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Syncope

Syncope. Jeff Ricketson, October 27. 1 79 M. SYNCOPE THIS AFTERNOON AT HOME. BROUGHT IN BY EMS. NO EMESIS OR MELENA. HG 120 LAST WK. Hit the refresh button, and hope that someone else signed up in the past 5 seconds that it took you to read the note.

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Syncope

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  1. Syncope Jeff Ricketson, October 27

  2. 1 79 M. SYNCOPE THIS AFTERNOON AT HOME. BROUGHT IN BY EMS. NO EMESIS OR MELENA. HG 120 LAST WK. • Hit the refresh button, and hope that someone else signed up in the past 5 seconds that it took you to read the note. • Remember that you haven’t gone to the bathroom all shift and that your last preceptor said you should take care of yourself, including ins and outs. • Try and think of something you didn’t ask your last patient, or didn’t order, so that you can go do a more thorough job of your previous patient. • Sign up for the patient and hope it’s a clear vasovagal episode.

  3. Reasons we don’t like syncope • 50-60% of patients will leave without a diagnosis • Exhaustive list of potential causes • History is key, but often difficult to obtain • Lack of organized approach

  4. Goals for the session 1 Pt expect 3 minutes. 20 M, MVC, OBVIOUS DISLOCATED LEFT SHOULDER, ABSENT BREATH SOUNDS TO THE LEFT SIDE, GSC 4 AT THE SCENE, NOT INTUBATED “Maybe I need to go to the washroom, because number 2 is an 80 year old with syncope, and I would really rather see that patient than put in a chest tube, intubate, and reduce a shoulder.”

  5. Epidemiology

  6. Epidemiology -Lots of people have syncope -$$$$$ To healthcare system -Admission rate 10-15% in Canada, 40-60% in US -In Canada: 1/100 will die within 1 month 1/10 will die within 1 year

  7. Case 1 Vital signs all normal 22 year old female. Syncope in the bathroom this morning. Had 3 glasses of wine last night. Ate breakfast this morning. Roomate witnessed event.

  8. History • There are 3 questions that need answering: 1. Is this immediately life threatening? 2. Is this true syncope? 3. What is the etiology?

  9. Is this immediately life threatening? Chest pain Palpitations SOB HA Abdominal Pain

  10. Is this true syncope? • Define syncope: “A transient, brief, loss of consciousness associated with inability to maintain postural tone that spontaneously and completely resolves without medical intervention.”

  11. Is this true syncope? Sx of syncope Sx of seizure Classic aura Post-ictal confusion Head turning Extremity movement (less helpful) Urinary incontinence (less helpful) • Diaphoresis • Nausea • Warmth • Palpitations • Chest pain • Dyspnea

  12. What is the etiology? Cardiopulmonary Structural Dysrhythmia Neural/Reflex Mediated Vasovagal Situational Carotid Sinus Syndrome Orthostatic Neurologic Medications Psychiatric

  13. Bad places to have a syncopal episode…

  14. What about the physical exam? 80 yo M. Got off couch to move pile of books. Syncopal event. Witnessed. No prodrome. Hx of SOBOE, and CP for which he uses SL nitro. Both stable, unchanged.

  15. Orthostatic vitals? -Supine x 5 minutes, then measure BP over 2-3 minutes while standing, SBP change >20mmHG -40% of asymptomatic pts >70 yo are positive -Orthostatic symptoms are just as good

  16. Carotid massage? Carotid massage?

  17. -Severe aortic stenosis the murmur may not be heard -Check for brachioradial delay

  18. Other physical exam… • Hyperventilation maneuver? • Rectal exam? • Exam for tongue biting?

  19. Another bad place for a syncopal event…

  20. Investigations? 1. ECG for everyone 2. CBC for Hematocrit 3. Other investigations as per clinical suspicion

  21. ECG

  22. QT measurement

  23. ECG Approach • Go through the usual, pay attention to: -Bradycardia -AV Block -Intraventricular conduction delays -Tachydysrhythmias -ACS 2. Add 4 things: WPW, Brugada, Long QT, HCM

  24. The pediatric athlete

  25. Driving restrictions??

  26. Management: It’s time to make a decision. Handover Admit Discharge

  27. What research has been done? • OESIL, Italian study, 2003 • San Francisco Syncope Rule, 2004 • Boston Syncope Rule, 2007 • Short and Long Term Prognosis of Syncope (STePS), 2008 • …. and many others

  28. -SFSR and the OESIL = Level 2 criteria. Level 2 criteria means can be applied in various clinical settings with confidence in their accuracy. -The rest = Level 4 criteria. Level 4 criteria means need further evaluation before being able to apply in a clinical setting.

  29. A brief word on OESIL -Italian study. 2003. -Derivation phase evaluated death from any cause at 12 months. -Validation phase evaluated death from any cause at 6 months. -Useful for decisions on admission? Survey says….

  30. Criteria: Abnormal ECG Complaint of SOB Hematocrit <30% SBP <90 at triage History of CHF Sensitivity: 96%, (valid’n 98%) Specificity: 62%, (valid’n 52%) -Could have reduced admissions from 55% to 45%

  31. -Worldwide external validations ranged sensitivity 69-90% (with 1 at 100%), and specificity 38-57% -This study: Sensitivity 90%, Specificity 33% -Baseline admission rate: 12% -Implementing rule would increase to 77% -Practice pattern missed 30% events outside ED

  32. Meta-analysis of SFSR: Sensitivity 87%, specificity 48% Conclusion: “All the clinical prediction guides used in the study need further development before they can be routinely used in clinical practice.”

  33. Thoughts?...

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