Collapse

1. Overview

Collapse is a broad presenting complaint. Patients may use the term to describe fainting, blackout, fall, seizure, near-syncope, weakness, mechanical fall or cardiac arrest. In an OSCE, the first task is to establish whether there was true loss of consciousness, whether the patient has recovered, and whether there are features suggesting a life-threatening cause.

Cardiac causes are especially important because collapse may be due to arrhythmia, structural heart disease, myocardial infarction, pulmonary embolism or severe haemodynamic compromise. A normal examination after recovery does not exclude intermittent arrhythmia.

Key OSCE priorities

• Assess whether the patient is currently stable or unstable.
• Clarify whether there was true loss of consciousness.
• Ask about events before, during and after the collapse.
• Seek collateral history from a witness if available.
• Identify cardiac red flags such as chest pain, palpitations, exertional collapse and family history of sudden cardiac death.
• Distinguish syncope from seizure, hypoglycaemia, mechanical fall and intoxication.
• Check observations, capillary blood glucose and ECG early.
• Escalate immediately if the patient is unstable or has ongoing symptoms.

Important causes of collapse

• Vasovagal syncope.
• Orthostatic hypotension.
• Cardiac arrhythmia.
• Structural heart disease such as aortic stenosis or hypertrophic cardiomyopathy.
• Acute coronary syndrome.
• Pulmonary embolism.
• Seizure.
• Hypoglycaemia.
• Stroke or TIA, especially if focal neurological symptoms are present.
• Sepsis or shock.
• Major bleeding.
• Drug or alcohol intoxication.
• Mechanical fall.

High-risk collapse features

• Collapse during exertion.
• Collapse while lying flat.
• Collapse without warning.
• Palpitations before collapse.
• Chest pain before or after collapse.
• Severe breathlessness.
• Known structural heart disease.
• Abnormal ECG.
• Family history of sudden cardiac death.
• Persistent hypotension.
• Prolonged confusion.
• Focal neurological deficit.
• Significant injury.

2. History Taking

Opening

• Wash hands.
• Introduce yourself.
• Confirm patient identity.
• Explain that you would like to ask about the collapse episode.
• Gain consent.
• Check whether the patient currently has chest pain, breathlessness, palpitations, dizziness, weakness or confusion.
• If the patient is acutely unwell, state that you would assess using ABCDE and call for senior help.

Clarify what happened

• Ask the patient to describe exactly what happened.
• Clarify whether they lost consciousness.
• Ask whether they remember falling.
• Ask whether the collapse was witnessed.
• Ask how long they were unconscious.
• Ask whether they recovered quickly or slowly.
• Ask whether they were confused afterwards.
• Ask whether there was injury, head trauma or tongue biting.
• Ask whether this has happened before.

Events before collapse

• Ask what the patient was doing immediately before collapse.
• Ask whether they were standing, sitting, lying down or exercising.
• Ask whether they had just stood up.
• Ask about prolonged standing, heat, pain, fear or emotional stress.
• Ask about dehydration, vomiting, diarrhoea or poor oral intake.
• Ask about coughing, urination, defecation or swallowing as triggers.
• Ask whether there was alcohol or drug use.
• Ask about recent illness or fever.

Prodromal symptoms

• Light-headedness.
• Dizziness.
• Nausea.
• Sweating.
• Feeling hot.
• Blurred vision or tunnel vision.
• Ringing in the ears.
• Pallor.
• Chest pain.
• Palpitations.
• Shortness of breath.
• No warning symptoms, which is concerning for cardiac collapse.

Symptoms during the episode

• Loss of postural tone.
• Abnormal jerking movements.
• Eye rolling.
• Tongue biting.
• Urinary or faecal incontinence.
• Colour change such as pallor or cyanosis.
• Noisy breathing.
• Duration of unconsciousness.
• Pulse or breathing abnormality reported by a witness.
• Injury during the fall.

Recovery after collapse

• Rapid full recovery supports syncope.
• Prolonged confusion suggests seizure or neurological cause.
• Ask about drowsiness.
• Ask about headache.
• Ask about muscle aches.
• Ask about focal weakness or numbness.
• Ask about chest pain or breathlessness after recovery.
• Ask whether the patient returned to baseline.

Cardiac symptoms

• Chest pain or pressure.
• Palpitations before collapse.
• Shortness of breath.
• Collapse during exertion.
• Collapse while supine.
• Reduced exercise tolerance.
• Orthopnoea.
• Paroxysmal nocturnal dyspnoea.
• Peripheral oedema.
• Known murmur.

