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'''Drop attacks''' are sudden spontaneous [[falls]] while [[Standing (position)|standing]] or [[walking]], followed by a very swift recovery, within seconds or minutes.
'''Drop attacks''' are sudden spontaneous [[falls]] while [[Standing (position)|standing]] or [[walking]], followed by a very swift recovery, within seconds or minutes.
Drop attacks are typically seen in [[elderly]] [[patients]], and the most common cause is [[carotid sinus]] hypersensitivity, resulting in either short periods of reversible [[asystole]], or in marked drop in [[blood pressure]] in response to [[carotid sinus]] stimulation.
Drop attacks are typically seen in [[elderly]] [[patients]], and the most common cause is [[carotid sinus]] hypersensitivity, resulting in either short periods of reversible [[asystole]], or in marked drop in [[blood pressure]] in response to [[carotid sinus]] stimulation. Drop attacks are differnetiated from [[Vasovagal Syncope|vaso-vagal]] and other causes of [[syncope]] due to the characteristic feature of drop attack that is a sudden feeling of being pulled or pushed towards the ground without any [[loss of consciousness]].


==Causes==
==Causes==
Causes of drop attacks include.
Causes of drop attacks include:


# [[Vascular]] - [[transient ischemic attack]], [[cerebrovascular accident]], [[dissection]], [[occlusion]], [[hemorrhage]]
# '''[[Vascular]]''' - [[transient ischemic attack]], [[cerebrovascular accident]], [[dissection]], [[occlusion]] and [[hemorrhage]]
#* Intracranial hemorrhage
#* [[Intracranial hemorrhage]]
#* Posterior circulation [[infarction]], emboli, vasospasm
#* [[Posterior circulation infarct|Posterior circulation infarction]], [[emboli]] and [[vasospasm]]
#* Bilateral anterior circulation occlusion
#* [[Bilateral]] [[anterior]] [[stroke|circulation occlusion]]
#* [[Migraine]] - develop over 1hr with assoc [[paresthesia]], HA
#* [[Migraine]] - develops over 1 hour, with associated [[paresthesia]], ''[[Hypertonia]] arterialis''
#* [[Basilar artery]] insuff - older pt with no LOC, transient loss of LE tone
#* [[Basilar artery insufficiency]] - older [[patient]] with no [[loss of consciousness]], [[transient]] loss of [[lower extremity]] [[muscle tone|tone]]
# [[Epilepsy]]/paroxysmal
# '''[[Epilepsy]]/paroxysmal''':
#* Neurally mediated syncope - 75% of all causes
#* [[Neurally mediated syncope]] - 75% of all causes
#* [[Myoclonic seizure]], astatic seizure, or [[Absence seizure|petit mal syndrome]]
#* [[Myoclonic seizure]]
#* Lennox Gaustaut - atonic, myoclonic, GTC typically in neuro abnormal pt
#* [[Idiopathic generalized epilepsy|Myoclonic-astatic seizure]]
#* [[Juvenile myoclonic epilepsy|Juvenile Myoclonic Epilepsy]] - fall with [[myoclonus]]
#* [[Absence seizure|Petit mal syndrome]]
#* Laugh or cough triggered [[epilepsy]]
#* [[Lennox-Gastaut syndrome]] - [[atonic seizure]], [[myoclonic seizure]] and [[Seizure classification|generalized tonic-clonic seizure]] typically occurring in neurologically abnormal [[patients]]
#* [[Juvenile myoclonic epilepsy|Juvenile Myoclonic Epilepsy]] - [[fall]] with [[myoclonus]]
#* [[Valsalva maneuver|Laugh]] or [[cough]] triggered [[epilepsy]]
#* [[Cataplexy]] associated with [[narcolepsy]]
#* [[Cataplexy]] associated with [[narcolepsy]]
#* Periodic [[paralysis]]
#* [[Periodic paralysis]]
#* [[Complex partial seizure]]
#* [[Complex partial seizure]]
#* Breatholding spells - associate pallor/[[cyanosis]], emotional aspect
#* [[Breath-holding spells]] - associated [[pallor]]/[[cyanosis]], [[emotion]] related
#* [[Pure autonomic failure]] (Riley Day, long standing DM)
#* [[Pure autonomic failure]] ([[Riley-Day Syndrome]], long standing [[diabetes mellitus]])
#* [[Episodic ataxia]]
#* [[Episodic ataxia]]
#* Panayiotopoulos syndrome
#* Panayiotopoulos syndrome
# Degenerative  
# '''[[Degenerative disease]]''':
#* Postural instability with [[Parkinsons]]
#* [[Postural instability]] with [[Parkinsons]]
# Structural
# '''Structural''':
#* Chronic odontoid instability
#* [[Chronic]] [[odontoid process|odontoid]] [[instability]]
#* [[Spinal cord trauma]] with transient [[paraplegia]]
#* [[Spinal cord trauma]] with transient [[paraplegia]]
#* [[Brainstem]] mass
#* [[Brainstem]] [[mass]]
# metabolic
# '''[[Metabolic]]''':
#* [[Hypoglycemia]], [[hypocalcemia]], [[Hypomagnesemia]]
#* [[Hypoglycemia]]
#* [[Toxins]], [[drugs]] - [[cocaine]], [[sedatives]], [[antihistamine]], TCA
#* [[Hypocalcemia]]
# [[Cardiac]]
#* [[Hypomagnesemia]]
#* Prolonged QT, [[tachycardia]], [[bradycardia]], [[sick sinus syndrome]], [[Cardiac arrhythmia|arhythmia]], IHSS. AS
#* [[Toxins]], [[drugs]] - [[cocaine]], [[sedatives]], [[antihistamine]] and [[tricyclic antidepressants]]
# '''[[Cardiac]]''':
#* [[Prolonged QT]]
#* [[Tachycardia]]
#* [[Bradycardia]]
#* [[Sick sinus syndrome]]
#* [[Cardiac arrhythmia|arhythmia]]
#* [[Hypertrophic cardiomyopathy]]
#* [[Aortic stenosis]]
#* [[Hypovolemia]]
#* [[Hypovolemia]]
# Psychologic
# '''[[Psychology|Psychologic]]''':
#* Malingering, conversion, [[panic]], [[anxiety]]
#* [[Malingering]]
#* [[Conversion disorder]]
#* [[Panic attack]]
#* [[Anxiety]]


