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{{SI}}
{{CMG}}


{{CMG}}; {{AE}} {{FK}}


==Overview==


'''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.
==Common causes==
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]].
*seizure
*transient ischemic attack
*cerebrovascular accident
*basilar artery insufficiency
*hypoglycemia
*hypotension
*cataplexy associated with narcolepsy
*cardiac arrhythmia
*sick sinus syndrome
*migraine
*aortic stenosis
*conversion disorder


===Causes by Organ System===
==Causes==
{|style="width:80%; height:100px" border="1"
Causes of drop attacks include:
|style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" | '''Cardiovascular'''
|style="height:100px"; style="width:75%" border="1" bgcolor="Beige" |


[[Cardiac arrest]],
# '''[[Vascular]]''' - [[transient ischemic attack]], [[cerebrovascular accident]], [[dissection]], [[occlusion]] and [[hemorrhage]]
[[bradycardia]],
#* [[Intracranial hemorrhage]]
[[prolonged QT]],
#* [[Posterior circulation infarct|Posterior circulation infarction]], [[emboli]] and [[vasospasm]]
[[sick sinus syndrome]],
#* [[Bilateral]] [[anterior]] [[stroke|circulation occlusion]]
[[Stokes-Adams attacks]],
#* [[Migraine]] - develops over 1 hour, with associated [[paresthesia]], ''[[Hypertonia]] arterialis''
[[tachycardia]],
#*  [[Basilar artery insufficiency]] - older [[patient]] with no [[loss of consciousness]], [[transient]] loss of [[lower extremity]] [[muscle tone|tone]]
[[ventricular tachycardia]],
# '''[[Epilepsy]]/paroxysmal''':
[[aortic stenosis]]
#* [[Neurally mediated syncope]] - 75% of all causes
#* [[Myoclonic seizure]]
#* [[Idiopathic generalized epilepsy|Myoclonic-astatic seizure]]
#* [[Absence seizure|Petit mal syndrome]]
#* [[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]]
#* [[Periodic paralysis]]
#* [[Complex partial seizure]]
#* [[Breath-holding spells]] - associated [[pallor]]/[[cyanosis]], [[emotion]] related
#* [[Pure autonomic failure]] ([[Riley-Day Syndrome]], long standing [[diabetes mellitus]])
#* [[Episodic ataxia]]
#* Panayiotopoulos syndrome
# '''[[Degenerative disease]]''':
#* [[Postural instability]] with [[Parkinsons]]
# '''Structural''':
#* [[Chronic]] [[odontoid process|odontoid]] [[instability]]
#* [[Spinal cord trauma]] with transient [[paraplegia]]
#* [[Brainstem]] [[mass]]
# '''[[Metabolic]]''':
#* [[Hypoglycemia]]
#* [[Hypocalcemia]]
#* [[Hypomagnesemia]]
#* [[Toxins]], [[drugs]] - [[cocaine]], [[sedatives]], [[antihistamine]] and [[tricyclic antidepressants]]
# '''[[Cardiac]]''':
#* [[Prolonged QT]]
#* [[Tachycardia]]
#* [[Bradycardia]]
#* [[Sick sinus syndrome]]
#* [[Cardiac arrhythmia|arhythmia]]
#* [[Hypertrophic cardiomyopathy]]
#* [[Aortic stenosis]]
#* [[Hypovolemia]]
# '''[[Psychology|Psychologic]]''':
#* [[Malingering]]
#* [[Conversion disorder]]
#* [[Panic attack]]
#* [[Anxiety]]


==Common Causes==
*[[Seizure]]
*[[Transient ischemic attack]]
*[[Cerebrovascular accident]]
*[[Basilar artery insufficiency]]
*[[Hypoglycemia]]
*[[Hypotension]]
*[[Cataplexy]] associated with [[narcolepsy]]
*[[Cardiac arrhythmia]]
*[[Sick sinus syndrome]]
*[[Migraine]]
*[[Aortic stenosis]]
*[[Conversion disorder]]
==Causes by Organ System==
{| style="width:80%; height:100px" border="1"
| style="width:25%" bgcolor="LightSteelBlue" ; border="1" | '''Cardiovascular'''
| 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]]
|-
|-
|-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"| No underlying causes
| bgcolor="Beige" | [[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"| No underlying causes
| bgcolor="Beige" | [[Hypoglycemia]], [[Hypocalcemia]]
|-  
|-  
|-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"| No underlying causes
| bgcolor="Beige" | [[Idiopathic generalized epilepsy|Astatic seizure]], [[Episodic ataxia]], [[Juvenile myoclonic epilepsy]], [[Migraine]], [[Myoclonic seizure]], Panayiotopoulos syndrome
[[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"| No underlying causes
| bgcolor="Beige" | [[Malingering]], [[Conversion disorder]], [[Panic attack]], [[Anxiety]], [[Panic disorder]], [[Trypanophobia]]
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Pulmonary'''
| '''Pulmonary'''
|bgcolor="Beige"| No underlying causes
| 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==
==Causes in alphabetical order==
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.
{{col-begin|width=80%}}
 
