Collapse (Monday) - CLIND 1552 - PDF

CLIND 1552 – Week #7 – Collapse (Monday) Collapse SOS Mr. Wright is a 70-year-old functionally independent male with poorly controlled systolic hypertension, hyperlipidemia, and osteoarthritis. He presents to his primary care office after having fallen while working in his yard 90 minutes previousl...

CLIND 1552 – Week #7 – Collapse (Monday) Collapse SOS Mr. Wright is a 70-year-old functionally independent male with poorly controlled systolic hypertension, hyperlipidemia, and osteoarthritis. He presents to his primary care office after having fallen while working in his yard 90 minutes previously. He states, “This is the first time anything like this has ever happened.” His fall was preceded by the abrupt onset of lightheadedness, numbness in his left hand, and vague visual disturbance with questionable loss of consciousness. After 10–15 minutes all symptoms were resolved, and he was able to get up unaided and has since felt fine. He is concerned about a stroke and if it would happen again while he was mowing his lawn or driving. Symptom – Organ System – Science – 1. 2. 3. 4. 5. Objectives Differentiate collapse from syncope and conduct a history related to transient loss of consciousness Describe the related organ system approach to this complex symptom List the various etiologies of seizures List the signs and symptoms common to seizures List the signs and symptoms uncommon to seizures Objective #1: Differentiate collapse from syncope and conduct a history related to transient loss of consciousness Rule out a SIMPLE FALL • Before moving forward, use a careful history and observation of the patient to rule out a simple fall • • • • Collapse Fall together (Latin); to fall down and become unconscious Collapse is a VERY nonspecific term with multiple etiologies Structure (anatomy), organ, science (pathophysiology) A popular mnemonic AEIOU TIPS • • A – Alcohol (or drug intoxication), acidosis (Diabetic Ketoacidosis, Hypoventilation) E – Epilepsy (epileptic seizure), electrolytes, encephalopathy (Wernicke’s encephalopathy) I – Infection (encephalitis, meningitis, sepsis) O – Overdose (prescription or non-prescription drug overdose), oxygen deficiency U – Uremia (excess urea in the blood due to kidney failure, CHF, urinary obstruction) T – Trauma (concussion, traumatic brain injury), tumor (brain tumor, metastasis to brain) I – Insulin (hypoglycemia, hyperosmolar hyperglycemic state), intestinal (intussusception) P – Psychogenic (psychosis, pseudoseizure), poisons (carbon monoxide poisoning, lead poisoning) S – Stroke (hemorrhagic stroke due to arteriovenous malformation), shock (neurogenic shock) Syncope (aka.Vasovagal Syncope, Neurocardiogenic syncope, Fainting) The most common cause of “collapse” (of the many possible causes of collapse) A temporary loss of consciousness usually related to insufficient blood flow to the brain (i.e. hypotension, hypoxemia); person will appear pale, flushed - Some stimulus causes a neural reflex due to certain triggers - Characterized by bradycardia (+ Vagus nerve) and/or peripheral vasodilation (- Sympathetic) - Benign, self-limiting NOTE: If someone is observed in this state, set them down gently in the supine position, taking care of their head. Clear the area of anything that may fall on them or their head, and lift their legs to promote more blood flow to the head. • • • • • • Differentials Related to Collapse Cardiac syncope Cerebrovascular accident (CVA) Vasovagal syncope Seizure Pulmonary embolism Differential #1: Cardiac Syncope (aka Cardiogenic Syncope) Loss of adequate cerebral perfusion resulting from a sudden reduction in cardiac output. It is caused most commonly by a cardiac arrythmia (an irregular cardiac rhythm) - Signs and symptoms – collapse, blurred vision, dizziness, pale or dusky appearance, cardiac arrythmia or murmur (on auscultation) - Etiology – usually from ventricular rates < 35 or > 180 bpm, such as asystole, A-V block, WolffParkinson-White (WPW_ syndrome, ventricular tachycardia, ventricular fibrillation, sinus bradycardia, tachyarrythmias, myocardial infarction, aortic stenosis, tetralogy of Fallot, pericardial effusion (cardiac tamponade) Abnormal Electrical Pathways at the Atria On EKG - - History and ROS for Cardiac Syncope – History of HTN, CVD, Hypercholesterolemia, DM o Associated with increased physical activity, rising