==Common Causes==
==Common Causes==
*Seizure
*[[Seizure]]
*Transient ischemic attack
*[[Transient ischemic attack]]
*Cerebrovascular accident
*[[Cerebrovascular accident]]
*Basilar artery insufficiency
*[[Basilar artery insufficiency]]
*Hypoglycemia
*[[Hypoglycemia]]
*Hypotension
*[[Hypotension]]
*Cataplexy associated with narcolepsy
*[[Cataplexy]] associated with [[narcolepsy]]
*Cardiac arrhythmia
*[[Cardiac arrhythmia]]
*Sick sinus syndrome
*[[Sick sinus syndrome]]
*Migraine
*[[Migraine]]
*Aortic stenosis
*[[Aortic stenosis]]
*Conversion disorder
*[[Conversion disorder]]


==Causes by Organ System==
==Causes by Organ System==
{|style="width:80%; height:100px" border="1"
{| style="width:80%; height:100px" border="1"
|style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" | '''Cardiovascular'''
| style="width:25%" bgcolor="LightSteelBlue" ; border="1" | '''Cardiovascular'''
|style="height:100px"; style="width:75%" border="1" bgcolor="Beige" |
| style="width:75%" bgcolor="Beige" ; border="1" | [[Cardiac arrest]], [[Bradycardia]], [[Prolonged QT]], [[Sick Sinus Syndrome]], [[Stokes-Adams attacks]], [[Tachycardia]], [[Ventricular Tachycardia]], [[Aortic Stenosis]], [[Cardiac]] [[Syncope]], [[Cardiac tamponade]], [[Vertebrobasilar insufficiency|Vertebrobasilar Artery Insufficiency]]
 
[[Cardiac arrest]],
[[bradycardia]],
[[prolonged QT]],
[[sick sinus syndrome]],
[[Stokes-Adams attacks]],
[[tachycardia]],
[[ventricular tachycardia]],
[[aortic stenosis]]
 
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Chemical / poisoning'''
| '''Chemical / poisoning'''
|bgcolor="Beige"| No underlying causes
| bgcolor="Beige" | No underlying causes
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Dermatologic'''
| '''Dermatologic'''
|bgcolor="Beige"| No underlying causes
| bgcolor="Beige" | No underlying causes
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Drug Side Effect'''
| '''Drug Side Effect'''
|bgcolor="Beige"|
| bgcolor="Beige" | [[Sedatives]], [[Antihistamine]], [[Tricyclic antidepressants]]
 
