138 Journal of the Royal Society of Medicine Volume 87 March 1994. Collapse ... 2Department of Medicine, Groby Road Hospital, Leicester, and 3Accident and ...
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Journal of the Royal Society of Medicine Volume 87 March 1994
Collapse in
an
accident and
emergency
department
Andrew J McLaren BM BCh'
John Lear M ChB2 R G Daniels MRCP 'Harlow Wood Orthopaedic Hospital, Nottingham Road, Mansfield, Nottingham NG18 4TH, 2Department of Medicine, Groby Road Hospital, Leicester, and 3Accident and Emergency Department, Northampton General Hospital, Northampton NN1 5BD, UK
Keywords: collapse; emergency
Summary Collapse is a common presenting complaint to accident and emergency (A & E) departments. This retrospective study of 4180 new attendances at a district general hospital A & E showed that this accounted for 2.9%. A wide disease spectrum was implicated. This patient group has a high admission rate (47.8%) and a high mortality rate (31.3%). The deaths occurred largely in the elderly and it is suggested that elderly patients should either be admitted for observation, or a careful screening carried out for underlying pathology. The diversity of disease precludes a standard management protocol. Introduction Collapse is a broad based term used by both lay people and medical personnel to describe a variety of medical problems, as they present to accident and emergency (A & E) departments. A retrospective study was carried out to ascertain the final diagnoses reached in this patient group and to establish the burden they place on the department.
Method The A & E register was searched for all patients presenting with a complaint of 'collapse', as recorded by the reception staff, over a 1 month period (January 1992). The A & E notes were retrieved and a record made of the patient's age, mode of arrival, stay length in the department, investigations performed, admission rate and final diagnosis. For those patients admitted, hospital notes were retrieved to establish the final discharge diagnosis and outcome. Results During the study period a total of 4180 new patients attended the A & E department at Northampton General Hospital. 'Collapse' was used in the initial complaint in 121 patients (2.89%). For comparison, during the same period, 100 patients presented with chest pain and 60 with abdominal pain. A & E records were retrieved on 112. Fifty-seven were male and fifty-five female. Over half (65) were aged 60 or over. The overall range being between 8 and 93 years with a median of 66 years. The majority of patients (102) arrived as a result of a '999' emergency ambulance call, with nine arriving by private transport and one man walking into the department off the street. Correspondence to: Dr A McLaren, Greenacres, Nicker Hill, Keyworth, Nottingham NG12 5ED, UK
Table 1. Diagnoses reached by the accident and emergency officer
Diagnosis
No.
Diagnosis
Cardiac arrest Faint Collapse CVA Left ventricular failure Hypoglycaemia Epileptic fit Alcohol intoxication Chest infection Brought in dead Asthma Anxiety Bowel obstruction Cardiac arrhythmia Subarachnoid haemorrhage Viral illness Transient ischaemic attack
19 15 8 8 6
Acute confusion Addisonian crisis Angina Anorexia nervosa Asleep Fractured humerus Gastrointestinal bleed Headache Heat stroke Hyperventilation Left ventricular hypertrophy Menstrual period ME syndrome Oesophagitis Overdose Postural hypotension Ulcers (infected) Urinary tract infection Vestibular neuronitis
5 5 5 4 4 2 2 2 2 2 2
2
No. 1 1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
CVA=cardiovascular accident; ME=myalgic encephalomyelitis
Patients remained in the department for an average of 2 h (range 0-7 h). The diagnoses reached by the A & E officer are shown in Table 1. Forty-four patients (39.3%) were referred for assessment by another team, only one of whom was subsequently sent home from A & E. This rate increases to 47.8% if those patients who died within the department are excluded from the total patient number. This compares to an admission rate of 62% for chest pain, of 33% for abdominal pain and an overall rate of 21.7% for the whole study period. Two-thirds of the patients had investigations in the A & E department to supplement clinical history and examination. The commonest were electrocardiogram (33.9% of patients) and blood sugar estimation (28.6%). Of the 43 patients admitted the diagnosis remained unchanged in all but 10. The average duration of admission was 6 days; 12 patients died prior to
discharge. These deaths contributed to a high overall mortality rate of 31.3%. All patients presenting with cardiac arrest died in the department. The initial rhythms recorded were asystole (16), electromechanical dissociation (2) and ventricular fibrillation (1).
Journal of the Royal Society of Medicine Volume 87 March 1994
Discussion In this study of 112 patients a wide spectrum of disease was implicated as the cause of presentation with 'collapse'. These ranged from the expected diagnoses of cardiac arrest, stroke and epileptic fits to those such as leg ulcers, urinary tract infection and anxiety where collapse has not actually occurred. Despite this the general public obviously considers the event serious as the vast majority of patients arrived via an emergency ambulance call. Six patients were discharged from the department with no causal diagnosis. These patients were all investigated with full blood count, creatinine and electrolytes, electrocardiogram and chest radiograph to exclude most underlying pathology. It could be argued that given the high mortality within this patient group these six patients should have been admitted for a short period of observation. However, previous studies of patients presenting with syncope have shown that even after long-term follow-up a diagnosis can only be made in 60% of cases'. Contrary to expectation, there was no significant difference between the average age of the group referred for admission and those discharged (65.3 years versus 66 years). However, all deaths following admission occurred in the over-70 years age group.
The cardiac arrest group represent an area where management could be improved. Ideally all of these patients would have been attended by a paramedic ambulance crew capable of instituting advanced cardiac life support at the scene. This is unfortunately not the case and undoubtedly plays a role in the irretrievability of these patients following arrival in the department. In summary, the term collapse appears to be used inappropriately in many cases. It does serve though to identify patients at high risk. The diversity of possible causes makes it impossible to suggest a management protocol. However, such patients should not be discharged with neither a causal diagnosis nor full investigation. Acknowledgments: This work was performed at the Accident Department of Northampton General Hospital, Northampton, UK. Reference 1 Kapoor WN, Karpf M, Wieland S, Peterson JR, Levey GS. A prospective evaluation and follow-up of patients with syncope. N Engl J Med 1983;309:197-204
(Accepted 19 May 1993)
THE ROYAL SOCIETY OF MEDICINE A ONE DAY CONFERENCE * THURSDAY 26 MAY 1994
OPPORTUNITIES, PROBLEMS, AND SOLUTIONS OF WORKING IN DEVELOPING COUNTRIES Venue: The Royal Society of Medicine, 1 Wimpole Street, London WlM 8AE
Welcoming address: Baroness Linda Chalker Opening remarks: Sir George Pinker KCVO FRCOG A conference covering intentions, realities, and realistic goals of working in developing countries. Areas include: * Good intentions: Chairman - Sir David Innes WilliamsA report of the policies of Colleges and similar bodies towards work in developing countries * Reality for those in the field: Chairman - Sir Ian Todd KBE Ten thumbnail sketches from field workers * Setting realistic goals: Chairman - Professor Eldryd Parry OBE . Undergraduate teaching * Postgraduate development Emergency reponses * Causes of death in the community Minimum skills needed for life saving surgery Details and registration forms: Tel: 071-290 2981 Fax: 071-290 2977
Mrs Marty Adair, The Royal Society of Medicine 1 Wimpole Street, London WlM 8AE
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