What is the appropriate management for a 73-year-old patient with collapse and loss of consciousness (LOC), taking Ranolazine (ranolazine), Bisoprolol (bisoprolol), Tamsulosin (tamsulosin), and Pregabalin (pregabalin), with a history of lumbar radiculopathy and a clear computed tomography (CT) spine?

From the Guidelines

For this 73-year-old patient with collapse and loss of consciousness (LOC), immediate evaluation of cardiovascular and neurological status is essential, with a focus on identifying potential cardiac causes, as they are the most common underlying conditions for transient loss of consciousness (TLoC) 1. The patient's history of lumbar radiculopathy and current medications, including ranolazine, bisoprolol, tamsulosin, and pregabalin, should be carefully considered in the assessment.

• Obtain vital signs, perform ECG monitoring, and check orthostatic blood pressure to assess for cardiac causes, as recommended by the National Institute for Health and Clinical Excellence guideline for management of TLoC 1.
• Blood tests should include complete blood count, electrolytes, renal function, glucose, and cardiac enzymes to rule out other potential causes.
• Review his medications, as both ranolazine and bisoprolol can cause hypotension, bradycardia, or conduction abnormalities, especially in combination, and consider temporary dose reduction or holding these medications pending investigation results.
• Neurological examination should be thorough, including assessment for focal deficits and evaluation of his lumbar radiculopathy symptoms, and further neuroimaging with brain CT or MRI may be warranted to rule out stroke or other intracranial pathology.
• Continuous cardiac monitoring for at least 24 hours is recommended to detect arrhythmias, and if no clear cause is identified after initial workup, consider tilt-table testing or 24-hour ambulatory ECG monitoring.
• Medication reconciliation is crucial, as pregabalin can cause dizziness and tamsulosin may contribute to orthostatic hypotension, particularly in elderly patients, and hydration status should be optimized and fall precautions implemented during hospitalization.

From the FDA Drug Label

In the postmarketing experience, the most commonly reported adverse events observed with pregabalin when taken in overdose include reduced consciousness, depression/anxiety, confusional state, agitation, and restlessness. Treatment or Management of Overdose There is no specific antidote for overdose with pregabalin. If indicated, elimination of unabsorbed drug may be attempted by emesis or gastric lavage; observe usual precautions to maintain the airway General supportive care of the patient is indicated including monitoring of vital signs and observation of the clinical status of the patient.

The patient's symptoms of collapse and LOC (loss of consciousness) could be related to an overdose of pregabalin.

• Monitoring of vital signs is necessary.
• Observation of the clinical status of the patient is required.
• Contact a Certified Poison Control Center for up-to-date information on the management of overdose with pregabalin 2.
• Consider hemodialysis as it can remove pregabalin, with approximately 50% clearance in 4 hours 2.

From the Research

Assessment and Management of Syncope

The patient's presentation with collapse and loss of consciousness (LOC) suggests syncope, which is defined as a brief loss of consciousness due to an abrupt fall in cerebral perfusion 3. The goals of the clinical assessment are to identify the precise cause and quantify the risk to the patient.

Classification of Syncope

Syncope can be classified into cardiac, orthostatic, and reflex (neurally mediated) mechanisms 3. The patient's medications, including ranolazine, bisoprolol, tamsulosin, and pregabalin, should be reviewed to determine if any may be contributing to the syncope.

Evaluation and Investigation

A structured approach to the patient with syncope is required, with history-taking being the most important aspect of the clinical assessment 3, 4. The patient's history of lumbar radiculopathy and clear CT spine should be taken into account. Investigations, such as a complete blood count and basic metabolic panel, may be helpful in identifying underlying causes of syncope 5, 6.

Risk Stratification

Risk stratification is important to determine the venue for subsequent care, with patients at high short-term risk of adverse outcomes requiring prompt hospitalization 7. The patient's age, medical history, and presentation should be considered when determining the risk of adverse outcomes.

Management

Management of the patient should focus on addressing any exacerbating medications and providing general measures to increase blood pressure, such as physical counter-pressure maneuvers 3. If a cardiac cause is suspected, a specialist opinion should be sought, and the problem should be corrected if possible. The main objectives of management are to prolong survival, limit physical injuries, and prevent recurrences.

• Key considerations:
  • Review medications for potential contributors to syncope
  • Conduct a thorough history and physical examination
  • Consider investigations, such as complete blood count and basic metabolic panel
  • Risk stratification to determine the need for hospitalization
  • Management focused on addressing underlying causes and preventing recurrences