Syncope

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    Introduction/Definition

    • Definition:
      • Temporary loss of consciousness caused by a sudden fall in blood pressure
    • Based on previous studies cited in the CCS Guidelines 2011:
      • 0.7% of patients die in the next 7- 30 days
      • 10% of patients die within 1 year.
      • 7.5% of syncope ED visits have "severe outcome" (significant new diagnosis, a clinical deterioration, serious injury with recurrence, or a significant therapeutic intervention)
      • 4.5% have a nonfatal severe outcome in the next 7-30 days.
      • Half of nonfatal severe outcomes have cardiovascular causes.
      • Therefore, only a small minority of patients will benefit from urgent assessment and treatment outside the ED, and only half of these are for cardiovascular disorders. The purpose of assessment in the ED is to stabilize the 7.5% of patients with an adverse outcome while there, identify the 4.5% of patients likely to have an early adverse outcome, and arrange urgent assessment and treatment in either ambulatory or acute care settings.

    Differential Diagnosis

    • 1. Hypovolemia
    • 2. Cardiac
      • Structural / Obstructive
        • LV Dysfunction
          • ACS
          • Aortic Stenosis
          • Hypertrophic Cardiomyopathy
        • Outside the Heart
          • Cardiac Tamponade
          • Constrictive Pericarditis
      • Arrhythmias (AV block, sinus node dysfunction, AFib w/ tachy/bradycardia, SVT or VT).
    • Respiratory
      • Massive Pulmonary Embolus
      • Pulmonary HTN, Hypoxia, Hypercapnia
    • Neurologic
      • Stroke/TIA  (vertebrobasilar insufficiency)
      • Migraine
      • Seizure
      • Autonomic Dysfunction
        • Diabetic neuropathy
    • Metabolic
      • Anemia
      • Hypoglycemia
    • Drugs
      • Antihypertensives
      • Antiarrhythmics
      • Diuretics
    • Vasovagal
    • Psychiatric
      • Panic Attack

     

    Assessment

    • Based on CCS Guidelines 2011
    • Should focus around finding patients with "risk factors" of adverse outcomes
      • RiskFactors.png
    • All patients with syncope should get:SyncopeInvestigations.png
      • ECG
      • Orthostatic Vitals
      • Short-term ECG monitoring
      • Basic Blood Work  (do Hb, electrolytes [seizures?], cardiac biomarkers based on clinical suspicion) 
    • Tests with clinical suspicion:
      • Echocardiography
      • Coronary Angiogram
      • Radionucleotide Imaging
    • CT Head:
      • ONLY if:
        • Neuro deficits
        • Seizure strongly suspected
        • Head trauma (r/o hemorrhage)

    Scoring Systems

    • Two most common scoring systems:
    • San Francisco Syncope Rule (SFSR)
      • Independent risk factors for 7-day mortality
      • SFSR Score  
        Dyspnea 1 point
        Hypotension 1 point
        Congestive Heart Failure 1 point
        Abnormal ECG 1 point
        Anemia 1 point
        Score:   
      • 96% Sensitivity, 62% specificity (but subsequent studies had lower numbers)
    • Osservatorio Epidemiologico della Sincope nel Lazio (OESIL)
      • 4 equally-weighed risk factors for 1y mortality:
        • OESIL Score  
          Age > 65 1 point
          Hx of Cardiovascular Disease 1 point
          Syncope without prodrome 1 point
          Abnormal ECG 1 point
          1 year mortality: 0.7 - 57% 
    • Recent study: SFSR = physician judgement (same outcomes): Quinn JV et al - Am J Emerg Med 2005;23:782-6.
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