{{col-break|width=33%}}
Other causes include the following:
*[[Anaphylaxis]]
 
*[[Antihistamines]]
# vascular - [[transient ischemic attack]], [[cerebrovascular accident]], dissection, occlusion, [[hemorrhage]]
*[[Aortic stenosis]]
#* intracranial hemm
*[[Idiopathic generalized epilepsy|Astatic seizure]]
#* posterior circulation [[infarction]], emboli, vasospasm
*[[Bradycardia]]
#* bilateral anterior circulation occlusion
*[[Brain stem]] [[mass]]
#* [[migraine]] accompagnee - develop over 1hr with assoc [[paresthesia]], HA
*[[Breath-holding spells]]
#* [[basilar artery]] insuff - older pt with no LOC, transient loss of LE tone
*[[Cardiac arrest]]
# [[epilepsy]]/paroxysmal
*[[Cardiac]] [[syncope]]
#* neurally mediated syncope - 75% of all causes
*[[Cardiac tamponade]]
#* [[Myoclonic seizure]], astatic seizure, or [[Absence seizure|petit mal syndrome]]
*[[Cocaine]]
#* Lennox Gaustaut - atonic, myoclonic, GTC typically in neuro abnormal pt
*[[Conversion disorder]]
#* [[Juvenile myoclonic epilepsy|Juvenile Myoclonic Epilepsy]] - fall with [[myoclonus]]
*[[Episodic ataxia]]
#* laugh or cough triggered [[epilepsy]]
*[[Gout]]
#* [[cataplexy]] associated with [[narcolepsy]]
{{col-break|width=33%}}
#* periodic [[paralysis]]
*[[Hypocalcemia]]
#* [[complex partial seizure]]
*[[Hypoglycemia]]
#* reatholding spells - associate pallor/[[cyanosis]], emotional aspect
*[[Hypokalemic periodic paralysis]]
#* [[pure autonomic failure]] (Riley Day, long standing DM)
*[[Hypomagnesemia]]
#* [[episodic ataxia]]
*[[Juvenile myoclonic epilepsy]]
#* Panayiotopoulos syndrome
*[[Lennox-Gastaut Syndrome]] - drop attacks
# degenerative
*[[Malingering]]
#* postural instability with [[Parkinsons]]
*[[Migraine]]
# structural
*[[Myoclonic seizure]]
#* chronic odontoid instability
*Panayiotopoulos syndrome
#* [[spinal cord trauma]] with transient [[paraplegia]]
*[[Parkinson's disease]]
#* [[brainstem]] mass
*[[Paraplegia]]
# metabolic
*[[Panic attack]]
#* [[hypoglycemia]], [[hypocalcemia]], [[Hypomagnesemia]]
*[[Panic disorder]]
#* [[toxins]], [[drugs]] - [[cocaine]], [[sedatives]], [[antihistamine]], TCA
{{col-break|width=33%}}
# [[cardiac]]
*[[Prolonged QT]]
#* prolonged QT, [[tachycardia]], [[bradycardia]], [[sick sinus syndrome]], [[Cardiac arrhythmia|arhythmia]], IHSS. AS
*[[Pure autonomic failure]]
#* [[hypovolemia]]
*[[Sedatives]]
# psych
*[[Seizures]]
#* malingering, conversion, [[panic]], [[anxiety]]
*[[Sick sinus syndrome]]
*[[Sleep apnea]]
*[[Spinal cord trauma]]
*[[Stokes-Adams attacks]]
*[[Superior canal dehiscence syndrome]]
*[[Tachycardia]]
*[[Trypanophobia]]
*[[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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