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
   4. CXR (dissection)
   5. Troponin
   6. Guaiac

DDX

1. Cardiac syncope
2. Blood loss
3. Pulmonary embolism
4. Subarachnoid hemorrhage
5. 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

• 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)

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