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SYNCOPE KELLIE ZAYLOR PGY-2 OCTOBER 5, 2006 OBJECTIVES Discuss Causes of Syncope Understand those causes that are an immediate life threat to the patient Cover important elements of the evaluation and workup of the syncopal patient Discuss management options Definition SYNCOPE: Transient loss of consciousness with a loss of postural tone and absence of prolonged confusion (post-ictal period) Basic Pathophysiology Caused by CNS dysfunction Can be secondary to hypoperfusion of brainstem (reticular activating system) or both cerebral hemispheres Blood flow can be regional (cerebral vasoconstriction) or systemic (hypotension) Hypoperfusion resulting in 35% or more reduction in cerebral blood flow usually produces unconsciousness Other CNS dysfunction: Hypoglycemia, toxins, metabolic abnormalities, failure of autoregulation, and primary neurological derangements Epidemiology 12-48% of general population experiences a syncopal event sometime in their lives Institutionalized pts >75 years old, have 6% annual incidence 15-50% of children have at least one episode Five percent of ED complaints 1-6% of hospitalized patients have syncope as a reason for admission Statistics Most common cause overall: vasovagal No identifiable cause in 30% of cases 17-18% of cases attributable to arrhythmias Statistics (cont’d) 30% of athletes dying during exercise had syncope as a sentinel event Factors associated with 1 year mortality Abnormal ECG Ventricular dysrhythmias Presence of CHF Age > 45 years old Etiology: Life threatening Wide range of causes: Seek out the life threatening ones! Cardiac Acute Coronary Syndrome Dysrhythmias (WPW, Blocks, Prolong QT) Structural Abnormalities (Aortic Stenosis, Hypertrophic Cardiomyopathy {HCM} ) Vascular Aortic Dissections Ruptured Aneurysms Other Hemorrhage (GI bleed, Ruptured Ectopic Pregnancy) Etiology: Life threatening Pulmonary CNS Pulmonary Embolism Pneumothorax Ischemia/Hemorrhage Toxic/Metabolic Derangements Glucose, Electrolyte abnormalities, Ingestions, CO poisoning etc. Etiology: Other Causes Hyperventilation Vasovagal (Emotion, Pain) Carotid Sinus Sensitivity (Necktie/shaving) Miscellaneous Reflex Cough, sneeze Exercise GI-swallowing, vomiting, defecation Postmicturition Increased intrathoracic pressure (weightlifting) Hypoperfusion (Orthostasis, Anemia) Etiology: Other Causes Seizures Narcolepsy Psychogenic Anxiety Conversion disorder Somatization disorder Panic disorder Breath holding spells Etiology: Drugs CV Bblockers, vasodilators, diuretics, antihypertensives, QT prolonging agents, dysrhythmics Psychoactive Anticonvulsants, antiparkinson, CNS depressants, MAOI, TCA, narcotics, antihistamines, cholinesterase inhibitors Etiology: Drugs Other drugs to consider Drugs of abuse (THC, cocaine, etoh, heroine) Diabetes medications Neuropathic drugs (vincristine) NSAIDS Bromocriptine Evaluation of Syncope Patient Rapid Assessment: If patient unstable: ABC’s and other necessary means of stabilization BUT… Since syncope is a transient event, most patients are able to give history Also important to talk to family members or other individuals at the scene Evaluation Important information to gather… Abrupt or gradual onset If it is abrupt while sitting or supine, suspicious for cardiac etiology Events prior to the syncopal episode Associated with exertion? Possible outflow obstruction Hot environment? Orthostasis Associated with Chest pain/SOB? Possible MI, Dissection, PE, Pneumothorax Evaluation (cont’d) Events prior to syncopal episode Headache? Possible intracranial hemorrhage Abdominal Pain? r/o Dissection, Ruptured aneurysm or Ectopic pregnancy Diaphoresis/lightheaded/dim vision? Vasovagal Aura? Consider seizure What happened during the event and how long did it last? Tonic-clonic mvmts? Possible seizure Trauma from fall/ or did they pass out before they fell? Further information to distinguish between Syncope vs. Seizure Factors favoring syncope Nausea or diaphoresis preceding spell Orientation upon awakening Age > 45 years old Prolonged sitting or standing prior to episode History of CHF or CAD Factors favoring seizure History of seizure disorder Tongue biting Post-ictal period LOC > 5 minutes Preceding Aura Age < 45 years old Observed unusual posturing/jerking or head turning History Pertinent Past Medical History History of Seizure disorder CAD CHF Aneurysms Aortic Stenosis GI bleed Hypertension Diabetes Migraines Medications Remember to get a full medication list and ask about… Changes in meds Compliance with medications Eating after medications (i.e. Insulin) Physical Exam System Pivotal Finding Significance Vital signs Pulse rate/rhythm RR and depth Blood Pressure Temperature Skin Color, diaphoresis Arrhythmias Tachypnea suggests hypoxia, hyperventilation or PE Underlying shock may be present and may contribute to syncope in 15-30% pts. Fever from sepsis may cause orthostasis Signs of decreased organ perfusion Physical Exam System Pivotal Finding Significance HEENT Tenderness/deform. Papilledema Breath Signs of trauma Increased ICP Ketones for DKA Neck Bruits JVD Source of cerebral emboli Right heart failure from ischemia, tamponade or PE Lungs Breath sounds, crackles, wheezes Infection, left heart failure from ischemia, PE Physical Exam System