limbs.
   
   
4. Reflexes: Assess deep tendon reflexes and check for pathological reflexes like the Babinski sign.

E. Other Examinations

1. Abdominal: Palpate for tenderness, masses, or organomegaly which could indicate intra-abdominal pathology.
   
   
2. Skin: Look for signs of infection, rash, or bruising.

Step 4: Initial Investigations
A. Laboratory Tests

1. Blood Glucose: Immediate check to rule out hypoglycemia.
   
   
2. Full Blood Count (FBC): To detect anemia, infection, or other hematologic abnormalities.
   
   
3. Electrolytes and Renal Function: Assess for imbalances and renal impairment.
   
   
4. Cardiac Enzymes: Troponin levels to evaluate for myocardial infarction.
   
   
5. Liver Function Tests: To check for hepatic pathology.
   
   
6. Toxicology Screen: If substance abuse is suspected.

B. Imaging

1. Chest X-ray: To assess for pulmonary or cardiac causes of collapse.
   
   
2. Computed Tomography (CT) Scan: Head CT if a neurological cause such as stroke or hemorrhage is suspected.

C. Electrocardiogram (ECG)

Perform an ECG to identify arrhythmias, ischemic changes, or other cardiac abnormalities.

D. Additional Tests Based on Initial Findings

1. Echocardiography: If a structural heart problem is suspected.
   
   
2. Holter Monitoring: For ongoing arrhythmia detection.
   
   
3. Tilt Table Test: If vasovagal syncope or orthostatic hypotension is suspected.
   
   
4. Electroencephalogram (EEG): If seizures are a concern.

Step 5: Management
A. Immediate Management

1. Stabilization: Continue to ensure airway, breathing, and circulation are maintained.
   
   
2. Treatment of Underlying Cause: Based on initial findings, treat the most likely cause of collapse (e.g., anti-arrhythmic drugs for arrhythmias, glucose for hypoglycemia).

B. Symptomatic Treatment

1. IV Fluids: To manage dehydration or shock.
   
   
2. Medications: Administer appropriate medications as per the identified cause (e.g., anticonvulsants for seizures).

C. Continuous Monitoring

1. Vital Signs: Regular monitoring of vital signs to detect any deterioration.
   
   
2. Telemetry: Continuous cardiac monitoring for arrhythmias.

D. Referral and Consultation

1. Specialists: Involve cardiologists, neurologists, or other specialists as needed.
   
   
2. Admission: Decide on the need for hospital admission based on the severity of the condition and the initial response to treatment.

E. Discharge Planning

1. Education: Educate the patient and caregivers about warning signs and when to return to A&E.
   
   
2. Follow-Up: Arrange follow-up appointments with appropriate outpatient services.

Step 6: Documentation and Legal Considerations
A. Detailed Documentation

1. Clinical Findings: Document all findings meticulously, including history, physical examination, investigations, and management steps.
   
   
2. Patient Communication: Record any discussions with the patient and their family regarding the diagnosis, treatment plan, and prognosis.

B. Legal and Ethical Considerations

1. Consent: Ensure informed consent is obtained for any invasive procedures or treatments.
   
   
2. Capacity: Assess the patient’s capacity to understand and make decisions about their care.
   
   
3. Confidentiality: Maintain patient confidentiality throughout the process.

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