Why sudden breathlessness with collapse matters
Sudden breathlessness with a faint means a problem big enough to drop the blood pressure, even briefly. Support him, look for shock, and decide quickly which diagnosis would change treatment now, because some need it within minutes.
What to ask in the history
- Exactly what happened: what he was doing, how fast it came on, how long he was out
- Chest pain: central or sharp and worse on breathing
- Palpitations
- Cough, coughing up blood
- Leg pain or swelling
- Recent immobility, surgery, plaster casts, long journeys
- Previous clots, cancer, family history of clots
- Heart disease, medicines
Red flags
- Low blood pressure or signs of shock
- Fainting
- Low oxygen saturation despite oxygen
- Very fast heart rate
- Raised neck veins
- Confusion
What to examine
- Airway, breathing, circulation; full set of observations
- Jugular venous pressure
- Heart sounds; signs of strain on the right side of the heart
- Chest: breath sounds on each side, trachea
- Legs, including around any cast, for swelling or tenderness
First investigations
- ECG
- Blood gas
- Chest X-ray
- Troponin, natriuretic peptide
- Bedside echocardiogram if he is unstable
- CT pulmonary angiography once he is stable enough to travel
- D-dimer only when the clinical probability is low
- Full blood count, kidney function, clotting
Differential diagnosis of sudden breathlessness with collapse
Grouped, not ranked. Which one fits this patient is for you to work out in the case.
Heart
- Myocardial infarction
- Arrhythmia
- Cardiac tamponade
- Aortic dissection
Lung circulation
- Pulmonary embolism
Lung
- Tension pneumothorax
- Severe asthma
Other
- Sepsis
- Anaphylaxis
- A simple faint with anxiety, once the others are excluded
Common mistakes
- Sending an unstable patient to the CT scanner.
- Ordering a D-dimer when the clinical suspicion is already high.
- Calling it a simple faint when it came with breathlessness.