Pivotal Finding Significance Heart Systolic Murmur Rub Aortic stenosis, HCM Pericarditis, tamponade Abdomen Pulsatile mass AAA Rectum Hematest stool Anemia, hypovolemia Pelvis Uterine bleeding, adnexal tenderness Anemia, ectopic, hypovolemia Extremities Pulse equality in upper extremities Subclavian steal, aortic dissection Neurologic Mental status, focal deficits Seizure, stroke, other primary neurologic disease Diagnostic Studies: What to look for… 12 lead EKG Orthostatics Orthostatic hypotension CBC/Electrolytes, Glucose Dysrhythmias, ischemia Anemia, metabolic abnormalities, hypoglycemia B-HCG Pregnancy ? Normal IUP vs ectopic Diagnostic Studies: What to look for… Drug screen and therapeutic drug levels Serum etoh ABG CXR Hypoxemia, hyperventilation Pneumothorax, dissection Head CT Check if new-onset seizure, history of trauma Diagnostic studies: Ultrasound Ultrasound can quickly help identify multiple causes. Abdominal Pelvic Abdominal aortic aneurysm/dissection, intraabdominal hemorrhage Ectopic vs. IUP Cardiac Tamponade, outflow obstruction Aortic Dissection and syncope Ultrasound can be invaluable if you suspect dissection! Need to rule out tamponade- the most common mechanism of death in acute aortic dissection American Journal of Med, 2002: International registry of aortic dissection (IRAD) collected data on 728 pts with acute aortic dissection. Syncope reported in 96 (13%) of patients Aortic Dissection and Syncope The study further showed that patients with acute aortic dissection who had a syncopal episode Were more likely to die in the hospital (34%) than those without (23% P=0.01) Were more likely to have tamponade (28%) vs (8% P=0.001) Stroke was a more common complication (18%) vs (4% P=<0.001) Experienced more neurological deficits (25%) vs (14% P=.005) Aortic dissection and Syncope Patients with proximal dissections more often had syncope than with distal dissections 19% vs 3% P<0.001 * Keep in mind that acute paraplegia secondary to spinal cord ischemia occurs in dissections involving the descending aorta and may be mistaken as syncope Aortic dissection and Syncope Excluding those complications discussed prior (tamponade, stroke etc), syncope alone does not appear to increase the risk of death. Forty-six percent of patients with syncope had no explanation for their LOC and could have been caused by… Vasovagal secondary to pain from the dissection Direct stretching of the baroreceptors in the aortic wall Admission vs Discharge Treat the underlying cause, and if one is found, admit or discharge appropriately. Potential guideline to help physicians with decision making called The San Franciso Syncope Rule San Francisco Syncope Rule If the patient has any of these, they are at a high risk for a serious outcome and require admission At the time of triage: systolic <90 Patient complaint of SOB History of CHF Hematocrit <30 EKG Does the patient have a rhythm that is not sinus? Does the patient have new changes on their EKG? San Francisco Syncope Rule C: CHF history H: Hematocrit < 30 E: EKG changes S: Systolic <90 S: Short of Breath San Francisco Syncope Rule If the patient does not meet any of those criteria – the patient is at a low risk for serious outcome requiring admission A study was conducted in June 00-Feb 02 (J of EM Oct 2005) comparing the application of this rule vs physician judgment in predicting which patients will have a serious outcome within 7 days of the ED visit San Francisco Syncope Rule Study (cont’d): Serious outcomes were defined as MI, arrhythmia, PE, hemorrhage, stroke, death. Both physicians and the SFSR were able to predict those who will have a serious outcome BUT, physicians still admitted many patients even though they felt they were low risk If the SFSR had been utilized, there could have been a 10% decrease in admission of the low risk group. Low Risk Patients & Negative ED workup Journal of EM 2004. A small study of 45 patients conducted over a 3 month period of time. Patients presented with syncope, had a negative workup in the ED and were followed up in one month. If asymptomatic patients who… Denied any chest pain, abdominal pain or focal neurological symptoms Have acceptable vital signs Lack new cardiopulmonary or neurological findings Have normal glucose levels Have normal or unchanged ED tracings during their ED eval. Low risk patients and negative ED workup Those patients that meet those criteria may not benefit from hospitalization. Considering hospitalization is not completely benign and may pose unforeseen risk to otherwise healthy patients due to… Medication changes and errors Instrumentation Risk of nosocomial infections Forced bed rest (risk of DVT, PE) Summary There are many causes of syncope Be vigilant in ruling out the life-threatening ones! Use the ultrasound machine Take into account the risks of hospitalization Sources Quinn, Stiell, McDermott, Kohn, Wells: The San Francisco Syncope Rule vs physician decision making. Am J Med 2005; 23, 782-786. Nallamothu, Mehta, Saint: Syncope in Acute Aortic Dissection: Diagnostic, Prognostic and Clinical Implications. Am J Med 2002; 113, 468-471. Junaid, Dubinsky: Establishing an approach to syncope in the emergency department. J EM; 15, 593-599 Rosen’s Emergency Medicine: Concepts and Clinical Practice. Chapter 20. Syncope.