[[Sedatives]], [[antihistamine]], [[tricyclic antidepressants]]
 
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Ear Nose Throat'''
| '''Ear Nose Throat'''
|bgcolor="Beige"| No underlying causes
| bgcolor="Beige" | [[Superior canal dehiscence syndrome]]
|-  
|-  
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Endocrine'''
| '''Endocrine'''
|bgcolor="Beige"|  
| bgcolor="Beige" | [[Hypoglycemia]], [[Hypocalcemia]]
Hypoglycemia
 
|-  
|-  
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Environmental'''
| '''Environmental'''
|bgcolor="Beige"| No underlying causes
| bgcolor="Beige" | No underlying causes
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Gastroenterologic'''
| '''Gastroenterologic'''
|bgcolor="Beige"| No underlying causes
| bgcolor="Beige" | No underlying causes
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Genetic'''
| '''Genetic'''
|bgcolor="Beige"| No underlying causes
| bgcolor="Beige" | No underlying causes
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Hematologic'''
| '''Hematologic'''
|bgcolor="Beige"| No underlying causes
| bgcolor="Beige" | [[Gout]]
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Iatrogenic'''
| '''Iatrogenic'''
|bgcolor="Beige"| No underlying causes
| bgcolor="Beige" | [[Antihistamines]], [[Sedatives]]
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Infectious Disease'''
| '''Infectious Disease'''
|bgcolor="Beige"| No underlying causes
| bgcolor="Beige" | No underlying causes
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Musculoskeletal / Ortho'''
| '''Musculoskeletal / Ortho'''
|bgcolor="Beige"| No underlying causes
| bgcolor="Beige" | [[Gout]], [[Paraplegia]], [[Spinal cord trauma]]
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Neurologic'''
| '''Neurologic'''
|bgcolor="Beige"| Astatic seizure , [[Episodic ataxia]] , [[Juvenile myoclonic epilepsy]] , [[Migraine]] , [[Myoclonic seizure]] , Panayiotopoulos syndrome
| bgcolor="Beige" | [[Idiopathic generalized epilepsy|Astatic seizure]], [[Episodic ataxia]], [[Juvenile myoclonic epilepsy]], [[Migraine]], [[Myoclonic seizure]], Panayiotopoulos syndrome
[[Parkinsons]] , [[Pure autonomic failure]] , [[Seizure]] , Verterbrobasilar artery insufficiency , [[Paraplegia]], Brain stem mass
[[Parkinsons]], [[Pure autonomic failure]], [[Seizure]], [[Vertebrobasilar insufficiency|Vertebrobasilar artery insufficiency]], [[Paraplegia]], [[Brain stem]] [[mass]], [[Breath-holding spells]], [[Conversion disorder]], [[Episodic ataxia]], [[Hypokalemic periodic paralysis]], [[Lennox-Gastaut Syndrome]], [[Superior canal dehiscence syndrome]]
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Nutritional / Metabolic'''
| '''Nutritional / Metabolic'''
|bgcolor="Beige"|
| bgcolor="Beige" | [[Hypoglycemia]], [[Hypocalcemia]], [[Hypomagnesemia]], [[Gout]], [[Hypomagnesemia]]
Hypoglycemia, [[hypocalcemia]], [[hypomagnesemia]]
 
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Obstetric/Gynecologic'''
| '''Obstetric/Gynecologic'''
|bgcolor="Beige"| No underlying causes
| bgcolor="Beige" | No underlying causes
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Oncologic'''
| '''Oncologic'''
|bgcolor="Beige"| No underlying causes
| bgcolor="Beige" | [[Brain stem]] [[mass]]
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Opthalmologic'''
| '''Opthalmologic'''
|bgcolor="Beige"| No underlying causes
| bgcolor="Beige" | No underlying causes
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Overdose / Toxicity'''
| '''Overdose / Toxicity'''
|bgcolor="Beige"|[[Cocaine]]
| bgcolor="Beige" |[[Cocaine]], [[Sedatives]]
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Psychiatric'''
| '''Psychiatric'''
|bgcolor="Beige"|
| bgcolor="Beige" | [[Malingering]], [[Conversion disorder]], [[Panic attack]], [[Anxiety]], [[Panic disorder]], [[Trypanophobia]]
 
