Syncope

Pearls

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?

Work-Up

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

DDX

Syncope (DDx)

Disposition

1. Admit (ACEP Clinical Policy 2007)* Abnormal ECG
   1. Ischemia, dysrhythmias, conduction abnormalities
   2. History, or presence of heart failure, CAD, or structural heart disease
   3. Older age and associated comorbidities
   4. Hematocrit <30 (if obtained)
2. Consider Admitting (Hockberger 2003)
   1. Age>60
   2. H/O cardiovasc dz
   3. Frequent syncope
   4. Meds that cause vent arrythmia
   5. FHx of sudden death or arrythmia
   6. Injuries d/t fall
   7. Mod-severe orthostatics
   8. Social situation

-even if pacer looks nl could be loose

San Francisco Syncope Rule (Annals 5/06)

1. SBP <90 ever
2. C/O SOB
3. H/O CHF
4. Non-sinus EKG
5. New change on EKG
6. HCT < 30

7d serious outcome

Syncope Rule: Pts > 60yo (Annals 12/09)

1. Age > 90
2. Male
3. Hx of arrhythmia
4. Triage Sys BP >160
5. Abnl EKG
6. Abnl TnI
7. Near-Syncope

Add 1 point for each, subtract 1 for near-syncope

Statification (30 day serious event rate):

Low Risk: -1, 0 (2.5%)

Medium: 1, 2 (6.3%)

High: >3 (20%)

F/U

Holter (heart disease suspected) vs tilt-test (heart disease not suspected)

Source

UpToDate, ACEP Clinical Policy