Syncope

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Background

  • Syncope is the transient loss of postural tone and consciousness from cerebral hypoperfusion
  • Syncope and pre-syncope are worked up the same
  • 3 Questions
  1. Is this true syncope or something else (eg, stroke, seizure, head injury)?
  2. If this is true syncope, is there a clear life-threatening cause?
  3. If this is true syncope and the cause is not clear, is the patient at high risk?

Risk Factors for Serious Cause

  • Exertion preceding the event
  • History of cardiac disease in the patient
  • Family history of sudden death, deafness, or cardiac disease
  • 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
Criteria (CHESS Pneumonic)[1]

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 [2]
    • Associated with head movement or pressure on neck
  • Orthostatic hypotension-mediated syncope
    • After standing up
    • Change in medications

Differential Diagnosis

Seizure

Syncope Causes

Evaluation

  • Overall yield of testing is low
  • Cardiovascular findings and evidence of bleeding strongest predictors of adverse outcomes after syncope[3]

Work-Up

  • ACEP only recommends ECG and H&P as must haves
  • ECG
    • Normal ECG has high NPV[4]
    • 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, Brugada, HOCM
    • ECG findings associated with adverse cardiac outcome in 30 days: [5][6]
      • 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
  • Orthostatics (symptomatic)
  • Troponin
    • Not recommended to rule out AMI in patients with isolated syncope[7]
    • Elevated troponin predicts adverse cardiac outcome in syncope[8]
    • May be useful for risk stratification
  • Guaiac
  • Bedside US
    • PSL view may show thickened ventricular septum
    • High sensitivity to rule out AAA
  • CT scan of head is not recommended in asymptomatic, insignificant trauma with normal neurologic examination

Management

Disposition

Admit[9]

  • 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)

Discharge

  • None of the above findings (esp if age <45)
  • Consider referral for holter or til-table test

External Links

See Also

References

  1. ↑ 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.
  2. ↑ 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
  3. ↑ 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
  4. ↑ 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
  5. ↑ Quinn J, McDermott D. Electrocardiogram findings in emergency department patients with syncope. Acad Emerg Med. 2011;18(7):714-718
  6. ↑ 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
  7. ↑ 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
  8. ↑ Reed MJ, Mills NL, Weir CJ. Sensitive troponin assay predicts outcome in syncope. Emerg Med J. 2012;29(12):1001- 1003
  9. ↑ 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
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