Neurological symptoms

• Prolonged confusion.
• Witnessed tonic-clonic movements.
• Lateral tongue biting.
• Focal weakness.
• Facial droop.
• Speech disturbance.
• Visual disturbance.
• Severe headache.
• Previous seizures.

Metabolic and systemic symptoms

• Sweating, hunger, tremor or confusion suggesting hypoglycaemia.
• Fever or rigors suggesting infection.
• Bleeding symptoms such as haematemesis, melaena, PR bleeding or heavy menstrual bleeding.
• Weight loss or poor intake.
• Vomiting or diarrhoea.
• Symptoms of anaemia such as fatigue and exertional dyspnoea.
• Symptoms of adrenal crisis if relevant.

Past medical history

• Previous collapse, syncope or blackouts.
• Known arrhythmia.
• Atrial fibrillation.
• Previous myocardial infarction.
• Ischaemic heart disease.
• Heart failure.
• Valvular heart disease.
• Cardiomyopathy.
• Congenital heart disease.
• Pacemaker or ICD.
• Epilepsy.
• Diabetes mellitus.
• Stroke or TIA.
• Anaemia.
• Chronic kidney disease.
• Previous DVT or PE.

Drug history and allergies

• Current regular medications.
• Antihypertensives.
• Diuretics.
• Beta-blockers.
• Rate-limiting calcium channel blockers.
• Nitrates.
• Anti-arrhythmic medications.
• Anticoagulants.
• Insulin or sulfonylureas.
• Antiepileptic medications.
• Antidepressants or antipsychotics that may prolong QT interval.
• Recent medication changes.
• Alcohol or recreational drug use.
• Drug allergies and reaction.

Family history

• Sudden cardiac death, especially at a young age.
• Inherited arrhythmia syndromes.
• Long QT syndrome.
• Brugada syndrome.
• Hypertrophic cardiomyopathy.
• Dilated cardiomyopathy.
• Epilepsy.
• Premature ischaemic heart disease.

Social history

• Occupation, especially driving, operating machinery, flying, working at heights or safety-critical work.
• Driving status and whether they drive professionally.
• Alcohol intake.
• Recreational drug use.
• Smoking history.
• Living situation and support.
• Baseline mobility.
• Falls risk at home.
• Impact on independence and daily activities.

Witness history

• Ask what the witness saw before the collapse.
• Ask whether the patient went pale, blue or flushed.
• Ask whether the patient stiffened or jerked.
• Ask how long the patient was unconscious.
• Ask whether the patient was breathing normally.
• Ask whether a pulse was checked.
• Ask whether CPR was started.
• Ask how quickly the patient recovered.
• Ask whether there was confusion after the event.

Ideas, concerns and expectations

• Ask what the patient thinks caused the collapse.
• Ask what they are most worried about.
• Ask whether they are worried about heart disease, epilepsy, stroke or another serious cause.
• Ask what they were hoping would happen today.
• Acknowledge that collapse can be frightening and explain that serious causes will be assessed carefully.

Red flags

• Collapse during exertion.
• Collapse while supine.
• No prodrome.
• Palpitations before collapse.
• Chest pain.
• Severe breathlessness.
• Known structural heart disease.
• Abnormal ECG.
• Family history of sudden cardiac death.
• Persistent hypotension.
• Focal neurological deficit.
• Prolonged confusion.
• Recurrent unexplained episodes.
• Significant injury.

Closing the history

• Summarise the key points back to the patient.
• Ask if they would like to add anything else.
• Thank the patient.
• State that you would examine them, check observations, capillary blood glucose, lying and standing blood pressure, and perform a 12-lead ECG.

3. Physical Examination

The examination should first determine whether the patient is currently stable. Then assess for cardiac, neurological, metabolic, traumatic and systemic causes of collapse.

Before starting the examination

• Wash hands or use alcohol gel.
• Introduce yourself with name and role.
• Confirm the patient's identity.
• Explain the examination clearly.
• Gain consent.
• Ask if the patient currently feels faint, dizzy, confused, breathless or has chest pain.
• Position the patient safely.
• Ensure adequate exposure while maintaining dignity.
• Ask for a chaperone if appropriate.

Initial assessment

• Check responsiveness.
• If unresponsive, shout for help.
• Open airway and assess breathing.
• If not breathing normally, start basic life support and call the resuscitation team.
• If breathing, assess using ABCDE.
• Look for pallor, sweating, cyanosis, respiratory distress, confusion or injury.
• Look for oxygen, cardiac monitor, IV lines, glucose gel, GTN spray, pacemaker or ICD.