[[Malingering]], conversion, [[panic attack]], [[anxiety]]
 
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Pulmonary'''
| '''Pulmonary'''
|bgcolor="Beige"|[[Sleep apnea]]
| bgcolor="Beige" |[[Sleep apnea]]
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Renal / Electrolyte'''
| '''Renal / Electrolyte'''
|bgcolor="Beige"| No underlying causes
| bgcolor="Beige" | [[Hypocalcemia]], [[Hypomagnesemia]]
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Rheum / Immune / Allergy'''
| '''Rheum / Immune / Allergy'''
|bgcolor="Beige"| No underlying causes
| bgcolor="Beige" | [[Anaphylaxis]]
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Sexual'''
| '''Sexual'''
|bgcolor="Beige"| No underlying causes
| bgcolor="Beige" | No underlying causes
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Trauma'''
| '''Trauma'''
|bgcolor="Beige"| No underlying causes
| bgcolor="Beige" | [[Spinal cord trauma]]
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Urologic'''
| '''Urologic'''
|bgcolor="Beige"| No underlying causes
| bgcolor="Beige" | No underlying causes
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Dental'''
| '''Dental'''
|bgcolor="Beige"| No underlying causes
| bgcolor="Beige" | No underlying causes
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Miscellaneous'''
| '''Miscellaneous'''
|bgcolor="Beige"| No underlying causes
| bgcolor="Beige" | [[Sleep apnea]]
|-
|-
|}
|}


==Causes in alphabetical order==
==Causes in alphabetical order==
*Anaphylaxis
{{col-begin|width=80%}}
*Antihistamines
{{col-break|width=33%}}
*Aortic stenosis
*[[Anaphylaxis]]
*Astatic seizure
*[[Antihistamines]]
*Bradycardia
*[[Aortic stenosis]]
*Brain stem mass
*[[Idiopathic generalized epilepsy|Astatic seizure]]
*Breath holding spells
*[[Bradycardia]]
*Cardiac arrest
*[[Brain stem]] [[mass]]
*Cardiac syncope
*[[Breath-holding spells]]
*Cardiac tamponade
*[[Cardiac arrest]]
*Cocaine
*[[Cardiac]] [[syncope]]
*Conversion disorders
*[[Cardiac tamponade]]
*Episodic ataxia
*[[Cocaine]]
*Gout
*[[Conversion disorder]]
*Hypocalcemia
*[[Episodic ataxia]]
*Hypoglycemia
*[[Gout]]
*Hypokalemic periodic paralysis
{{col-break|width=33%}}
*Hypomagnesemia
*[[Hypocalcemia]]
*Juvenile myoclonic epilepsy
*[[Hypoglycemia]]
*Lennox-Gastaut Syndrome - drop attacks
*[[Hypokalemic periodic paralysis]]
*Malingering
*[[Hypomagnesemia]]
*Migraine
*[[Juvenile myoclonic epilepsy]]
*Myoclonic seizure
*[[Lennox-Gastaut Syndrome]] - drop attacks
*[[Malingering]]
*[[Migraine]]
*[[Myoclonic seizure]]
*Panayiotopoulos syndrome
*Panayiotopoulos syndrome
*Parkinsons disease
*[[Parkinson's disease]]
*Paraplegia
*[[Paraplegia]]
*Panic attack
*[[Panic attack]]
*Panic disorder
*[[Panic disorder]]
*Prolonged QT
{{col-break|width=33%}}
*Pure autonomic failure
*[[Prolonged QT]]
*Sedatives
*[[Pure autonomic failure]]
*Seizures
*[[Sedatives]]
*Sick sinus syndrome
*[[Seizures]]
*Sleep apnea
*[[Sick sinus syndrome]]
*Spinal cord trauma
*[[Sleep apnea]]
*Stokes-Adams attacks
*[[Spinal cord trauma]]
*Superior canal dehiscence syndrome
*[[Stokes-Adams attacks]]
*Tachycardia
*[[Superior canal dehiscence syndrome]]
*Trypanophobia
*[[Tachycardia]]
*Ventricular tachcardia
*[[Trypanophobia]]
*Verterbrobasilar artery insufficiency
*[[Ventricular tachycardia]]
*[[Vertebrobasilar insufficiency|Vertebrobasilar artery insufficiency]]
{{col-end}}


