Syncope: Difference between revisions
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===Discharge=== | ===Discharge=== |
Revision as of 10:20, 31 August 2019
For pediatric patients patients see syncope (peds)
Background
- Transient loss of postural tone and consciousness due to cerebral hypoperfusion
- Syncope and pre-syncope assessed similarly
- Important considerations:
- Is this true syncope or something else (eg, stroke, seizure, head injury)?
- If this is true syncope, is there a clear life-threatening cause?
- If this is true syncope and the cause is not clear, is the patient at high risk for serious outcome?
Risk Factors for Serious Cause
- Exertion preceding the event
- Note that syncope during exertion much more concerning than syncope after exertion
- History of cardiac disease in the patient
- Family history of sudden death, deafness, or cardiac disease
- Consider unexplained deaths and deaths due to single vehicle accidents
- Recurrent episodes
- Recumbent episode
- Prolonged loss of consciousness
- Associated chest pain or palpitations
- Use of medications that can alter cardiac conduction
San Francisco Syncope Rule
- 1.4% of patients who are rule-negative will have a 7-day serious outcome
- 10% of patients meeting the below criteria will have a 7-day serious outcome
- NOT validated by external studies[1]
- Criteria (CHESS Pneumonic)[2]
- CHF History
- Hct < 30%
- ECG Abnormality
- SOB history
- SBP < 90mmHg at triage
Clinical Features
Physical Exam
- Evaluate volume status
- Evaluate for head and neck trauma (related to fall from syncopal event)
- Focus cardiac exam on detecting murmurs (aortic stenosis, mitral regurgitation, tricuspid stenosis)
- Evaluate for signs of heart failure
- Palpate abdomen for pulsating mass (AAA)
- Rectal exam to eval for GI bleed
- Thorough neurologic exam
- Examine for possible sources of infection
Clinical Features by Cause
- Cardiovascular-mediated syncope
- Usually occurs without warning (absence of prodrome)
- History of structural heart disease
- Family history of sudden cardiac death
- Syncope during exertion
- Chest pain or palpitations associated with syncope
- Abnormal ECG
- Neurally mediated syncope
- Trigger event (fear/pain, prolonged standing, warm environment)
- Prodrome of nausea, vomiting, tunnel vision, lightheadedness, diaphoresis, warmth [3]
- Associated with head movement or pressure on neck
- Orthostatic hypotension-mediated syncope
- After standing up
- Change in medications
Differential Diagnosis
Syncope Causes
- Cardiovascular-mediated syncope
- Dysrhythmias:
- Cardiovascular disease
- Neurally mediated syncope
- Vasovagal:
- Fear, pain, emotion, valsalva, breath-holding spell
- Situational (associated with):
- Vasovagal:
- Orthostatic hypotension-mediated syncope:
- Volume depletion:
- Autonomic Dysreflexia
- Autonomic failure due to meds
- Other serious causes
- Stroke
- SAH
- TIA
- Vertebrobasilar Insufficiency
- Subclavian steal
- Heat syncope
- Hypoglycemia
- Hyperventilation
- Asphyxiation
- Seizure
- Narcolepsy
- Psychogenic (anxiety, conversion disorder, somatic symptom disorder)
- Toxic (drugs, carbon monoxide, etc.)
Evaluation
- Overall yield of testing is low
- Cardiovascular findings and evidence of bleeding strongest predictors of adverse outcomes after syncope[4]
Work-Up
ACEP only recommends ECG and H&P as must haves
- ECG
- Normal ECG has high NPV[5]
- Perform on every patient, unless trigger clearly identified (i.e. following blood draw) and no risk factors
- Rule out: ischemia, heart block, WPW, long QT, short QT, Brugada, HOCM, ARVD, early repolarization, low voltage/pericardial effusion, RV strain pattern
- ECG findings associated with adverse cardiac outcome in 30 days: [6][7]
- LBBB, 2nd degree Mobitz II, 3rd degree AV block, RBBB w/LAFP or LPFB
- Urine pregnancy
- Consider based on history/symptoms
- CXR
- Obtain if symptomatic (i.e. to rule out dissection)
- Hemoglobin
- Chemistry
- Capillary glucose assessment sufficient in many cases
- Orthostatics (symptomatic)
- Troponin
- Guaiac
- Bedside US
- PSL view may show thickened ventricular septum
- High sensitivity to rule out AAA
- b-HCG in female patients of reproductive age to rule out ectopic pregnancy rupture as cause of syncope
- CT scan of head is not recommended in asymptomatic, insignificant trauma with normal neurologic examination
- Part of Choosing wisely ACEP
- Does PE need to be worked up?