from a seated position, decreased fluid intake, warm environment o Collapse, palpitations, cough, chest pain, arm or jaw pain, diaphoresis, nausea/vomiting Physical Exam – Abnormal vital signs, anxious appearance, respiratory distress, weakness, jugular venous distention (JVD), arrythmia, cardiac murmur, muffled heart sounds, bilateral crackles (pulmonary edema), peripheral edema o OMM/Musculoskeletal; Sympathetic T1 – 5 on left, Parasympathetic occiput, C1 C2 with lack of localized peripheral findings • Differential #2: Cerebrovascular Accident (CVA) The medical term for a stroke; the decreased (ischemic) or increased (hemorrhagic) blood flow to a specific brain region - Signs and symptoms – headache, altered mentation/confusion, vision changes, vertigo/dizziness, focal neurologic deficits (sensory or motor loss), papilledema, retinal hemorrhage, apraxia (inability to complete a task), agnosia (inability to recognize common things using the senses; visual, auditory, tactile), dysarthria (difficulty speaking), dysphagia (difficulty swallowing) - Etiology – ischemic (thrombotic, embolic or secondary to dissection/hypoperfusion) or hemorrhagic (spontaneous, trauma), embolic from a mural thrombi (forming within the blood vessel wall), abnormal cardiac valves or rhythms - Transient Ischemic Attacks (TIAs) o Are NOT strokes o TIAs are brief “stroke-like” events that, despite resolving within minutes to hours (usually ~24hrs), still require immediate medical attention to distinguish from an actual stroke o Usually associated with decreased blood flow to a specific portion of the brain o May be a warning sign for a CVA - CVAs, TIAs, and Bell’s Palsy o Bell’s palsy – a sudden weakness of the facial muscles on one side of the face - CVAs, TIAs, and Increased Blood Viscosity/Thickening o Sickle cell anemia, protein C deficiency and polycythemia from sludging, increase blood viscosity and thicken the blood. These may lead to ischemic episodes Supporting Images for CVA Bell’s Palsy Sickle cell anemia Types of strokes - - • • History and ROS for CVA – collapse, headache, altered mentation, confusion, vision changes, vertigo/dizziness, apraxia, agnosia Physical Exam – abnormal vital signs, acute visual acuity changes, focal neurologic deficits (sensory or motor loss), + Rhomberg’s, papilledema, retinal hemorrhage, carotid bruits o OMM/musculoskeletal; sensory/motor deficits Differential #3: Vasovagal Syncope (aka Vasovagal Syncope, Neurocardiogenic syncope, Fainting) The transient loss of consciousness associated with loss of tone; ultimately, the lack of oxygen to the brainstem from decreased cardiac output - Signs and symptoms – prodromal symptoms may be vague and include lightheadedness, diaphoresis, dimming vision, nausea, weakness, signs of resulting trauma (from loss of consciousness) - Etiology – reflex response causing vasodilation, initiated by pain or fear, cough, sneeze, GU/GI stimulation, volume depletion, drugs, hemorrhage. Precipitating factors can include stress (emotional and/or physical), pregnancy, dehydration, or previous history of similar event - History and ROS for Vasovagal Syncope – collapse, prodromal symptoms, lightheadedness, diaphoresis, dimming vision, nausea, weakness volume depletion, drugs, hemorrhage. Precipitating factors can include stress (emotional &/or physical), pregnancy, dehydration, or previous history of similar event - Physical Exam – normal vitals, normal physical examination findings o OMM/Musculoskeletal; normal, except for the possible injury from fall itself Differential #4: Seizure The physical manifestations (clinical and/or subclinical) resulting from abnormal electrical discharges in the brain Partial (Focal) Seizures Generalized Seizures Affect single area of brain (most common is medial Affect brain diffusely temporal) - Absence (“petit mal”), blank stare, no post- Can be preceded by an aura ictal confusion - Can secondarily generalize - Myoclonic (quick, repetitive jerks) - Simple partial (consciousness maintained) - Tonic-clonic (“grand mal”), alternating can be motor, sensory, autonomic, psychic stiffening & movement - Complex partial (impaired consciousness) - Atonic (“drop” seizures); commonly mistaken for fainting NOTE: Diagnostic testing for seizures can be done using an electroencephalogram (EEG), which tests the electrical impulses of the brain. - - - - Signs and