Syncope
Revision as of 17:48, 12 March 2011 by Rossdonaldson1 (talk | contribs)
Pearls
- 3 questions
- 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 pt at high risk?
Work-Up
- ECG
- Urine pregnancy
- Consider:
- Hemoglobin
- Chemistry
- Orthostatics
- CXR (dissection)
- Troponin
- Guaiac
Differential Diagnosis
- Cardiac syncope
- Blood loss
- Pulmonary embolism
- Subarachnoid hemorrhage
- Syncope (DDx)
Disposition
- Admit (ACEP Clinical Policy 2007)* Abnormal ECG
- Ischemia, dysrhythmias, conduction abnormalities
- History, or presence of heart failure, CAD, or structural heart disease
- Older age and associated comorbidities
- Hematocrit <30 (if obtained)
- Consider Admitting (Hockberger 2003)
- Age>60
- H/O cardiovasc dz
- Frequent syncope
- Meds that cause vent arrythmia
- FHx of sudden death or arrythmia
- Injuries d/t fall
- Mod-severe orthostatics
- Social situation
- Orthostatics = lie flat, wait 5 minutes, measure, then stand 3 minute and measure, HR rise by 20, or SBP drop by 20 with Sx should be worked up
-unless sig neuro signs and sx before and/or after TIA unlikely (need b/l cortex, or brainstem tia for LOC)
-elderly and sy think MI, 50% in this group are silent
-even if pacer looks nl could be loose
San Francisco Syncope Rule (Annals 5/06)
- SBP <90 ever
- C/O SOB
- H/O CHF
- Non-sinus EKG
- New change on EKG
- HCT < 30
7d serious outcome
Syncope Rule: Pts > 60yo (Annals 12/09)
- Age > 90
- Male
- Hx of arrhythmia
- Triage Sys BP >160
- Abnl EKG
- Abnl TnI
- 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