The collapsed patient
Learn to think through transient loss of consciousness, step by step. Separating a benign faint from a cardiac cause that could be the last warning. Built for revision, not live patient decisions.
Settle them, and check the basics
all at once, calmlyRed flags — what each should make you think
The 12-lead ECG is the single most important test here. A faint with a prodrome while standing is usually benign; a collapse with no warning, on exertion, or lying down is cardiac until proven otherwise — and cardiac syncope can be the only warning before a sudden death.
Your first moves
- A–EAssess A–E, full obstreat instability as you find it
- ♥12-lead ECG + cardiac monitorthe key test — rhythm, ischaemia, QT, blocks
- gluBlood glucosehypoglycaemia is a reversible mimic
- BPLying & standing BPpostural drop points to a benign/volume cause
- ✚BloodsFBC, U&E; βhCG if possible; troponin/D-dimer only if indicated
- ◔Collateral historya witness account is worth more than any test
Understand what happened
before · during · afterThe three-part story sorts most of it
- Before — posture, prodrome (sweating, nausea = vasovagal), trigger, exertion, chest pain/palpitations
- During — a witness: colour, duration, any jerking, tongue-biting, incontinence (points toward seizure)
- After — quick recovery (syncope) vs prolonged confusion (seizure or other cause)
Sort the category: true syncope (transient, self-limiting), seizure, a mechanical fall, or a metabolic cause like hypoglycaemia. They diverge fast from here.
Work A–E — assess and act as you go
Rule out the killers
tap to open eachWhat points toward it, what would rule it in, and how to manage it.
Sudden collapse without prodrome, palpitations, exertional onset, known heart disease, or an abnormal ECG (heart block, long QT, pre-excitation, ischaemia).
Captured on ECG or cardiac monitor; may need prolonged monitoring.
Continuous monitoring, treat the rhythm, admit and refer to cardiology. Never discharge suspected arrhythmic syncope without a plan.
Exertional syncope with a murmur — severe aortic stenosis or hypertrophic cardiomyopathy (HOCM).
Echocardiogram.
Admit, cardiology referral, echo. Be cautious with vasodilators and fluids in outflow obstruction.
Syncope with breathlessness, pleuritic pain, hypoxia, tachycardia or VTE risk. A large PE can present as collapse.
CTPA (after Wells score / D-dimer).
Anticoagulate; thrombolysis if massive with instability.
Collapse with tearing chest/back pain, unequal pulses, or an older patient with abdominal/back pain and a pulsatile mass.
CT angiogram; unstable AAA goes straight to theatre.
Resuscitate, urgent vascular/cardiothoracic referral, crossmatch.
Collapse with pallor, melaena or PR bleeding, or a positive pregnancy test (ruptured ectopic).
Low haemoglobin, PR exam, βhCG + ultrasound.
Resuscitate, crossmatch, refer to the relevant team (GI/surgery/gynae).
Collapse with a sudden severe headache, vomiting or neck stiffness.
CT head (± LP for xanthochromia if later).
Neurosurgery/stroke referral, BP control, nimodipine.
The common, benign end
Vasovagal syncope (clear trigger and prodrome, quick recovery) and orthostatic hypotension are common — but they're a diagnosis of exclusion, made only once the cardiac and other serious causes are cleared.
Investigate — what to order, when, and what it tells you
test with a question in mind12-lead ECG
Lying & standing BP
Bloods & glucose
Imaging
How the plan comes together
disposition · handoverdischarge
A clear vasovagal or orthostatic faint, normal ECG and exam, no red flags.
Safety-net: return advice, GP follow-up, and DVLA driving advice where relevant.
admit / refer
Any red flag, abnormal ECG, exertional or unexplained syncope → admit, monitor, cardiology.
Hand over: the before/during/after story, ECG findings, and your working cause.
Ask yourself one question before discharge: could this have been the heart? If you can't confidently say no, they don't go home. Nicely done getting here.
Clerking template
copy or downloadThe collapsed patient — documentation structure
A structure and prompt list to help you document and think systematically. It is not a completeness check and cannot guarantee nothing is missed — use your trust's own proforma, your seniors, and your clinical judgement. Content is AI-generated and not yet fully reviewed.