==Diagnosis==
==Diagnosis==
* important if there was an inciting event (NMS, breatholding, postural), any LOC, and presence of postictal pd
*Important in the presence of an inciting event ([[Neuroleptic malignant syndrome]], breatholding, postural), any [[loss of consciousness]] and presence of [[post-ictal]] period
* initially get [[glucose]], [[EKG]], [[pregnancy]] test, Utox, [[Computed tomography|CT head]], lytes
*Initial tests:
* later consider [[EEG]], [[echocardiogram]], [[MRI]], [[tilt table test|tilt test]]
#[[Glucose]]
 
#[[EKG]]
#[[Pregnancy]] test
#[[Urine]] toxicology test
#[[Computed tomography|CT head]]
#[[Electrolytes]]
#Later consider: [[EEG]], [[Echocardiogram]], [[MRI]] and [[tilt table test|Tilt test]]


[[Category:Symptoms]]
[[Category:Signs and symptoms]]
[[Category:Signs and symptoms]]
[[Category:Cardiology]]
[[Category:Cardiology]]
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Latest revision as of 03:21, 9 August 2017


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Farman Khan, MD, MRCP [2]

Overview

Drop attacks are sudden spontaneous falls while standing or walking, followed by a very swift recovery, within seconds or minutes. Drop attacks are typically seen in elderly patients, and the most common cause is carotid sinus hypersensitivity, resulting in either short periods of reversible asystole, or in marked drop in blood pressure in response to carotid sinus stimulation. Drop attacks are differnetiated from vaso-vagal and other causes of syncope due to the characteristic feature of drop attack that is a sudden feeling of being pulled or pushed towards the ground without any loss of consciousness.

Causes

Causes of drop attacks include:

  1. Vascular - transient ischemic attack, cerebrovascular accident, dissection, occlusion and hemorrhage
  2. Epilepsy/paroxysmal:
  3. Degenerative disease:
  4. Structural:
  5. Metabolic:
  6. Cardiac:
  7. Psychologic:

Common Causes

Causes by Organ System

Cardiovascular Cardiac arrest, Bradycardia, Prolonged QT, Sick Sinus Syndrome, Stokes-Adams attacks, Tachycardia, Ventricular Tachycardia, Aortic Stenosis, Cardiac Syncope, Cardiac tamponade, Vertebrobasilar Artery Insufficiency
Chemical / poisoning No underlying causes
Dermatologic No underlying causes
Drug Side Effect Sedatives, Antihistamine, Tricyclic antidepressants
Ear Nose Throat Superior canal dehiscence syndrome
Endocrine Hypoglycemia, Hypocalcemia
Environmental No underlying causes
Gastroenterologic No underlying causes
Genetic No underlying causes
Hematologic Gout
Iatrogenic Antihistamines, Sedatives
Infectious Disease No underlying causes
Musculoskeletal / Ortho Gout, Paraplegia, Spinal cord trauma
Neurologic Astatic seizure, Episodic ataxia, Juvenile myoclonic epilepsy, Migraine, Myoclonic seizure, Panayiotopoulos syndrome

Parkinsons, Pure autonomic failure, Seizure, Vertebrobasilar artery insufficiency, Paraplegia, Brain stem mass, Breath-holding spells, Conversion disorder, Episodic ataxia, Hypokalemic periodic paralysis, Lennox-Gastaut Syndrome, Superior canal dehiscence syndrome

Nutritional / Metabolic Hypoglycemia, Hypocalcemia, Hypomagnesemia, Gout, Hypomagnesemia
Obstetric/Gynecologic No underlying causes
Oncologic Brain stem mass
Opthalmologic No underlying causes
Overdose / Toxicity Cocaine, Sedatives
Psychiatric Malingering, Conversion disorder, Panic attack, Anxiety, Panic disorder, Trypanophobia
Pulmonary Sleep apnea
Renal / Electrolyte Hypocalcemia, Hypomagnesemia
Rheum / Immune / Allergy Anaphylaxis
Sexual No underlying causes
Trauma Spinal cord trauma
Urologic No underlying causes
Dental No underlying causes
Miscellaneous Sleep apnea

Causes in alphabetical order

Diagnosis

  1. Glucose
  2. EKG
  3. Pregnancy test
  4. Urine toxicology test
  5. CT head
  6. Electrolytes
  7. Later consider: EEG, Echocardiogram, MRI and Tilt test

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