ABCDE assessment if acutely unwell

• Airway: check if the patient can speak and whether airway is patent.
• Breathing: assess respiratory rate, oxygen saturation, work of breathing and auscultate the chest.
• Circulation: assess pulse, blood pressure, capillary refill, skin temperature, ECG monitoring and obtain IV access.
• Disability: assess consciousness level, pupils if indicated and capillary blood glucose.
• Exposure: check temperature, inspect for injury, bleeding, rash, infection, drug patches and signs of DVT while maintaining dignity.

Vital signs

• Heart rate.
• Pulse rhythm.
• Blood pressure.
• Lying and standing blood pressure if safe.
• Respiratory rate.
• Oxygen saturation.
• Temperature.
• Level of consciousness.
• Capillary blood glucose.
• Pain score if injury or chest pain is present.

General inspection

• Assess whether the patient is alert or confused.
• Look for pallor suggesting anaemia or shock.
• Look for sweating suggesting hypoglycaemia, shock or ACS.
• Look for cyanosis suggesting hypoxia.
• Look for signs of trauma.
• Look for seizure markers such as tongue injury.
• Look for signs of intoxication.

Hands

• Check capillary refill.
• Assess peripheral temperature.
• Look for peripheral cyanosis.
• Look for palmar pallor.
• Look for tremor suggesting thyrotoxicosis, anxiety, alcohol withdrawal or hypoglycaemia.
• Look for track marks suggesting intravenous drug use.
• Look for injuries from the fall.

Pulse and blood pressure

• Assess radial pulse rate.
• Assess rhythm.
• An irregularly irregular pulse suggests atrial fibrillation.
• Bradycardia may suggest conduction disease or medication effect.
• Tachycardia may suggest arrhythmia, shock, sepsis, PE or bleeding.
• Measure blood pressure.
• Check lying and standing blood pressure if safe.
• Persistent hypotension is a concerning sign.

Cardiovascular examination

• Assess jugular venous pressure.
• Inspect the chest for scars, pacemaker or ICD.
• Palpate the apex beat.
• Auscultate heart sounds.
• Listen for murmurs, especially aortic stenosis.
• Listen for added heart sounds.
• Look for signs of heart failure: raised JVP, S3, bibasal crackles and peripheral oedema.
• Assess peripheral pulses if vascular disease is suspected.

Respiratory examination

• Assess respiratory rate and work of breathing.
• Auscultate for crackles suggesting heart failure or pneumonia.
• Listen for wheeze.
• Assess for reduced breath sounds or pleural effusion.
• Consider PE if hypoxia, tachycardia, pleuritic chest pain or unilateral leg swelling is present.

Neurological examination

• Assess level of consciousness.
• Check pupils if indicated.
• Assess speech and facial symmetry.
• Assess limb power and sensation if focal symptoms are present.
• Assess coordination if appropriate.
• Assess gait only if safe.
• Look for post-ictal confusion.
• Look for lateral tongue biting.

Trauma assessment

• Inspect for head injury.
• Assess neck pain or possible cervical spine injury.
• Look for bruises, lacerations and deformity.
• Assess pain before moving limbs.
• Check for bleeding.
• Be cautious if the patient is anticoagulated.

Abdominal and peripheral examination

• Assess abdomen for tenderness, distension or pulsatile mass if relevant.
• Look for signs of internal bleeding if hypotensive.
• Check for unilateral leg swelling suggesting DVT.
• Check for peripheral oedema.
• Look for signs of sepsis or rash.

Specific findings to mention in collapse OSCE

• Irregular pulse may suggest atrial fibrillation.
• Slow pulse may suggest heart block.
• Murmur of aortic stenosis is important in exertional collapse.
• Orthostatic hypotension suggests volume depletion, autonomic dysfunction or medication effect.
• Focal neurology suggests stroke or TIA.
• Prolonged confusion and lateral tongue biting suggest seizure.
• Hypoglycaemia may cause sweating, confusion and collapse.
• A normal examination does not exclude intermittent arrhythmia.

To complete the examination

To complete my examination, I would review observations, check capillary blood glucose, perform lying and standing blood pressure, request a 12-lead ECG, check blood tests including full blood count, renal function and electrolytes, and arrange further investigations based on the suspected cause. I would escalate urgently if the patient is unstable, has chest pain, exertional collapse, abnormal ECG, focal neurology, hypoglycaemia, significant injury or suspected cardiac cause.

