Syncope
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)