Syncope
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 --> D/C home
F/U: Holter (heart dz susp)
vs. Tilt-test (heart dz not susp)
Disposition
Admit (ACEP 2001)1) Hx of CHF or Vent arrythmia
2) CP c/w ACS
3) PE suggestive of CHF or valve dz
4) Abnormal EKG
-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
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 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
-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%)
Source
2/6/06 DONALDSON (adapted from Lampe, Hockberger)
11/3/10 SOTELO (EKG list describes common findings and is not complete list)
12/1 DeBo