4. Differential Diagnosis

Cardiac causes

• Ventricular tachycardia.
• Bradyarrhythmia or complete heart block.
• Supraventricular tachycardia.
• Atrial fibrillation with rapid ventricular response.
• Aortic stenosis.
• Hypertrophic cardiomyopathy.
• Acute coronary syndrome.
• Cardiac tamponade.
• Pacemaker or ICD malfunction.
• Inherited arrhythmia syndromes such as long QT syndrome or Brugada syndrome.

Vascular and obstructive causes

• Pulmonary embolism.
• Aortic dissection.
• Major haemorrhage.
• Severe dehydration.
• Septic shock.
• Anaphylaxis.

Syncope causes

• Vasovagal syncope.
• Situational syncope.
• Orthostatic hypotension.
• Carotid sinus syncope.
• Medication-related hypotension.

Neurological causes and mimics

• Epileptic seizure.
• Stroke or TIA.
• Subarachnoid haemorrhage if sudden severe headache is present.
• Psychogenic non-epileptic attacks.
• Mechanical fall without loss of consciousness.

Metabolic, toxic and systemic causes

• Hypoglycaemia.
• Electrolyte disturbance.
• Drug or alcohol intoxication.
• Anaemia.
• Sepsis.
• Adrenal crisis.
• Heat illness.

5. Investigations

Immediate bedside tests

• Full observations.
• Capillary blood glucose.
• 12-lead ECG.
• Continuous cardiac monitoring if unstable or arrhythmia suspected.
• Lying and standing blood pressure if safe.
• Oxygen saturation.
• Temperature.
• Urine dip if infection, dehydration or pregnancy-related issue is suspected.
• Pregnancy test in women of reproductive age when appropriate.

Blood tests

• Full blood count to assess anaemia, infection or bleeding.
• Urea and electrolytes.
• Creatinine and estimated GFR.
• Magnesium and calcium if arrhythmia is suspected.
• Liver function tests if systemic illness or alcohol-related disease is suspected.
• CRP if infection is suspected.
• Troponin if ACS is suspected.
• Thyroid function tests if arrhythmia or thyrotoxicosis is suspected.
• Venous or arterial blood gas if acutely unwell.
• Toxicology or alcohol level if intoxication is suspected and locally appropriate.

Cardiac investigations

• ECG to assess arrhythmia, conduction disease, ischaemia, long QT, Brugada pattern or pre-excitation.
• Ambulatory ECG monitoring if intermittent arrhythmia is suspected.
• Event monitor or implantable loop recorder if episodes are infrequent but concerning.
• Echocardiography if murmur, heart failure, structural heart disease or abnormal ECG is present.
• Exercise testing only under specialist guidance if exertional symptoms are present.
• Cardiology referral if high-risk cardiac features are present.

Neurological investigations

• CT brain if head injury, anticoagulation, focal neurology, persistent confusion or suspected intracranial pathology is present.
• EEG if seizure is suspected, usually after specialist assessment.
• MRI brain if indicated by neurology.
• Do not routinely image the brain for simple syncope without neurological features or head injury.

Other investigations based on suspected cause

• Chest X-ray if heart failure, pneumonia or other respiratory pathology is suspected.
• D-dimer or CT pulmonary angiography if PE is suspected according to clinical probability.
• Blood cultures if sepsis is suspected.
• Group and save or crossmatch if bleeding is suspected.
• Urine culture if urinary infection is suspected.
• Orthostatic assessment for suspected postural hypotension.

Important investigation points

• ECG is essential after collapse with possible transient loss of consciousness.
• A normal ECG does not exclude intermittent arrhythmia.
• Capillary blood glucose is a rapid reversible-cause test.
• Witness history may be as important as investigations.
• Investigations should be guided by red flags and clinical probability.

6. Management

Management depends on whether the patient is currently unstable, whether collapse was due to true loss of consciousness, and whether there are high-risk features. In an OSCE, start with safety and emergency assessment before discussing long-term management.

Immediate approach

1. Assess safety and call for help if needed.
2. Check responsiveness.
3. If unresponsive and not breathing normally, start CPR and call the resuscitation team.
4. If breathing, assess using ABCDE.
5. Check capillary blood glucose.
6. Check observations.
7. Attach cardiac monitoring if unstable or arrhythmia suspected.
8. Obtain IV access if clinically indicated.
9. Perform urgent 12-lead ECG.
10. Treat immediately reversible causes.

