Syncope: Difference between revisions

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==Pearls==
==Pearls==
 
#3 questions
 
##Is this true syncope or something else (eg, stroke, seizure, head injury)?
* 3 questions
##If this is true syncope, is there a clear life-threatening cause?
* Is this true syncope or something else (eg, stroke, seizure, head injury)?
##If this is true syncope and the cause is not clear, is the pt at high risk?  
* 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==
==Work-Up==
 
#ECG  
 
#Urine pregnancy
* ECG  
#Consider:
* Urine pregnancy
##Hemoglobin
* Consider:
##Chemistry
* Hemoglobin
##Orthostatics
* Chemistry
##CXR (dissection)
* Orthostatics
##Troponin
* CXR (dissection)
##Guaiac  
* Troponin
* Guaiac
 


==Differential Diagnosis==
==Differential Diagnosis==
 
#Cardiac syncope
 
#Blood loss
* Cardiac syncope
#Pulmonary embolism
* Blood loss
#Subarachnoid hemorrhage
* Pulmonary embolism
#Syncope (DDx)
* Subarachnoid hemorrhage
* Syncope (DDx)
== ==
 


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


==San Francisco Syncope Rule (Annals 5/06)==
==San Francisco Syncope Rule (Annals 5/06)==
 
#SBP <90 ever
 
#C/O SOB
1. SBP <90 ever
#H/O CHF
 
#Non-sinus EKG
2. C/O SOB
#New change on EKG
 
#HCT < 30
3. H/O CHF
 
4. Non-sinus EKG
 
5. New change on EKG
 
5. HCT < 30
 
7d serious outcome
7d serious outcome


==Syncope Rule: Pts > 60yo (Annals 12/09)==
==Syncope Rule: Pts > 60yo (Annals 12/09)==
 
#Age > 90  
 
#Male
Age > 90  
#Hx of arrhythmia
 
#Triage Sys BP >160
Male
#Abnl EKG
 
#Abnl TnI
Hx of arrhythmia
#Near-Syncope
 
Triage Sys BP >160
 
Abnl EKG
 
Abnl TnI
 
Near-Syncope


Add 1 point for each, subtract 1 for near-syncope
Add 1 point for each, subtract 1 for near-syncope
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High: >3 (20%)
High: >3 (20%)


==F/U==
 
==F/U:==
 
 
Holter (heart disease suspected) vs tilt-test (heart disease not suspected)
Holter (heart disease suspected) vs tilt-test (heart disease not suspected)


===Source===
 
UpToDate, ACEP Clinical Policy
===Source: UpToDate, ACEP Clinical Policy===
 
 
 
 


[[Category:Cards]]
[[Category:Cards]]

Revision as of 17:48, 12 March 2011

Pearls

  1. 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

Differential Diagnosis

  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

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