Syncope

Background

• 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 pt at high risk?

• Cardiac syncope usually occurs w/o warning
• TIA unlikely if no other s/s before or after
• In elderly think MI until proven otherwise

Risk Factors for Serious Cause

1. Exertion preceding the event
2. History of cardiac disease in the patient
3. Family history of sudden death, deafness, or cardiac disease
4. Recurrent episodes
5. Recumbent episode
6. Prolonged loss of consciousness
7. Associated chest pain or palpitations
8. 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
  • CHF history
  • Hct < 30%
  • ECG abnormal
  • SOB history
  • SBP < 90mmHg at triage

Work-Up

1. ECG
2. Urine pregnancy
3. Consider:
   1. Hemoglobin
   2. Chemistry
   3. Orthostatics (symptomatic)
   4. CXR (dissection)
   5. Troponin
   6. Guaiac

DDX

• Pulmonary
  • PE
• Cardiac
• Structural
  • Valvular heart disease
    • AS
    • Tricuspid stenosis
    • Mitral stenosis
    • Cardiomyopathy
    • Pulmonary hypertension
    • Myxoma
    • Pericardial disease
    • Aortic dissection
    • PE
    • Ischemia/infarction
  • Dysrhythmias
    • Bradydysrhythmias
    • Stokes-Adams attack
    • Sinus node disease
    • High degree AV block
    • Pacemaker malfunction
    • Tachydysrhythmias
    • V-tach
    • Torsades
    • SVT
    • A fib/flutter
• Neural/Reflex-Mediated
  • Vasovagal
  • Situational
    • Cough
    • Micturition
    • Defecation
    • Swallow
    • Neuralgia
  • Carotid sinus syndrome
• Neurologic
  • TIA
  • SAH
  • Subclavian steal
  • Migraine
• Orthostatic hypotension
• Medications

Source

Tintinalli

Treat

1. Treat cause
   1. See also Hypotension

Disposition

1. Admit
   1. Abnormal ECG
   2. CHF
   3. Suspicion of structural heart disease
   4. HCT <30
   5. Shortness of Breath
   6. SBP <90
   7. Family history of sudden cardiac death
   8. Advanced age
2. Discharge
   1. None of the above findings (esp if age <45)
   2. Consider referral for holter or til-table test

Source

• Tintinalli
• UpToDate
• ACEP Clinical Policy 2007
• The NNT (http://thennt.com/risk/syncope-in-the-emergency-department)