Syncope Jeff Ricketson, October 27

1 79 M. SYNCOPE THIS AFTERNOON AT HOME. BROUGHT IN BY EMS. NO EMESIS OR MELENA. HG 120 LAST WK. a)Hit the refresh button, and hope that someone else signed up in the past 5 seconds that it took you to read the note. b)Remember that you haven’t gone to the bathroom all shift and that your last preceptor said you should take care of yourself, including ins and outs. c)Try and think of something you didn’t ask your last patient, or didn’t order, so that you can go do a more thorough job of your previous patient. d)Sign up for the patient and hope it’s a clear vasovagal episode.

Reasons we don’t like syncope % of patients will leave without a diagnosis 2.Exhaustive list of potential causes 3.History is key, but often difficult to obtain 4.Lack of organized approach

Goals for the session 1 Pt expect 3 minutes. 20 M, MVC, OBVIOUS DISLOCATED LEFT SHOULDER, ABSENT BREATH SOUNDS TO THE LEFT SIDE, GSC 4 AT THE SCENE, NOT INTUBATED “Maybe I need to go to the washroom, because number 2 is an 80 year old with syncope, and I would really rather see that patient than put in a chest tube, intubate, and reduce a shoulder.”

Epidemiology

-Lots of people have syncope -$$$$$ To healthcare system -Admission rate 10-15% in Canada, 40-60% in US -In Canada: 1/100 will die within 1 month 1/10 will die within 1 year

Case 1 22 year old female. Syncope in the bathroom this morning. Had 3 glasses of wine last night. Ate breakfast this morning. Roomate witnessed event. Vital signs all normal

History There are 3 questions that need answering: 1. Is this immediately life threatening? 2. Is this true syncope? 3. What is the etiology?

Is this immediately life threatening? Chest pain Palpitations SOB HA Abdominal Pain

Is this true syncope? Define syncope: “A transient, brief, loss of consciousness associated with inability to maintain postural tone that spontaneously and completely resolves without medical intervention.”

Is this true syncope? Sx of syncope Diaphoresis Nausea Warmth Palpitations Chest pain Dyspnea Sx of seizure Classic aura Post-ictal confusion Head turning Extremity movement (less helpful) Urinary incontinence (less helpful)

What is the etiology? Cardiopulmonary Structural Dysrhythmia Neural/Reflex Mediated Vasovagal Situational Carotid Sinus Syndrome Orthostatic Neurologic Medications Psychiatric

Bad places to have a syncopal episode…

80 yo M. Got off couch to move pile of books. Syncopal event. Witnessed. No prodrome. Hx of SOBOE, and CP for which he uses SL nitro. Both stable, unchanged. What about the physical exam?

Orthostatic vitals? -Supine x 5 minutes, then measure BP over 2-3 minutes while standing, SBP change >20mmHG -40% of asymptomatic pts >70 yo are positive -Orthostatic symptoms are just as good

Carotid massage?

-Severe aortic stenosis the murmur may not be heard -Check for brachioradial delay

Other physical exam… Hyperventilation maneuver? Rectal exam? Exam for tongue biting?

Another bad place for a syncopal event…

Investigations? 1. ECG for everyone 2. CBC for Hematocrit 3. Other investigations as per clinical suspicion

ECG

QT measurement

ECG Approach 1.Go through the usual, pay attention to: -Bradycardia -AV Block -Intraventricular conduction delays -Tachydysrhythmias -ACS 2. Add 4 things: WPW, Brugada, Long QT, HCM

The pediatric athlete

Driving restrictions??

Management: It’s time to make a decision. Discharg e Handover Admit

What research has been done? OESIL, Italian study, 2003 San Francisco Syncope Rule, 2004 Boston Syncope Rule, 2007 Short and Long Term Prognosis of Syncope (STePS), 2008 …. and many others

-SFSR and the OESIL = Level 2 criteria. Level 2 criteria means can be applied in various clinical settings with confidence in their accuracy. -The rest = Level 4 criteria. Level 4 criteria means need further evaluation before being able to apply in a clinical setting.

A brief word on OESIL -Italian study Derivation phase evaluated death from any cause at 12 months. -Validation phase evaluated death from any cause at 6 months. -Useful for decisions on admission? Survey says….

Criteria: 1.Abnormal ECG 2.Complaint of SOB 3.Hematocrit <30% 4.SBP <90 at triage 5.History of CHF Sensitivity: 96%, (valid’n 98%) Specificity: 62%, (valid’n 52%) -Could have reduced admissions from 55% to 45%

-Worldwide external validations ranged sensitivity % (with 1 at 100%), and specificity 38-57% -This study: Sensitivity 90%, Specificity 33% -Baseline admission rate: 12% -Implementing rule would increase to 77% -Practice pattern missed 30% events outside ED

Meta-analysis of SFSR: Sensitivity 87%, specificity 48% Conclusion: “All the clinical prediction guides used in the study need further development before they can be routinely used in clinical practice.”

Thoughts?...