Syncope: Difference between revisions

(Created page with "==Work-Up== 1) CBC (Hb) 2) Chem 7 (+\-) 3) ECG 4) Icon 5) ?Orthostatics* Elderly add: 6) CXR (dissection) 7) Trop Other Poss 8) Guiac 9) Utox/ETOH 10) Carotid duplex...")
 
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==Work-Up==
==Pearls==




1) CBC (Hb)
* 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?


2) Chem 7 (+\-)
==Work-Up==


3) ECG
4) Icon
5) ?Orthostatics*
Elderly add:
6) CXR (dissection)
7) Trop
Other Poss
8) Guiac
9) Utox/ETOH
10) Carotid duplex --> D/C home


* ECG
* Urine pregnancy
* Consider:
* Hemoglobin
* Chemistry
* Orthostatics
* CXR (dissection)
* Troponin
* Guaiac
   
   
F/U: Holter (heart dz susp)
vs. Tilt-test (heart dz not susp)


   
   


==Disposition ==
==Differential Diagnosis==
 


Admit (ACEP 2001)1) Hx of CHF or Vent arrythmia


2) CP c/w ACS
* Cardiac syncope
* Blood loss
* Pulmonary embolism
* Subarachnoid hemorrhage
* Syncope (DDx)
== ==


3) PE suggestive of CHF or valve dz


4) Abnormal EKG
==Disposition ==


-arrythmogenic right ventricular cardiomyopathy: RBBB, LBBB with ectopic beats, QRS >110 in V1-V3 with T-wave inversions in V2 & V3, Epsilon wave
-Brugada syndrome:  RBBB with with ST segment elevation V1 to V3.  Incomplete RBBB with ST segment elevation in V1, V2
-Hyperkalemia: see Hyper K page
-Hypocalcemia: prolongs QT by lengthening ST segment, also decrease T wave voltage, flat T waves, terminal T wave inversion or deeply inverted T wave
-Hypokalemia:  see hypo K page
-Hypertrophic Cardiomyopathy
-Intracranial hemorrhage:  deep T waves, brady, prolonged QT, U waves, minor ST elevation
-Ischemia
-Prolonged QT: QTc interval >.46-.5ms
-Wellens syndrome: symmetric/deep inverted t waves V2/V3 (+/- V1-6) or biphasic T waves in V2,V3, ST elevation usually <1mm
-Wolf-Parkinson-White syndrome: delta wave, wide QRS, short PR interval, wide complex
-A Fib/SVT
5) Exertional syncope without benign cause


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)
   
   


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8) Social situation
8) Social situation


*Orthostatics = lie flat, wait 1 minute measure then sit up 1 minute and measure, then stand 1 minute and measure, HR rise by 20, or SBP drop by 20 with Sx should be worked up
*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)
-unless sig neuro signs and sx before and/or after TIA unlikely (need b/l cortex, or brainstem tia for LOC)
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==Syncope Rule: Pts > 60yo (Annals 12/09)==
==Syncope Rule: Pts > 60yo (Annals 12/09)==




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==Source ==
==F/U:==
 


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


2/6/06 DONALDSON (adapted from Lampe, Hockberger)


11/3/10 SOTELO (EKG list describes common findings and is not complete list)
===Source: UpToDate, ACEP Clinical Policy===


12/1 DeBo




Revision as of 23:42, 1 March 2011

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):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

5. 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

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