From the Guidelines
For this 73-year-old patient with collapse and loss of consciousness (LOC), immediate evaluation of vital signs, cardiac monitoring, and neurological assessment should be performed, with a focus on identifying the underlying cause of the transient loss of consciousness (TLoC) as recommended by the National Institute for Health and Clinical Excellence guideline 1. Given his medication profile and age, orthostatic hypotension should be considered, potentially exacerbated by the combination of ranolazine, bisoprolol, and tamsulosin. Initial management should include:
- IV access
- Blood tests (complete blood count, electrolytes, cardiac enzymes, glucose)
- 12-lead ECG
- Continuous cardiac monitoring Medication review is essential, as bisoprolol (beta-blocker) and tamsulosin (alpha-blocker) can cause hypotension, while ranolazine may prolong QT interval. Consider temporarily holding tamsulosin and evaluating for dose adjustment of bisoprolol. Additional workup should include:
- Carotid sinus massage (if no contraindications)
- Echocardiogram to assess cardiac function
- 24-hour Holter monitoring to detect arrhythmias Despite the clear CT spine, the history of lumbar radiculopathy and use of pregabalin suggest pain management should be optimized, as inadequate pain control could contribute to autonomic instability. Neurological consultation may be warranted to evaluate for other causes of syncope, including seizure activity or transient ischemic attack, as the guideline recommends referral for specialist neurologic assessment for persons with features that suggest epilepsy or other neurologic conditions 1.
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 essential.
- Observation of the clinical status of the patient is necessary.
- Consider contacting a Certified Poison Control Center for up-to-date information on the management of overdose with pregabalin 2.
- If overdose is suspected, consider hemodialysis as it can remove approximately 50% of pregabalin in 4 hours 2. Given the patient's history of lumbar radiculopathy and current symptoms, it is crucial to rule out any other potential causes of his condition. However, based on the information provided, the primary concern is the potential overdose of pregabalin.
From the Research
Assessment and Management of Transient Loss of Consciousness
The patient's presentation with collapse and loss of consciousness (LOC) requires a thorough assessment to determine the underlying cause. The patient's medication list, including ranolozine, bisoprolol, tamsulosin, and pregabalin, should be reviewed for potential contributing factors 3.
Potential Causes of Syncope
The patient's history of lumbar radiculopathy and clear CT spine suggest that the cause of syncope may not be related to a structural lesion in the spine. Other potential causes of syncope, such as cardiac, orthostatic, or reflex (neurally mediated) mechanisms, should be considered 3, 4.
Diagnostic Evaluation
A comprehensive diagnostic evaluation, including a thorough medical history, physical examination, and laboratory tests, is essential to determine the cause of syncope 5, 6. The patient's basic metabolic panel should be reviewed for any abnormalities that may contribute to syncope, such as electrolyte imbalances or renal dysfunction 7.
Management
The management of the patient should focus on addressing any underlying causes of syncope, as well as providing general measures to increase blood pressure and prevent recurrences 3. The patient's medication list should be reviewed, and any exacerbating medications should be adjusted or discontinued. The patient should be monitored closely for any signs of further deterioration or recurrence of syncope.
Key Considerations
- The patient's history and physical examination should be thoroughly reviewed to determine the underlying cause of syncope
- Laboratory tests, including basic metabolic panel, should be reviewed for any abnormalities that may contribute to syncope
- The patient's medication list should be reviewed, and any exacerbating medications should be adjusted or discontinued
- The patient should be monitored closely for any signs of further deterioration or recurrence of syncope 3, 4, 5, 6, 7.