Diagnosis
Management
- Treat underlying cause, if known (~50% of patients do not have a firm diagnosis)
Disposition
Admit[12]
- Abnormal ECG
- CHF
- Suspicion of structural heart disease
- Ischemic, dysrhythmic, obstructive, valvular
- HCT <30
- Shortness of Breath
- Hypotension(SBP <90)
- Family history of sudden cardiac death
- Advanced age
- Evidence of hemorrhage (occult blood)
- Syncope without prodrome
Discharge
- None of the above findings (esp if age <45)
- Consider referral for holter or til-table test
External Links
See Also
References
- ↑ Birnbaum A, Esses D, Bijur P, Wollowitz A, Gallagher EJ. Failure to validate the San Francisco Syncope Rule in an independent emergency department population. Ann Emerg Med. 2008;52(2):151-9.
- ↑ Quinn J, McDermott D, Stiell I, Kohn M, Wells G. Prospective validation of the San Francisco Syncope Rule to predict patients with serious outcomes. Ann Emerg Med. 2006 May;47(5):448-54. PubMed PMID: 16631985.
- ↑ Romme JJCM, van Dijk N, Boer KR, et al. Influence of age and gender on the occurrence and presentation of reflex syncope. Clin Auton Res. 2008;18(3):127-133
- ↑ D’Ascenzo F, Biondi-Zoccai G, Reed M, et al. Incidence, etiology and predictors of adverse outcomes in 43,315 patients presenting to the emergency department with syncope: an international meta-analysis. Int J Cardiol. 2013;167(1)57-62
- ↑ Sud S, Klein GJ, Skanes AC, et al. Predicting the cause of syncope from clinical history in patients undergoing prolonged monitoring. Heart Rhythm. 2009;6(2):238-243
- ↑ Quinn J, McDermott D. Electrocardiogram findings in emergency department patients with syncope. Acad Emerg Med. 2011;18(7):714-718
- ↑ Thiruganasambandamoorthy V, Hess EP, Turko E, et al. Defining abnormal electrocardiography in adult emergency department syncope patients: the Ottawa Electrocardiographic Criteria. CJEM. 2012;14(4):248-258
- ↑ Reed MJ, Newby DE, Coull AJ, et al. Diagnostic and prognostic utility of troponin estimation in patients presenting with syncope: a prospective cohort study. Emerg Med J. 2010; 27(4):272-276
- ↑ Reed MJ, Mills NL, Weir CJ. Sensitive troponin assay predicts outcome in syncope. Emerg Med J. 2012;29(12):1001- 1003
- ↑ Prandoni P, Lensing AW, Prins MH, Ciammaichella M, Perlati M, Mumoli N, Bucherini E, Visonà A, Bova C, Imberti D, Campostrini S, Barbar S; PESIT Investigators. Prevalence of Pulmonary Embolism among Patients Hospitalized for Syncope. N Engl J Med. 2016 Oct 20;375(16):1524-1531. PubMed PMID: 27797317.
- ↑ Prevalence Of Pulmonary Embolism In Patients Presenting With Syncope: A Systematic Review And Meta-Analysis Oqab, Z., et al, Am J Emerg Med 36(4):551, April 2018
- ↑ Huff JS, Decker WW, Quinn JV et al. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with syncope. Ann Emerg Med. 2007;49(4):431-444