Syncope
Background
- 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?
- 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
- 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]
- CHF History
- Hct < 30%
- ECG Abnormality
- SOB history
- SBP < 90mmHg at triage
Work-Up
- ECG
- Urine pregnancy
- Consider:
- Hemoglobin
- Chemistry
- Orthostatics (symptomatic)
- CXR (dissection)
- Troponin
- 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
- Valvular heart disease
- 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
- Treat cause
- See also Hypotension
Disposition
- Admit
- Abnormal ECG
- CHF
- Suspicion of structural heart disease
- HCT <30
- Shortness of Breath
- SBP <90
- Family history of sudden cardiac death
- Advanced age
- Discharge
- None of the above findings (esp if age <45)
- 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)
- ↑ 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.