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Dive into challenging clinical syncope cases to enhance diagnostic skills and create effective management plans. Suitable for ACEM trainees preparing for FACEM exams. Real-life scenarios for practice and learning.
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SYNCOPEa symptom, not a diagnosis… Clinical cases Dr Jaycen Cruickshank Ballarat Emergency Education
Learning objectivesthey need to be your objectives… • To apply your knowledge and the information presented in our syncope presentation to these cases • To make a diagnosis and safe management plan for each case • For ACEM trainees • To consider how these cases might appear and be answered in the FACEM exams • To write and complete practice questions • To realize that good answers in exams are often good answers when in charge of the ED.
Case 1 • 32 yo male, Intravenous drug user • Presents with frequent syncopal episodes and ? Seizure activity • Medication – methadone • PMHx – nil else significant
Reminder causes ofQT prolongation • Hypomagnesiuaemia • Hypokalamia • Hypocalcaemia • Na Channel blockers – type 1a, TCA • Raised ICP • Altered conscious state • Hereditary • Lange Nielsen – QT prolongation and deafness • Romano Ward - QT only • Hypothermia • Drugs
Clinical Case 2 • 19 year old university student • Wakes up Sunday morning to the sound of his mobile phone • Gets up out of bed, talks for half a minute, then feels funny and blacks out • Housemate hears phone and the fall, and runs into the room, he is coming around quickly • Referred by GP for ED assessment • ECG normal • Further assessment and management?
Case 3middle aged man with fainting episode • ED doctor presents to the ED physician… • Middle aged man with syncope • No features to suggest seizure • Full assessment and no obvious cause • Is there any role for a troponin now and eight hours, how long should we observe for?
Case 3 cont. • History of presenting complaint. • He drove 8 hours • Walked into house • Went to make cup of tea • Then syncopal episode • Rapid recovery to normal… he heard wife calling the ambulance • Background • Truck driver • Working 2 jobs • Very little sleep • Past history similar episode • Investigation EEG and echo and stress test normal
Case 39 year old • 39 yo syncopal episode • No prodrome • No pmhx • Normal physical examination • Ddx?
BRUGADA SYNDROMEPOLYMORPHIC VT1/3 will develop 2nd episode in 2 years
Case 416 year old • 16 year old with syncope whilst playing basketball at school • No prodromal symptoms • Awoke after a few seconds • No PMHx • No FHx
16 year old, syncope while playing basketballInterpret this ECG.
HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHYWALL THICKNESS PREDICTOR OF DEATHSUBGROUP WILL NEED AN ICD
Clinical case 5 • 25 year old with syncope during a lecture • No chest pain, no dyspnea • No PMHx • FHx – father died suddenly aged 60
Further history • Further history • Syncope while seated • May indicate arrhythmia • Need more details on what lecture was about, the family history • Needs ECG • AA Arrhythmia, brugada, CMP
Clinical case 6 • 68 yo presents following syncopal event following going to the bathroom at 4am • Situational • Micturition/defecation syncope • What if fainted before going to toilet? • How does that change things?
Clinical Case 6 • 45 year old man collapses and takes 6 or 7 minutes to wake up and then he is a little confused • Diagnosis? • Probably a seizure • What further history and examination would be relevant?
Clinical case 7courtesy emcore.com • A 52 year old man is brought to the ED following a collapse. • He had been sitting at the kitchen table reading the paper and the next thing he knew he was on the floor • He woke with a vice like headache and pins and needles down the left arm • He is in AF
Clinical Case 7 further history • The patient had a biopsy of his ear where there was carcinoma detected • He had just got home following a CT of his neck, looking for lymph node enlargement • He had the CT with him and had asked people to look at the report, but no one would tell him what it meant • His brother died three months earlier from cancer
Clinical case 7 • He was sitting at the kitchen table thinking about dying from cancer and getting very anxious. • He got hot and sweaty, felt a little dizzy and collapsed • When he awoke, he did have a vice like headache and pins and needles down left arm. He was in AF • He was seeing his cardiologist for AF, which was controlled and he was on aspirin • Two previous episodes • Previously investigated CT/LP normal, diagnosis migraines was made.
Summary • History, exam, ECG • Cardiac vs non cardiac • Admit for no diagnosis and high risk • Older/abnormal ECG, cardiac history including CCF • Don’t forget to look for other causes • E.g TIA, dissection.