If cardiac cause is suspected

• Escalate urgently to senior or cardiology team.
• Place on cardiac monitoring.
• Perform ECG and repeat if symptoms recur.
• Correct reversible causes such as electrolyte abnormality, hypoxia or drug toxicity.
• Treat tachyarrhythmia or bradyarrhythmia according to local resuscitation protocol.
• Arrange echocardiography if structural disease is suspected.
• Consider admission if high-risk features are present.

If vasovagal syncope is likely

• Explain the benign reflex mechanism.
• Identify triggers such as heat, pain, fear, dehydration or prolonged standing.
• Advise hydration and avoiding triggers where possible.
• Advise sitting or lying down when warning symptoms occur.
• Teach counter-pressure manoeuvres if appropriate.
• Safety-net for chest pain, palpitations, exertional collapse or recurrent unexplained episodes.

If orthostatic hypotension is suspected

• Review lying and standing blood pressure.
• Assess hydration and oral intake.
• Review medications such as antihypertensives, nitrates and diuretics.
• Treat dehydration, bleeding or sepsis if present.
• Advise slow position changes.
• Consider specialist assessment for recurrent or unexplained cases.

If seizure is suspected

• Obtain witness history.
• Check glucose and electrolytes.
• Assess and treat injuries.
• Refer for neurological assessment where appropriate.
• Advise not to drive until assessed according to local regulations.
• Do not diagnose epilepsy from one uncertain episode without appropriate assessment.

If hypoglycaemia is present

• Treat immediately according to local hypoglycaemia protocol.
• Recheck capillary blood glucose after treatment.
• Identify the cause, such as missed meals, insulin, sulfonylurea, alcohol or sepsis.
• Ensure the patient can eat safely after recovery.
• Review diabetes medication and education.

Admission or urgent referral features

• Abnormal ECG.
• Collapse during exertion.
• Collapse while supine.
• Palpitations before collapse.
• Chest pain or severe breathlessness.
• Known structural heart disease.
• Family history of sudden cardiac death.
• Persistent hypotension.
• Focal neurological deficit.
• Prolonged confusion.
• Severe anaemia or suspected bleeding.
• Significant injury or head injury.
• Recurrent unexplained collapse.

Driving and safety advice

• Advise the patient not to drive until medically assessed if the cause is unexplained or concerning.
• Follow local driving authority rules for syncope, seizure and arrhythmia.
• Avoid swimming alone, climbing ladders, working at heights or operating heavy machinery until assessed.
• Discuss occupational implications if the patient has a safety-critical job.

Follow-up

• Arrange follow-up based on suspected cause.
• Cardiology follow-up if arrhythmia or structural heart disease is suspected.
• Neurology follow-up if seizure is suspected.
• Primary care follow-up for vasovagal or orthostatic causes if low risk.
• Review medications and cardiovascular risk factors.
• Provide clear safety-net advice for recurrence, chest pain, palpitations, breathlessness, neurological symptoms or injury.

7. Examiner Questions

1. How would you approach a patient who has collapsed?
2. What is the difference between collapse and syncope?
3. What are the cardiac causes of collapse?
4. What red flags suggest cardiac collapse?
5. What features suggest seizure rather than syncope?
6. What immediate bedside tests would you perform?
7. Why is capillary blood glucose important?
8. Why is ECG important after collapse?
9. When would you admit a patient after collapse?
10. What features suggest vasovagal syncope?
11. What features suggest orthostatic hypotension?
12. What features suggest pulmonary embolism?
13. What advice would you give about driving?
14. Why is witness history important?

Suggested short answers

8. OSCE Pearls

• Collapse is a symptom description, not a diagnosis.
• First check whether the patient is currently stable.
• Always ask if there was true loss of consciousness.
• Always seek witness history if available.
• Always ask what happened before, during and after the event.
• Collapse during exertion is a cardiac red flag.
• Collapse while supine is a cardiac red flag.
• Palpitations before collapse suggest arrhythmia.
• Rapid recovery supports syncope.
• Prolonged confusion supports seizure.
• Check capillary blood glucose early.
• Perform a 12-lead ECG.
• A normal ECG does not exclude intermittent arrhythmia.
• Ask about driving and safety-critical work.
• Document safety-net and driving advice.

9. Example Presentation to Examiner

10. References

• NICE CG109: Transient loss of consciousness in over 16s.
• ESC Guidelines for the diagnosis and management of syncope.
• Resuscitation Council UK: Adult advanced life support and peri-arrest arrhythmia guidance.
• Local emergency medicine, cardiology and neurology protocols.
• Standard undergraduate acute medicine and OSCE teaching resources.