“I passed out” Frederick Korley M.D., Department of Emergency Medicine

Top 5 causes of Syncope 6.8% 9.4% 9.5% 21.2% 36.6% Medication5. Orthostatic4. Cardiac3. Vasovagal2. Unknown1. Study participants from the original Framingham Heart Study and in the Framingham Offspring Study who underwent routine clinical examinations between 1971 and patients followed 822 reported syncope. Soteriades ES, Evans JC, Larson MG, Chen MH, Chen L, Benjamin EJ, Levy D. Incidence and prognosis of syncope. N Engl J Med Sep 19;347(12):

Framingham Heart Study Soteriades ES, Evans JC, Larson MG, Chen MH, Chen L, Benjamin EJ, Levy D. Incidence and prognosis of syncope.N Engl J Med Sep 19;347(12): “Persons with cardiac syncope are at increased risk for death from any cause and cardiovascular events, and persons with syncope of unknown cause are at increased risk for death from any cause. Vasovagal syncope appears to have a benign prognosis.” Note: There is a very nice table in the article: PubMedPubMed

San Francisco Syncope Rule – Decision Tree Quinn JV, Stiell IG, McDermott DA, Sellers KL, Kohn MA, Wells GA. Derivation of the San Francisco Syncope Rule to predict patients with short-term serious outcomes. Ann Emerg Med Feb;43(2): CHESS Predictors of Short-Term Serious Outcomes Abnormal ECG Shortness of Breath Systolic Blood Pressure Hematocrit Congestive Heart Failure Very nice figure in Article: PubMed

Don’t forget to….. Confirm that patient is at baseline mental status Examine c-spine for tenderness Look for bruises, cuts, tongue laceration Listen for new murmur Rectal exam for those who may have GI bleed as the source of their syncope Tetanus shot for those who need one If female, make sure she is not pregnant Make sure patient is able to walk before you think of sending them home

EKG

Disposition Will you admit or you send the patient home?

ACEP Clinical Policy on Evaluation and Management of Syncope What data help to risk stratify patients with syncope? –Age > 60 + CAD = high risk –Age < 45, no CAD = low risk –Physical exam signs of CHF = high risk Who should be admitted after a syncopal event? –History of CHF or ventricular arrhythmias –Associated chest pain or symptoms compatible with ACS –Signs of CHF or valve disease on exam –EKG with ischemia, arrhythmia, prolonged QT, BBB –Consider admission for: age > 60, h/o CAD, congenital heart disease, FHx of sudden unexpected death, exertional syncope in younger patient

Torsades de pointes A form of polymorphic V. tach that occurs in the setting of prolonged QT interval, T wave abnormalities or increased U wave amplitude Changing morphology of QRS complexes that seem to twist around an imaginary baseline Corrected QT(QTc) > 440ms Usually self terminating but can result in V. fib

Causes of long QT and Torsades de pointes Gowda RM, Khan IA, Wilbur SL, Vasavada BC, Sacchi TJ. Torsade de pointes: the clinical considerations. Int J Cardiol Jul;96(1):1-6. There are significant causes of prolonged QT syndrome Congenital Acquired: Medications Electrolytes Cardiac disease Starvation …to name a few Nice Table in article:PubMed

Commonly used drugs that can prolong QT Antiarrhythmics Mainly Class 1A, 1C and III eg: Procainamide, flecainide, Sotalol, Ibutilide, amiodarone Antimicrobials e.g.: Macrolides, fluoroquinolones, azole antigungals, ampicillin, bactrim Antihistamines e.g.: Benadryl, Hydroxyzine Antidepressants e.g.: doxepin, fluoxetine, paroxetine, imipramine, clomipramine, citalopram Antipsychotics e.g.: Haldol, droperidol, lithium, chloral hydrate, chlopromazine, prochloperazine Others fosphenytoin, hydrochlorothiazide, tamoxifen, antimigraine agents, furosemide, reglan, cisapride, cocaine Gowda RM, Khan IA, Wilbur SL, Vasavada BC, Sacchi TJ. Torsade de pointes: the clinical considerations. Int J Cardiol Jul;96(1):1-6.

Risk factors for drug induced torsades de pointes Gowda RM, Khan IA, Wilbur SL, Vasavada BC, Sacchi TJ. Torsade de pointes: the clinical considerations. Int J Cardiol Jul;96(1):1-6. Nice Table in article:PubMed Congenital long QT Female Gender Electrolyte abnormalities Diuretics Bradycardia Etc. etc.

Methadone induced Torsades de pointes Can occur with increasing doses of methadone, polysubstance abuse, taking other drugs that also prolong QT, etc One Swiss paper reports 5 cases Sticherling C, Schaer BA, Ammann P, Maeder M, Osswald S. Methadone-induced Torsade de pointes tachycardias. Swiss Med Wkly May 14;135(19-20):282-5.

Treatment of Torsades IV, O2, Monitor, pacer pads Stop offending drugs Check electrolytes including mg Give Magnesium 2g over 1-2 mins, may repeat in 15 mins if necessary May use isoproterenol or atropine to increase HR and shorten QT (atropine may be easier to get in ED, ISO is contraindicated in ischemic heart and congential long QT) May overdrive pace with ventricular rate >90 Replete K if low