symptoms – various; altered level of consciousness, involuntary muscular movements (atonic, tonic posturing or clonic jerking; may have a preceding aura, focal, generalized or absent, impaired memory of the event o Other findings may include nuchal rigidity (stiff neck), papilledema (increased ICP), tongue lacerations, incontinence, postictal confusion or somnolence Etiology – multiple; infection, hypoxia, stroke (ischemic or hemorrhagic), toxins, fever (usually children), genetic, metabolic, trauma, idiopathic (unknown cause) o Epilepsy is characterized by recurrent seizure activity; febrile seizures are not epilepsy o Status epilepticus: Continuous or recurring seizure(s) that may result in brain injury; defined as ≥ 5 minutes duration Most Common Causes of Seizures by AGE o Infants – infection, prenatal injury/ischemia, genetic, metabolic o Children – fever, genetic, infection, trauma, metabolic o Adult – tumor, trauma, stroke, infection o Elderly – stroke, tumor, trauma, metabolic, infection o Fever in general also increases neuronal irritability which decreases the seizure threshold Diagnosis – Electroencephalogram (EEG) – an electrophysiological monitoring method to record the electrical activity of the brain - - • History and ROS for Seizures – history of collapse, altered level of consciousness, witnessed or unwitnessed involuntary muscular movements (atonic, tonic posturing or clonic jerking; may have a preceding aura, focal, generalized or absent, impaired memory of the event Physical Exam – tongue/cheek lacerations from teeth/biting, nuchal rigidity, papilledema (increased ICP {intracranial pressure}), tongue lacerations, incontinence, postictal confusion or somnolence (excess sleepiness) o OMM/musculoskeletal; possible injury from unconscious state Differential #5: Pulmonary Embolism (PE) or Pulmonary Thromboembolism (PTE) A pulmonary vessel obstruction causing ventilation-perfusion (VQ) mismatch to hypoxemia and hypocapnia (aka hypocarbia or reduced carbon dioxide in the blood) leading to respiratory alkalosis - Signs and symptoms – often variable and nonspecific, but may present with sudden onset dyspnea, cough, chest pain, tachypnea, collapse o Large embolis (traveled thrombus) or saddle embolis may cause sudden death - Etiology – majority from thrombus in the deep veins of the lower leg and pelvis, but embolism can be from fat, air, thrombus (blood), bacteria, amniotic, tumor - Risk factors – obesity, smoking, trauma, infection, heart disease, immobility, malignancy, surgery, Factor V Leiden deficiency, pregnancy, oral contraceptives (OTCs) NOTE: FAT BAT for causes of Pulmonary Embolism, Fat – Air – Thrombus – Bacteria – Amniotic – Tumor - Diagnosis – Spiral (Helical) Computed Tomography (CT) and VQ Scan - History and ROS for Pulmonary Embolism – history of collapse, sudden onset dyspnea, cough, unilateral/bilateral chest pain, nausea, tachypnea Physical Exam – normal/abnormal vitals, conversational dyspnea (hard to speak without SOB), fever, respiratory distress, unilateral adventitious (abnormal) lung sounds o OMM/Musculoskeletal; T 1-4 unilateral/bilateral, accessory respiratory muscle use Objective #2: Describe the related organ system approach to this complex symptom Evaluation of Syncope Objective #3: List the various etiologies of seizures [Information included in Objective #1 under Differential #4] Objective #4: List the signs and symptoms common to seizures High Risk (Hospital Admission Recommended) Symptoms • Clinical history suggestive of arrhythmic syncope (syncope during exercise, palpitations, or syncope without warning or prodrome) • Comorbidities (severe anemia, electrolyte abnormalities) • Electrocardiographic history, suggestive of arrhythmic syncope (bifascicular block, sinus bradycardia < 40 bpm in absence of sinoatrial block or medication use, QRS preexcitation, abnormal QT interval ST segment elevation) • Family history of sudden death • Hypotension (systolic blood pressure < 90 mmHg) • Older age • Severe structural heart disease, congestive heart Failure (CHF), or coronary artery disease Objective #5: List the signs and symptoms uncommon to seizures Low Risk (Outpatient Evaluation Recommended) Symptoms • Age less than 50 years • No history of cardiovascular findings • Symptoms consistent with neurally mediated or orthostatic hypotension syncope • Unremarkable cardiovascular findings