Sudden Collapse: An Emergency Physician’s Perspective in Ghana

As an emergency physician in Ghana, one of the most alarming and challenging presentations you will encounter is the sudden collapse of a patient. This situation requires rapid assessment, immediate intervention, and a systematic approach to identify and manage the underlying cause. In this blog post, we will explore the approach to a sudden collapse with a realistic case scenario, emphasizing the importance of a structured approach in the emergency department (ED).

Case Scenario

Mrs. Ama Mensah, a 55-year-old woman with a history of hypertension and diabetes, was brought to the ED by her family after suddenly collapsing at home. According to her daughter, she was in her usual state of health when she suddenly clutched her chest, became unresponsive, and fell to the ground. No seizure-like activity was noted.

Upon arrival at the ED, Mrs. Mensah was unresponsive, with a Glasgow Coma Scale (GCS) score of 3. Her vital signs were as follows:

• Blood Pressure: 90/60 mmHg
• Heart Rate: 40 beats per minute
• Respiratory Rate: 8 breaths per minute
• Oxygen Saturation: 85% on room air
• Temperature: 36.5°C

Initial Assessment and Management

The initial moments following a sudden collapse are critical. The primary goal is to ensure the patient’s airway, breathing, and circulation (ABCs) are adequately supported.

1. Airway: Ensure the airway is clear. Mrs. Mensah, being unresponsive, is at risk of airway obstruction. Immediate assessment revealed a patent airway, but due to her low GCS, airway protection was warranted. Orotracheal intubation was performed to secure the airway.
2. Breathing: After securing the airway, assist ventilation with a bag-valve mask and provide 100% oxygen. Mrs. Mensah was intubated and connected to a mechanical ventilator, with settings adjusted to ensure adequate oxygenation and ventilation.
3. Circulation: Assess circulation by checking the pulse, blood pressure, and signs of perfusion. Mrs. Mensah’s hypotension and bradycardia suggested a possible cardiac cause. Intravenous access was obtained, and she was given a bolus of normal saline. Continuous monitoring of her vital signs was initiated.

Differential Diagnosis

The differential diagnosis of sudden collapse is broad and includes cardiac, neurological, metabolic, and toxicological causes. Key considerations in Mrs. Mensah’s case included:

1. Cardiac Causes:
   • Myocardial infarction
   • Arrhythmias (e.g., bradyarrhythmias, tachyarrhythmias)
   • Pulmonary embolism
2. Neurological Causes:
   • Stroke
   • Seizure
   • Intracranial hemorrhage
3. Metabolic Causes:
   • Hypoglycemia
   • Electrolyte imbalances
4. Toxicological Causes:
   • Drug overdose
   • Poisoning

Focused Diagnostic Workup

1. Electrocardiogram (ECG): An urgent ECG was performed, revealing ST-segment elevation in the inferior leads, indicating a likely myocardial infarction (MI).
2. Point-of-Care Ultrasound (POCUS): Bedside echocardiography showed hypokinesis of the inferior wall, supporting the diagnosis of an inferior MI. No pericardial effusion or signs of tamponade were noted.
3. Blood Tests:
   • Cardiac biomarkers (elevated troponins)
   • Blood glucose (normal)
   • Electrolytes (within normal limits)
   • Complete blood count (no signs of infection or anemia)
4. Chest X-ray: To assess for other potential causes such as pulmonary embolism or pneumothorax, the chest X-ray was performed and showed no acute pathology.

Definitive Management

Given the diagnosis of an acute inferior MI, the focus was on reperfusion therapy. In Ghana, primary percutaneous coronary intervention (PCI) may not always be readily available. In such cases, thrombolytic therapy is a viable alternative.

1. Thrombolysis: Mrs. Mensah was administered tenecteplase, a thrombolytic agent, after confirming the absence of contraindications.
2. Antiplatelet and Anticoagulation Therapy: She was also given aspirin and clopidogrel to prevent further clot formation, along with a heparin infusion.
3. Management of Bradycardia: Given her bradycardia, atropine was administered. If bradycardia persisted, the next step would involve transcutaneous pacing.
4. Monitoring and Supportive Care: Continuous cardiac monitoring was essential to detect and manage any potential complications. She was transferred to the intensive care unit (ICU) for close observation and further management.

Admission Criteria

Patients with a sudden collapse, especially those with significant findings such as an acute MI, require admission to the hospital. Criteria for admission include:

• Hemodynamic instability (e.g., hypotension, bradycardia)
• Evidence of life-threatening conditions (e.g., MI, stroke)
• Need for continuous monitoring and advanced supportive care

Conclusion

The sudden collapse of a patient like Mrs. Ama Mensah is a medical emergency that requires a systematic and rapid approach. Initial stabilization of airway, breathing, and circulation is paramount, followed by a focused diagnostic workup to identify the underlying cause. In Mrs. Mensah’s case, timely recognition and management of an acute MI, including thrombolytic therapy, were crucial in stabilizing her condition.

As emergency physicians in Ghana, we must be prepared to handle such emergencies with limited resources. A structured approach, thorough assessment, and timely intervention can significantly impact patient outcomes. Continuous education, simulation training, and staying updated with current guidelines are essential to enhance our readiness to manage sudden collapses effectively.

In conclusion, the sudden collapse is a challenging presentation in the emergency department, but with a systematic approach, proper assessment, and timely intervention, we can provide life-saving care and improve patient outcomes.