EMERGENCY Awn khawaldeh

Syncope • Syncope is a symptom, not a diagnosis • Transient loss of consciousness with return to baseline neurologic function • Hypoperfusion to the cerebral cortex and RAS for 8-10 seconds

Causes of Syncope • Neural mediated • Orthostatic hypotension • Cardiac • Neurologic • Medication related

Causes-Orthostasis • A drop in blood pressure associated with symptoms • Is considered positive if the systolic blood pressure drops more than 20 mmHg or the blood pressure is below 90 mmHg regardless of symptoms • Should be taken after the patient is supine for 5 minutes and taken at 1 and 3 minutes after standing • Could also be secondary to acute blood loss

Causes-Neurologic • Could include TIA, seizure, migraine headache • Not uncommon to have brief convulsive activity if the brain is hypo-perfused • Confusion after the event for longer than 5 minutes suggests seizure • Tongue biting and incontinence also suggest seizure

Causes-Cardiac Related • Arrhythmia – Both tachy and brady arrhythmias • Ischemia • Valvular “Patients with cardiovascular causes have a strikingly higher incidence of sudden death than patients with a noncardiovascular or unknown cause.”

Causes-Medication Related • Medication related-prone to arrhythmia – Anti-arrhythmics – Anti-anginal medications – Anti-hypertensive medications – Diuretics

Causes-Neurally Mediated • Vasovagal (occurs because your body overreacts to certain triggers) – Associated with sense of warmth and/or nausea – Often associated with extreme emotional distress – Can be associated with prolonged standing The vasovagal syncope trigger causes your heart rate and blood pressure to drop suddenly • Carotid sinus syncope – Associated with neck pressure or head turning

ED Work-up • EKG • Consider glucose, CBC (hg) • Echo often helpful for admitted patients •neurological examination we should assess for obesity because syncope could occur due to obstructive sleep apnea

The San Francisco Syncope Rule to Predict Patients with Serious Outcomes Chf, Hct, ECG, SBP, SOB •Abnormal EKG •Complaint of SOB •HCT < 30 •SBP < 90 •History of CHF

Pulmonary Embolism Most of PE arise from proximal DVT Risk Factors for Thromboembolism Family History Cancer CHF Prior thromboembolism Estrogen use / Pregnancy / Obesity Low Abdominal/Pelvic surgery/trauma < 6 mos LE Paralysis/ Immobility / Trauma

Symptoms Vs Sign Dyspnea RR > 20/min Pleuritic Pain Rales Cough Tachycardia Leg Swelling Loud P2 Leg Pain Temp > 38.5C Hemoptysis Wheezes **97% with PE had at least ONE of the following Dyspnea Tachypnea Pleuritic pain

Strongest predictors for PE : Hx of Venous thromboembolism (VTE) Unilateral Leg Swelling O2 Sat < 95% Estrogen Use Surgery (GA) w/in 4 weeks

Diagnostic investigations In patients presenting with signs or symptoms of PE, carry out the following to exclude other causes: an assessment of their general medical history a physical examination a chest X-ray If PE suspected use the PE Wells score

Wells score for PE

D-dimer: usually for low risk patient to rule out thromboembolism Diagnostic tests chest X-ray : watermark sign and Hampton hump ABG : hypoxemia with elevated A-a gradient CTPA : CT pulmonary angiogram V\Q scan D-dimer: usually for low risk patient to rule out thromboembolism ECG

Normal CTPA = no pe Normal D-dimer = no pe Normal V\Q scan = no pe

1- Hemodynamically stable PE management : 1- Hemodynamically stable LMW heparin or UFH for 5-7 days and oral warfarin for 6 months if anticoagulation contraindicated we put IVC FILTER then we give anticoagulation 2- Hemodynamically unstable if patient can arrive hospital within 90 min we don’t give thrombolytic therapy but if it will take more than 90 min we give the patient thrombolytic therapy